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Nocturnal Enuresis. Aims. Understand aetiology of nocturnal enuresis Be aware of treatments available in Primary Care Known when to refer. Aetiology. 1/6 of 5 year olds will bed-wet, this is normal (although the parents may not think so) Enuresis more common in boys (2:1)

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Presentation Transcript
slide2
Aims
  • Understand aetiology of nocturnal enuresis
  • Be aware of treatments available in Primary Care
  • Known when to refer
aetiology
Aetiology
  • 1/6 of 5 year olds will bed-wet, this is normal (although the parents may not think so)
  • Enuresis more common in boys (2:1)
  • Genetic predisposition (70% have a 1st degree relative)
  • UTI – a history is more common in enuritic children
rates of enuresis
Rates of enuresis
  • Age 5: 20%
  • Age 6: 10–15%
  • Age 7: 7%
  • Age 10: 5%
  • Age 15: 1–2%
  • Age 18–64: 0.5–1%
secondary causes
Secondary Causes
  • Diabetes (mellitus or insipidus)
  • Renal failure
  • Structural abnormality of urinary tract
  • Impaired night-time arrousal
  • Neurogenic bladder
  • A secondary cause must be suspected if enuresis is new onset
  • Drugs – valproate, SSRIs, also caffeine
assessment history
Assessment - history
  • Detailed!
  • Urinary symptoms
  • Bowel habit
  • Developmental history
  • Family history
  • Secondary causes (see previous slide)
assessment examination
Assessment - examination
  • Growth parameters
  • Lower limb neurology
  • Abdominal examination
  • Blood pressure (raised in renal disease)
  • Consider examining genitalia especially if you suspect physical cause
investigation
Investigation
  • In primary care, relatively simple:
    • Dip urine and send for culture
    • Biochemical testing to rule out diabetes.
management
Management
  • Rule out all other causes first
  • Assess parental expectation
  • Non-pharmacological measures – 1st line
    • Bedwetting alarms (see next slide)
    • Bladder training in the day
    • Star charts to award progress and dry nights
  • Pharmacological measures – 2nd line, should not be used in <7s
bedwetting alarms
Bedwetting Alarms
  • Most effective treatment - 70-90% cure
  • Pad senses wetting and sounds alarm
  • Teaches child to recognise full bladder
  • Requires parental effort
  • 6 month training period, 1 month training for relapse
  • Considered successful once 14 consecutive dry nights are achieved
  • Available for lone from ‘local continence advisor’ – probably school nurse, advise there may be a waiting list. Also available to buy
desmopressin
Desmopressin
  • Synthetic vasopressin
  • Limits amount of water excreted by kidneys
  • 12-40% cure, 80% have some benefit
  • Can be used as ‘one-off’ dose (i.e. for if staying over at a friend’s house)
  • Use for over 3 months not recommended unless supervision by specialist
  • Risk of hyponatraemic convusions – need to avoid fluid overload
  • High relapse rate
more pharmacology
More pharmacology
  • TCAs
    • Imipramine main drug used
    • Antimuscarinic effect
    • Treatment success and relapse rate similar to desmopressin, however risk of SEs higher.
    • 2004 review states risks outweigh benefits
  • Oxybutynin
    • Sometimes used if symptoms of bladder insability
referral criteria
Referral criteria
  • Majority of cases can be managed in primary care
  • Referral criteria as follows:
    • Failure of treatment in primary care
    • Complex psychological difficulty – consider referral to a child psychologist
    • Suspicion of a physical abnormality – these cases rarely have problems only at night
the last word
The last word
  • Most of the presentation based on guidance in CKS 2005
  • HOWEVER, NICE are issuing their first guidelines on nocturnal enuresis in October 2010
  • Unfortunately this presentation has come a bit too early!