An introduction to managing enuresis

1. An introduction to managing enuresis Contributor Dr C M Ni Bhrolchain Huntingdon

2. Medical aspects of enuresis Definition of enuresis Persistent and frequent urination during sleep at an age when more bladder control would be expected

3. Prevalence and prognosis 10% of 5-year olds 5% of 10-year olds �Cure� rate without treatment occurs in approximately 15% per year of those still wet during that year Treatment with an enuresis alarm will cure approximately 75% if used properly. Drugs are nowhere near as effective in producing long-term cure

4. Theories of bedwetting Deep sleep Problems with ADH secretion Decreased bladder capacity Immature bladder control Emotional disturbance

5. Known facts Enuresis runs in families It is more common in boys It is more common in disadvantaged families Emotional disturbance can contribute Physical causes are rare but important

6. Initial assessment Find out exactly what the problem e.g. an alarm will not help a child who is wet only 1 night per week Think of physical causes i.e. neurological, anatomical, infection

7. General assessment Family information and history Can child: Stay dry during the day Tell when they need to go Able to dress/undress Sit on toilet Hold on Empty bladder completely

8. General assessment What is the attitude of the parents? What is the attitude of the child? What have they tried? Why hasn�t it worked?

9. Medical assessment Urinary symptomse.g. polyuria, dysuria, UTI? Soiling / constipation Examination including neurology: Have they had a dry night? Dribbling? Always wet?

10. Social assessment Sharing a room Bunk beds Access to toilet Transport to clinic

11. Management Explanation and education about enuresis Institute record keeping for at least 2 weeks and preferably for 4 weeks These may be enough in up to 20% of cases

12. Alarms Important to explain to parent and child How it works i.e. helps you to learn when to wake up Don�t restrict drinking Warn them the first 2 weeks may show no change and the whole learning process may take 3-4/12 Records help to show progress Provide regular support during treatment

13. Should always refer if: Primary enuresis with no dry nights Primary enuresis with soiling Daytime enuresis Personal or family history of infection Those who may benefit from medication Those not responding to treatment despite apparent compliance

14. Signs of progress Smaller wet patches More to �do� in toilet Wetting later at night Wet fewer times per night Waking better (though not waking is OK if not wet) Self-waking MORE DRY NIGHTS!

15. Problems with alarms Not waking False alarms Switching alarm off (sabotage) Alarm doesn�t go off although wet

16. Using drugs for enuresis Tricyclics Desmopressin Oxybutinin Not as successful as alarms High relapse rate Side effects Safety Expensive