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Hot Topic. Enuresis. Definition. Uncontrolled/Involuntary passage of urine by day/night/both Children aged 5 or over In absence of physical disease DSMM defines nocturnal enuresis as wetting at least x2/wk in the above group. Day or night?. 85% nocturnal enuresis

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  1. Hot Topic • Enuresis

  2. Definition • Uncontrolled/Involuntary passage of urine by day/night/both • Children aged 5 or over • In absence of physical disease • DSMM defines nocturnal enuresis as wetting at least x2/wk in the above group

  3. Day or night? • 85% nocturnal enuresis • Daytime enuresis more likely associated with pathology • Potentially large effect on family • Bullying, problems with schoolwork, social life

  4. Nocturnal enuresis • Common - approx 15% of children experience it, rising to 75% if both parents had it. • Disorder of sleep arousal, a low nocturnal bladder capacity and nocturnal polyuria • History needs to distinguish b/w primary and secondary nocturnal enuresis. • Primary - bladder control has never been achieved • Secondary - lost after having had bladder control for at least 6 months

  5. Nocturnal enuresis • 15% of 5 year olds • 5% of 10 year olds • Teenagers 1-2% occasionally wet the bed • Yearly spontaneous remission rate is 15% • Usually can be considered a variation of the normal rate of maturation • Girls usually ahead of boys • 23% of nocturnal enuresis is associated with encopresis and daytime incontinence

  6. Contributing factors • Genetics - 70% have +ve family history • Caffeine • Emotional stress • ADHD, premature delivery • Organic pathology • Disturbed sleep, mother young or smoker

  7. Organic causes • 1-2% have underlying physical cause • UTI • Chronic constipation • Bladder overactivity • Diabetes • Renal failure • Congenital anomalies eg ectopic ureter • Neurological disorders eg neural tube defect • Sleep apnoea

  8. Assessment - History • Age of child • Nocturnal or daytime or both? • Primary or secondary? • Other urinary symptoms? (UTI, bladder overactivity) • Hx of constipation/soiling? • Sx of diabetes or of sleep apnoea? • Family history? • Girls: early morning wetting? (ectopic ureter) • PMHx

  9. Assessment - history • How many dry nights past wk/month? • Any potential causes of emotional distress • Fluid intake at bedtime • Diet - caffeine containing foods eg chocolate • Impact on family • Any strategies tried so far, ways parents respond to the wetting

  10. Examination • Abdo exam - distended bladder/mass/constipation • Inspect perineum/genitals • Spine • Check lower limb neurology • Growth chart

  11. Investigations • Urine for glucose, protein, C&S in more or less all. • If daytime enuresis - consider USS abdo to exclude anatomical abnormalities/residual volume

  12. Management • If indication of underlying cause manage/refer as appropriate Eg deal with constipation/UTI • Most children with enuresis are normal • <5 yrs no need to treat • <7 yrs and parents/child coping ok often no need to treat • >10 treat promptly • Advice

  13. Management - advice • Primary enuresis - occurs because the volume of urine produced at night exceeds the bladder capacity and the sensation of a full bladder doesn’t wake the child • Not done out of defiance/contrariness • Try not to be angry with the child, stress aggravates the situation • Try to reinforce success • Give it time if child is young

  14. Simple advice for all • Empty bladder before bed • Avoid drinking after 1hr before bed • Otherwise don’t restrict fluids - encourage regular intake throughout the day but avoid any containing methylxanthines • Check access to bathroom at night • Waterproof covers for bed • Involve child in cleaning up mess but not as punishment

  15. Enuresis alarms • Tx of choice for long-term Mx. • Children >7yrs. Needs to be a well-motivated child and family; Usually needed for 3-5 months. 30-50% of children relapse • Sensor in pad under child or attached to underwear • Alarms if gets wet - child has to get up to stop it. Parents must hear it too (eg baby monitor). Child to help with cleaning up. • Child learns to waken before alarm sounds or to sleep through night without passing urine

  16. Enuresis alarms • If dry for 14 nights in a row can stop alarm • Can be used together with drug treatment of needed • Treat relapses promptly • “Overlearning” - once dryness achieved encourage drinking at bedtime to “over-condition” bladder, stop once 14 dry nights. • Avoid if child shares a room, more than one child has enuresis at once, unmotivated parents.

  17. Star charts • Alternative to enuresis alarm • Involves a wall calendar and star stickers • If dry in the morning child gets a sticker on the chart and praise as a reward • Child responds to rewards - reinforce success • As wetting less frequent can increase rewards value • If bed is wet - no punishment but stay calm and practical

  18. Desmopressin • 2nd line treatment • In general practice use as short-term measure • School trips, sleepovers, holidays • Effective in 70% but high relapse rate once stop use • Can be used longer term but not initiated in primary care • May be useful adjunct to alarm treatment

  19. Desmopressin • Synthetic version of antidiuretic hormone • Reduces amount of urine produced - increased water resorption from distal tubules and collecting ducts • Taken at night as tablet or a melt • SEs - headache, nausea, congestion, nosebleeds, sore throat, cough, mild abdo cramps • Risk of water overload - need to counsel parents and child - limit fluid intake to 1 cup from 1hr before to 8hrs after taking tab

  20. Desmopressin • Preferably use in >7yr olds • Never use for daytime enuresis due to risk of fluid overload • Usual dose 200mcg tab/120mcg sublingual tab at bedtime • To determine dose and effectiveness trial of 2wks desmopressin. If not enough can try 2wks at double dose • Once effective dose established can prescribe it for intermittent use when needed eg school trip

  21. Secondary enuresis • If wets after being dry for min 6 months • Look for underlying cause physical/emotional • Treat when able but consider referral for some causes or if can’t identify cause - enuresis clinic/paediatrics/child psychologist

  22. Daytime enuresis • Rule out organic causes • Refer on to secondary care • MSU + dipstix • Usually USS • Star charts/bladder training/pelvic floor exercises

  23. When to refer • Most cases can be managed in primary care • Failed trials of alarm/star chart/desmopressin • If parents not coping • If suspicion of underlying cause • Older children • Daytime enuresis • Severe psychological distress • Secondary nocturnal enuresis if caused by emotional distress, cause not clearly identified or enduring/big impact

  24. Who can you involve? • Health visitor if child is pre-school • School nurse • Local enuresis clinic • Voluntary groups eg ERIC for support and advice for parents

  25. Resources • ERIC - Education and Resources for Improving Childhood Continence www.eric.org.uk • Clinical Knowledge Summaries www.cks.nhs.uk • Tayside intranet - Bedwetting leaflet in Children’s hospital section wih local clinic details • Oxford Handbook of General Practice • DXS has selection of leaflets/evidence

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