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Nocturnal Enuresis

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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Nocturnal Enuresis

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  1. Nocturnal Enuresis

  2. Aims • Understand aetiology of nocturnal enuresis • Be aware of treatments available in Primary Care • Known when to refer

  3. 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

  4. 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%

  5. 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

  6. Assessment - history • Detailed! • Urinary symptoms • Bowel habit • Developmental history • Family history • Secondary causes (see previous slide)

  7. Assessment - examination • Growth parameters • Lower limb neurology • Abdominal examination • Blood pressure (raised in renal disease) • Consider examining genitalia especially if you suspect physical cause

  8. Investigation • In primary care, relatively simple: • Dip urine and send for culture • Biochemical testing to rule out diabetes.

  9. 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

  10. 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

  11. 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

  12. 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

  13. 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

  14. 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!

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