The ICCS MNE standardisation document

1. The ICCS MNE standardisation document Disclaimer These slides are produced by the International Children’s Continence Society (ICCS) and may be freely used for educational purposes as long as they are not altered and the source is acknowledged. The originals can be found at the ICCS website: www.i-c-c-s.org Evaluation and treatment of monosymptomatic enuresis - a standardisation docu-ment from the International Children’s Continence Society (ICCS). Nevéus T, Eggert P, Evans J, Macedo Jr A, Rittig S, Tekgül S, Vande Walle J, Yeung CK, Robson L. 2009

2. The ICCS MNE standardisation document An attempt to reach a consensus on recommended evaluation and treatment of children with monosymptomatic nocturnal enuresis, based on the evidence and experience available in 2009 Authors: T Nevéus (Sweden), P Eggert (Germany), J Evans (UK), A Macedo Jr (Brazil), S Rittig (Denmark), S Tekgül (Turkey), J Vande Walle (Belgium), CK Yeung (Hong Kong), L Robson (Canada) Endorsement also from the AAP, ESPU and ICS Evaluation and treatment of monosymptomatic enuresis - a standardisation docu-ment from the International Children’s Continence Society (ICCS). Nevéus T, Eggert P, Evans J, Macedo Jr A, Rittig S, Tekgül S, Vande Walle J, Yeung CK, Robson L. 2009

3. Background: definitions Enuresis: Intermittent (i.e. not continuously dribbling) incontinence while asleep in a child at least five years of age* Monosymptomatic nocturnal enuresis (MNE): Enuresis in children without any other lower urinary tract symptoms* But: Pathogenesis, evaluation and treatment overlap between MNE and non-monosymptomatic nocturnal enuresis (NMNE) * Nevéus T, von Gontard A, Hoebeke P, Hjälmås K, Bauer S, Bower W, et al. The standardisation of terminology of lower urinary tract function in children and adolescents: report from the standardisation committee of the International Children’s Continence Society (ICCS). J Urol. 2006; 176(1): 314-24 Evaluation and treatment of monosymptomatic enuresis - a standardisation docu-ment from the International Children’s Continence Society (ICCS). Nevéus T, Eggert P, Evans J, Macedo Jr A, Rittig S, Tekgül S, Vande Walle J, Yeung CK, Robson L. 2009

4. Background: pathogenesis, comorbidity Etiology Often inherited Pathogenesis Nocturnal polyuria and/or detrusor overactivity and high arousal thresholds. Thus: inability to awaken from sleep in spite of nocturnal bladder (over-)filling and/or nocturnal detrusor contractions. Comorbidity Constipation and/or psychiatrical comorbidity not uncommon (but this is more typical for NMNE than for MNE) Evaluation and treatment of monosymptomatic enuresis - a standardisation docu-ment from the International Children’s Continence Society (ICCS). Nevéus T, Eggert P, Evans J, Macedo Jr A, Rittig S, Tekgül S, Vande Walle J, Yeung CK, Robson L. 2009

5. % 14 12 Wet occasionally 10 8 6 Wet every night 4 2 Age 2 4 10 6 8 12 14 16 18 20 Background: epidemiology and prognosis Evaluation and treatment of monosymptomatic enuresis - a standardisation docu-ment from the International Children’s Continence Society (ICCS). Nevéus T, Eggert P, Evans J, Macedo Jr A, Rittig S, Tekgül S, Vande Walle J, Yeung CK, Robson L. 2009

6. Primary evaluation: case history General Health and development. Weight loss? Excessive thirst? UTIs? Timeframe Primary/secondary enuresis? Frequent/sporadic accidents? Bladder Daytime bladder symptoms, now or previously? Voiding frequency. Bowel Constipation symptoms, fecal incontinence? Behaviour Problems at home or at school? Distressed by enuresis? Previous treatment strategies Which strategies have been used? Have they been used correctly? Other Enuresis in the family? Difficult to arouse from sleep? Evaluation and treatment of monosymptomatic enuresis - a standardisation docu-ment from the International Children’s Continence Society (ICCS). Nevéus T, Eggert P, Evans J, Macedo Jr A, Rittig S, Tekgül S, Vande Walle J, Yeung CK, Robson L. 2009

7. Primary evaluation: examinations and tests Physical examination (usually unexceptional in pure MNE) Height, weight, blood pressure, general neurological exam Genital inspection. Consider rectal exam if constipation suspected Urine tests Dipstick test: glucose, leukocytes, protein, erythrocytes and bacteria Blood tests, radiology, urodynamics Not indicated in uncomplicated MNE Bladder diary/voiding charts Strongly recommended Evaluation and treatment of monosymptomatic enuresis - a standardisation docu-ment from the International Children’s Continence Society (ICCS). Nevéus T, Eggert P, Evans J, Macedo Jr A, Rittig S, Tekgül S, Vande Walle J, Yeung CK, Robson L. 2009

8. Primary evaluation: voiding charts Why? Objectifies history data. Detects NMNE. Detects children who need extra evaluation. Detects polydipsia. Gives prognostic information. Detects families with poor compliance. Recommended charts can be found at the ICCS website! www.i-c-c-s.org Evaluation and treatment of monosymptomatic enuresis - a standardisation docu-ment from the International Children’s Continence Society (ICCS). Nevéus T, Eggert P, Evans J, Macedo Jr A, Rittig S, Tekgül S, Vande Walle J, Yeung CK, Robson L. 2009

9. Warning signs Enuresis in a previously dry child Comorbidity (somatic or psychiatric) more common. Daytime incontinence or other micturition symptoms NMNE. Voiding charts mandatory. Treat daytime symptoms first. Weak stream, straining to void, interrupted micturitions Suspect neurogenic/anatomic bladder problem. Consult urologist. Weight loss, excessive thirst, nausea Exclude diabetes or kidney disease without delay. Glucosuria, proteinuria Exclude diabetes or kidney disease without delay. Significant problems with peer relations Suspect psychiatric comorbidity. Evaluation and treatment of monosymptomatic enuresis - a standardisation docu-ment from the International Children’s Continence Society (ICCS). Nevéus T, Eggert P, Evans J, Macedo Jr A, Rittig S, Tekgül S, Vande Walle J, Yeung CK, Robson L. 2009

10. Primary treatment strategy General advice* given to all children: Explanation, demystification, removal of guilt Regular voiding. Sufficient, but non-excessive fluid/solute intake. Active treatment with the enuresis alarm or desmopressin offered to children age 6 years or older who are bothered by their condition Alternative strategies for the choice of the first therapy Measure nocturnal urine produc-tion. Offer desmopressin to children with nocturnal polyuria + normal voided volumes. Offer the alarm to the rest Present the assets and drawbacks of the alarm and desmopressin and let the family choose *Experience based. Evidence level IV Evaluation and treatment of monosymptomatic enuresis - a standardisation docu-ment from the International Children’s Continence Society (ICCS). Nevéus T, Eggert P, Evans J, Macedo Jr A, Rittig S, Tekgül S, Vande Walle J, Yeung CK, Robson L. 2009

11. First-line therapy: the enuresis alarm* Assets: Curative potential. Cheap. Harmless Drawbacks: Requires time, motivation and hard work Prognostic indicators: best effect in motivated families Practicalities Information, motivation and early follow-up are essential! The parents need to help the child to wake up Use consistently every night without interruptions Use until either 14 consecutive dry nights or 2-3 months without effect New attempts recommended if enuresis recurs *Evidence level Ia Evaluation and treatment of monosymptomatic enuresis - a standardisation docu-ment from the International Children’s Continence Society (ICCS). Nevéus T, Eggert P, Evans J, Macedo Jr A, Rittig S, Tekgül S, Vande Walle J, Yeung CK, Robson L. 2009

12. First-line therapy: desmopressin* Assets: Easy to use. Quick effect. Harmless if not combined with excessive fluid intake Drawbacks: Low curative potential Prognostic indicators: best effect if nocturnal polyuria present and daytime voided volumes normal Practicalities Dosage: oral tablets 0.2-0.4 mg or oral lyophilisate 240-480 ug, taken 30-60 minutes before going to sleep Keep evening fluid intake below 2 dL/6 oz, and no nighttime drinking Stop treatment if no effect within two weeks Continuous treatment or on ”important nights” only are both OK *Evidence level Ia Evaluation and treatment of monosymptomatic enuresis - a standardisation docu-ment from the International Children’s Continence Society (ICCS). Nevéus T, Eggert P, Evans J, Macedo Jr A, Rittig S, Tekgül S, Vande Walle J, Yeung CK, Robson L. 2009

13. Therapy-resistant enuresis: evaluation These children should see a pediatrician or pediatric urologist Case history Was the alarm correctly used? Exclude occult constipation. Is there heavy snoring? Extra evaluations Voiding charts (if not already performed) Measurement of nocturnal urine production Ultrasound (increased bladder wall thickness? Rectal distension?) Uroflowmetry with measurement of residual urine (recommended) Consider psychiatric/psychological evaluation Evaluation and treatment of monosymptomatic enuresis - a standardisation docu-ment from the International Children’s Continence Society (ICCS). Nevéus T, Eggert P, Evans J, Macedo Jr A, Rittig S, Tekgül S, Vande Walle J, Yeung CK, Robson L. 2009

14. Therapy-resistant enuresis: treatment First line New attempt with the alarm if incorrectly used Combine alarm and desmopressin if nocturnal polyuria present Exclude/treat constipation if present Consider correction of airway obstruction in heavy snorers New attempt with the alarm approximately every 2nd year Second line Anticholinergics*, with or without desmopressin First exclude residual urine and/or constipation Third line Imipramine**, with or without desmopressin Please note: cardiotoxic if overdosed! Only to be used by specialists! *Evidence level Ib ** Evidence level Ia Evaluation and treatment of monosymptomatic enuresis - a standardisation docu-ment from the International Children’s Continence Society (ICCS). Nevéus T, Eggert P, Evans J, Macedo Jr A, Rittig S, Tekgül S, Vande Walle J, Yeung CK, Robson L. 2009

15. Further information The document is scheduled for publication in the Journal of Urology February/March 2010, and will be made freely available on the ICCS website 6 months later An extended draft version of the document is available for paying members on the ICCS website ICCS-approved voiding charts, minimal evaluation protocols and other materials are available for paying members on the ICCS website ICCS website: www.i-c-c-s.org Evaluation and treatment of monosymptomatic enuresis - a standardisation docu-ment from the International Children’s Continence Society (ICCS). Nevéus T, Eggert P, Evans J, Macedo Jr A, Rittig S, Tekgül S, Vande Walle J, Yeung CK, Robson L. 2009