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Interesting Case Rounds

Interesting Case Rounds. Nadim Lalani R5 08.21.08. Which of the following are/were “Famous Bedwetters”?. “Fergie Wets Pants!”.

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Interesting Case Rounds

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  1. Interesting Case Rounds Nadim Lalani R5 08.21.08

  2. Which of the following are/were “Famous Bedwetters”?

  3. “Fergie Wets Pants!” “I was late ... I didn’t go to the restroom before I went onstage. It was horrible. But, whatever. It happened ... everyone knows I wet my pants on-stage and had a crystal-meth addiction. That sucks. You have to laugh.”

  4. Objectives • Management of primary nocturnal enuresis • Case • Background • Treatment • Alarms • Pharmacotherapy • Behavioural therapy • Other • NOT discussing DIURNAL or SECONDARY

  5. Case • 11 yo Boy brought to you by parents because of bedwetting. • History? • Primary vs Secondary • Nocturnal vs diurnal • Fam hx [enuresis, DM, DI, kidney, neuro, Sickle] • UTI? Sz? Polyuria/Polydypsia? Constipation?encop? • Sleep? [terrors, OSA] • Psychosocial. Developmental. Sexual ab? Parental response. • Meds [SSRI]

  6. Case • Physical? • General [growth chart] • Abdo [distended bladder, stool in rectum] • GU [ectopic ureter, labial adhesions, Sexual ab] • Neuro exam[ Sacral dimples or tufts of hair] • Diagnostics? • Urinalysis. First void SG • Unless secondary or treatment failure [see algorithm]

  7. Case conclusion • Child had primary NE • Parents working with GP • Tried various methods [albeit suboptimally] • Child had normal urinalysis • Had ++ hx behavioural problems/anxiety/depression/hydrophobia • Was on Citalopram • Refered to Community pediatrician

  8. Background: • Definition: Involuntary discharge of urine at night. Beyond age of bladder control. > Twice per week for 3 months Uncomplicated [85%] vs Complicated* [10%] • Epidemiology: • Boys >> girls [2:1] • 15% of 5yo  [8% of 8yo]  1% 15yo • 5% are due to organic pathology * Have other symptoms [const/encop]

  9. Pathophysiology • Often no clear etiology • Causes: • Maturational delay of voiding coordination • Sleep arousal dysfunction: [kids unable to wake up when they senses that the bladder is full] • Small functional bladder capacity: • habit polydipsia : [i.e. the child sips drinks all night long]. • Secondary nocturnal enuresis : • related to stressors at home/school • DM/UTI/Neuro dis/Bladder dysfxn/ Meds [SSRI, diuretix]

  10. Pathophysiology • Genetics: • Risk: 43% [one parent with NE] 77% [both parents with NE] • 75% of kids with NE have a first-degree relative who had enuresis • Linkage studies have shown associated genetic loci on chromosomes 8q, 12q, 13q, and 22q11

  11. General Measures • Clarify the goal of getting up at night and using the toilet. • Assure the child’s access to the toilet. • Avoid caffeine-containing foods and excessive fluids before bedtime [<2 oz after 6pm [<75 lb], 3 oz for 75–100 lb, & 4 oz for >100 lb]. • Have the child empty the bladder at bedtime. • Take the child out of diapers. • Include the child in morning cleanup in a nonpunitive manner. • Preserve the child’s self-esteem. • Best for those < 6yo

  12. Treatment • Alarms • Invented in 1907. • Many different kinds. “mini alarms” [wear device] • Alarm/light/buzzer goes off when urine present • Least effective <5yo. Most after 7 -8 yo • More effective than drugs • Trial minimum 4 months • Continue until 14 consecutive dry nights • Overlearn by drinking 2 cups water  7 dry nights • Relapse  back to alarm for 14 dry nights

  13. Cochrane review 2005 • 56 studies. Over 3200 children • RCT’s & quasi-RCT’s involving alarms [2400 pts] • Excluded diurnal • Results: • Alarm 60% effective at stopping bedwetting • 50% relapse . Less relapse with overlearning and dry bed training. • No difference in alarm types [but kids prefer wearable ones] • DDAVP faster than alarm but not sustainable • TCA no different, but also not sustainable

  14. Alarms • Overall cure rate of 50% • Requires buy in from whole family as it’s disruptive • Impractical for ‘sleepovers’ and camp • No need to go high-end, kids like mini • Don’t buy second-hand [don’t work well after 2-3 pts]

  15. Treatment • Pharmacotherapy : DDAVP • Studied since 1970s • Enuretic kids have decreased nighttime ADH secretion  produce more urine. • Side effects  water intoxication • Expensive • IN preparation pulled by FDA/health Canada • HYponatremia • 5 cases /10 million doses IN vs 1/10 million PO

  16. Cochrane review in 2002 • 47 studies >2200 kids used DDAVP • Results: • Compared with no treatment : • 1.3 fewer wet nights/week • 20% reduction in bedwetting at end of treatment • DDAVP no different to TCA [TCA more side effects] • DDAVP + alarm better than DDAVP during Rx, but same relapse rate

  17. DDAVP • Do not use IN preparation • Can use 200-600 mcg tablets before bedtime • Avoid water after 6pm • CPS: • Useful only for sleep overs or camp

  18. Pharmacotherapy • TCA • Imipramine best studied • Mechanism unclear . Anticholnergic? • Side effects [mood/weight/OD/Cardiac/Sz] • CPS Position Statement: • Short-term • Distressed, Older kids • Reliable parents

  19. Cochrane review 2003 • 58 studies that used TCA > 3000 kids • Results: • Compared with no treatment: • 1 free night/week • 20% dry during Rx, but relapsed • Not enough evidence to compare other TCA/doses • Equivalent to Alarm during therapy, but relapse more than alarm after. • Equivalent to DDAVP during Rx. But relapse more • Better than simple behaviour/diet. Worse than complex behav/hypnosis.

  20. Treatment • Simple Behavioural • Night time Fluid Restriction • Lifting • Picking up asleep child and taking to BR before they wet bed. • Scheduled Awakening • Star Charts & reward systems • Retention Control training • Daytime overload of bladder and attempt to delay micturation.

  21. Cochrane Review 2004 • 17 studies > 700 kids [380 got behaviour training] • Results: • Star charts, Lifting and Waking better than nothing • Might be worth initiating 1st • Drop out associated with frustration and family strife.

  22. Treatment • Complex behavioural Dry Bed Training: • Intensive 1st night  woken Q1h • If bed wet  clean bed [cleanliness] & practice going to BR • Subsequent nights awoken once/night [getting earlier and earlier] Full spectrum Home Training: • Alarm + cleanliness + retention control + overlearning

  23. Cochrane Review 2004 • 18 trials >1000 kids • Results: • Complex training better than nothing • No better than alarm alone

  24. Behavioural Therapy • CPS Position: • Insufficient evidence • Labor intensive and can contribute to frustration and conflict • Might do more harm than good • Shouldn’t be recommended without careful consideration

  25. Treatment • Other modalities Include: • 31 other drugs have been studied • Hypnosis • Psychotherapy • Accupuncture • Chiropractic adjustment. • Not enough evidence to recommend.

  26. Summary • Distinguish NE from Diurnal and secondary • Most important to have supportive environment & minimise impact • Conditioning using alarm most efficacious • Special situations can use DDAVP • Difficult circumstances  imipramine • Judicious use of behavioural therapy • Should be handled by paediatrician • Persistence  urology referral

  27. Feri-Feri

  28. Management of primary nocturnal enuresis Canadian Paediatric Society (CPS) Paediatrics & Child Health 2005;10(10): 611-614

  29. Parent Handout http://www.caringforkids.cps.ca/growing&learning/Bedwetting.htm

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