Enuresis

CSN Vittal

Enuresis

Definition :

Involuntary voiding of urine at least two nights per month beyond the age of 5

years by which bladder control is normally obtained and without any

congenital or acquired defects of the urinary tract.

Enuresis

Achievement of bladder control

85% by 5 yrs Remaining 15% at a rate of 15% per year Only 0.5 to 1% - no control at adolescence

Types of Enuresis

PrimaryChild who never

gained nocturnal urinary control

Accounts of 85% of cases

SecondaryAt least a 6 –

month period of dryness has preceeded the onset of wetting

Enuresis

Presentation

Type I : Monosymptomatic Type II : Diurnal enuresis without daytime frequency Type III : Nocturnal enuresis with daytime frequency Type IV : Nocturnal enuresis with daytime frequency

and voiding dysfunction

Types of Enuresis

Uncomplicated Complicated

OnsetOnset Primary Secondary

Daytime Daytime symptomssymptoms

Absent Present

StreamStream Normal Abnormal

Physical Exam.Physical Exam. Normal Abnormal

UrinalysisUrinalysis Normal Abnormal

Therapeutic Responses

Initial success:14 consecutive dry nights have been achieved with treatment

Lack of success:Failure to meet the above criteria

Relapse:When 2 or more wet nights within two weeks of initial success and the interval between the initial success and relapse measured

Continued success:There is no relapse after 6 months of initial success

Complete success:There has been no relapse in 2 years after an initial success

Development of Urinary Control

1. Nocturnal bowel control

2. Day time bowel control

3. Day time voiding control

4. Night time voiding control

Genetics

1. Familial pattern2. Risk of enuresis 7.5 when father was

enuretic than when mother was.3. 75% if both parents were enuretic4. 45% in families with one parent enuretic5. 15% when neither parent was enuretic6. Primary – aut. Dominant with

penetrance above 90% with disease locus in chr 13q

Evaluation

1. Complete history• Primary or sec.• Nocturnal or diurnal• Does encopresis associated• Associated urinary tract symptoms like dysuria, polyuria,

pollakiuria, hematuria, pyuria, etc.

2. Developmental history• Birth history• Achievement of milestones• Neurological deficits• CNS disorders

3. Family history• H/o. enuresis in parents• Traumatic incidents• Parental harmony

Physical Examination

1. Visualization of urinary system2. Abdomen exam – for renal / bladder mass3. Genitals – hypospadiasis4. Neurological

1. Peripherl reflexes2. Perianal sensations3. Tone4. Gait

5. Lower back1. Tuft of hair2. Vertebral anomaly

Types of Nocturnal Enuresis

Polysymptomatic

Daytime enuresis, encopresis, urgency, dribbling

PE, neurological abnormalities +

+ve urinalysis, c/s, USG

Need contrast studies, urodynamic assessment

Monosymptomatic

Solely nocturnal

Normal physical exam. & urethrogram

No further investigations

General Tratement

1. Avoid excessive fluids2. Empty bladder at bed time3. Told to wake up at night and use

toilet to remain dry4. Improve access to toilet5. Include the child in morning

cleaning up of urine-soiled cloths

Behavioural Intervention

Active participation & commitment of

• parents• the child & • the pediatrician

Motivation Therapy (for > 7 yrs. Old)

1. Convince parents that the child wants to be dry

2. Child is encouraged to assume responsibility for his enuresis and actively participate in treatment

3. Move from blame for wet nights to praise for dry nights.

4. A dry morning should receive positive recognition and should receive lavish words of praise from everyone in family.

5. A major breakthrough may warrant material reward.

Alarm Therapy

1. Alarm triggered when the diaper gets wet to awaken the child from sleep and stop micturition.

2. By repetitive inhibition of micturition a conditioning process occurs ultimately.

3. With 3 mo. of treatment – 92% cured4. Relapse rate is 30%5. Response to retreatment is good6. Adjuvant pharmacotherapy helps

Wet Alarm Therapy

Multidimentional behavioural Therapy

1. Full spectrum home training2. Scharf’s Comprehensive

Treatment Program

Bladder Stretching

1. Increased oral fluids, lengthening of period between daytime voiding

2. Holding back urination until the point of incontinences – can help increase anatomical and functional bladder capacity

Pharmacotherapy

1. DDAVP (1-deamino-8 Arginine Vasopressin) for > 4 yrs old.

• Reduces nocturnal urine output to a volume lower than functional bladder capacity

• Useful in those who do not manifest diurnal rhythm of vasopressin

• Dose: 20 micrograms (one spray) in each nostril

• Max. up to 80 micrograms

Adverse EffectsHyponatremia, disorientationm seizures, coma

Pharmacotherapy

2. Anticholinergics• Oxybutenin chloride

Acts by increasing bladder capacity and reducing frequency of detrusor contractions.

Adverse Effects:Dryness of mouth, blurred vision, facial

flushing.Dose: For > 7 yrs : 5 mg 2-3 times a day

Pharmacotherapy

3. Tricyclic antidepressants• Imipramine

Alteration of sleep mechanisms and rousal patternCholinergic properties

Adverse Effects:Anxiety, insomnia, dry mouth, nausea, personality changes.Cardiac arrhythmias, hypotension, respiratory complications,

convulsionsDose: 25 mg for 6-8 yrs old

50-75 mg for older childrenAdministered at 6 pm.Treatment for 3 – 6 months, then tapered offAntidote: Physostigmine

Surgical Therapy

Cystoplasty

In select cases

Conclusion

Enuresis is basically a symptom and not a disease stateIntervention is justified for psychological benefit of child and

familyProblem of enuresis should be solved with 5 “P” regimen

• Praise• Patience• Perseverance• Passion• Positive attitude