Hot TopicEnuresis

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

• Daytime enuresis more likely associated with pathology

• Potentially large effect on family

• Bullying, problems with schoolwork, social life

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

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

Contributing factors

• Genetics - 70% have +ve family history

• Caffeine

• Emotional stress

• ADHD, premature delivery

• Organic pathology

• Disturbed sleep, mother young or smoker

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

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

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

Examination• Abdo exam - distended

bladder/mass/constipation

• Inspect perineum/genitals

• Spine

• Check lower limb neurology

• Growth chart

Investigations

• Urine for glucose, protein, C&S in more or less all.

• If daytime enuresis - consider USS abdo to exclude anatomical abnormalities/residual volume

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

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

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

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

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.

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

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

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

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

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

Daytime enuresis

• Rule out organic causes

• Refer on to secondary care

• MSU + dipstix

• Usually USS

• Star charts/bladder training/pelvic floor exercises

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

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

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