The ICCS MNE standardisation document

The ICCS MNE standardisation document

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

DisclaimerThese 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

http://www.i-c-c-s.org/

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


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



EtiologyOften inherited

PathogenesisNocturnal 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.

ComorbidityConstipation and/or psychiatrical comorbidity not uncommon (but this is more typical for NMNE than for MNE)

Background: pathogenesis, comorbidity


Background: epidemiology and prognosis

2 104 6 8 12 14 16 18 20 Age

%

2

4

6

8

10

12

14

Wet occasionally

Wet every night


Primary evaluation: case history

GeneralHealth and development. Weight loss? Excessive thirst? UTIs? TimeframePrimary/secondary enuresis? Frequent/sporadic accidents?BladderDaytime bladder symptoms, now or previously? Voiding frequency. BowelConstipation symptoms, fecal incontinence?BehaviourProblems at home or at school? Distressed by enuresis?Previous treatment strategiesWhich strategies have been used? Have they been used correctly?OtherEnuresis in the family? Difficult to arouse from sleep?

Primary evaluation: examinations and tests


Physical examination(usually unexceptional in pure MNE)Height, weight, blood pressure, general neurological examGenital inspection. Consider rectal exam if constipation suspected

Urine testsDipstick test: glucose, leukocytes, protein, erythrocytes and bacteria

Blood tests, radiology, urodynamicsNot indicated in uncomplicated MNE

Bladder diary/voiding chartsStrongly recommended

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

Warning signs


Enuresis in a previously dry childComorbidity (somatic or psychiatric) more common.Daytime incontinence or other micturition symptomsNMNE. Voiding charts mandatory. Treat daytime symptoms first.Weak stream, straining to void, interrupted micturitionsSuspect neurogenic/anatomic bladder problem. Consult urologist.Weight loss, excessive thirst, nauseaExclude diabetes or kidney disease without delay.Glucosuria, proteinuriaExclude diabetes or kidney disease without delay.Significant problems with peer relationsSuspect psychiatric comorbidity.

Primary treatment strategy


General advice* given to all children:Explanation, demystification, removal of guiltRegular 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

Present the assets and drawbacks of the alarm and desmopressin and let the family choose

Measure nocturnal urine produc-tion. Offer desmopressin to children with nocturnal polyuria + normal voided volumes. Offer the alarm to the rest

*Experience based. Evidence level IV

First-line therapy: the enuresis alarm*


Assets: Curative potential. Cheap. HarmlessDrawbacks: Requires time, motivation and hard workPrognostic indicators: best effect in motivated families

PracticalitiesInformation, motivation and early follow-up are essential!The parents need to help the child to wake upUse consistently every night without interruptionsUse until either 14 consecutive dry nights or 2-3 months without effect

New attempts recommended if enuresis recurs

*Evidence level Ia

First-line therapy: desmopressin*


Assets: Easy to use. Quick effect. Harmless if not combined with excessive fluid intakeDrawbacks: Low curative potentialPrognostic indicators: best effect if nocturnal polyuria present and daytime voided volumes normal

PracticalitiesDosage: oral tablets 0.2-0.4 mg or oral lyophilisate 240-480 ug, taken 30-60 minutes before going to sleepKeep evening fluid intake below 2 dL/6 oz, and no nighttime drinkingStop treatment if no effect within two weeksContinuous treatment or on ”important nights” only are both OK

*Evidence level Ia

Therapy-resistant enuresis: evaluation


These children should see a pediatrician or pediatric urologist

Case historyWas the alarm correctly used? Exclude occult constipation. Is there heavy snoring?

Extra evaluationsVoiding charts (if not already performed)Measurement of nocturnal urine productionUltrasound (increased bladder wall thickness? Rectal distension?)Uroflowmetry with measurement of residual urine (recommended)Consider psychiatric/psychological evaluation

Therapy-resistant enuresis: treatment


First lineNew attempt with the alarm if incorrectly usedCombine alarm and desmopressin if nocturnal polyuria presentExclude/treat constipation if presentConsider correction of airway obstruction in heavy snorersNew attempt with the alarm approximately every 2nd yearSecond lineAnticholinergics*, with or without desmopressinFirst exclude residual urine and/or constipationThird lineImipramine**, with or without desmopressinPlease note: cardiotoxic if overdosed! Only to be used by specialists!

*Evidence level Ib ** Evidence level Ia

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

The ICCS MNE standardisation document

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