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
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