Dr Dina Kamal Specialist Pediatrician in PFBS, Tabuk

1/22/2012

Enuresis
y Involuntary discharge of urine y Nocturnal enuresis - nighttime wetting y Diurnal enuresis - daytime wetting y 15% normal children have nocturnal enuresis at 5

years of age y 99% are dry by age 15 y Nocturnal enuresis is 50% more common in boys y More girls dry day and night by age 2

1/22/2012

Enuresis
y 80% enuretics are wet only at night y most are primary enuretics - never been dry y 25% are secondary enuretics y initially dry at night by age 12 y relapse for 2.5 years y may be associated with emotional stress y Only 10% who develop daytime dryness relapse wet for 1.2 years

1/22/2012

Development of Urinary Control

y Infant y spontaneous micturation as a spinal cord reflex y distention simulates a detrusor contraction y voluntary sphincter is integrated into the reflex
y y y

constricts to prevent incontinence relaxation during micturation low pressure voinding

y As bladder capacity increases and fluid intake decreases,

number of voidings decrease

1/22/2012

Development of Urinary Control

y Development of adult type control y Capacity of the bladder must increase y Voluntary control over the striated sphincter
y

usually complete by 3 years

y Direct volitional control over the spinal micturition reflex

to initiate or inhibit bladder contraction

y Complete by age 4

1/22/2012

Rule of 15 s

1/22/2012

Development of Urinary Control

y Order of Control
y Control of bowel at night y Control of bowel during the day y Control of bladder during the day y Control of bladder at night

1/22/2012

Etiology
y Urodynamic Factors
y Reduced bladder capacity by 50% y anticholinergics increase capacity by 25 - 60% y Bladder instability seen in many with day and night

enuresis
y y

in children with daytime symptoms of frequency/urgency anticholinergics are helpful

y Those with nocturnal enuresis do not have a higher

incidence of daytime instability

y

nighttime contraction is just as likely to wake the child as to cause wetting anticholinergics not effective

1/22/2012

Etiology
y Sleep Factors
y Theory that sleep disturbance causing the child to sleep

too deeply or fail to awaken y Enuretics do not sleep more soundly than controls y Enuresis occurs in deep sleep and in REM sleep y Enuresis may be a developmental delay
y

perception and inhibition of bladder filling and contraction by the CNS

1/22/2012

Etiology
y Sleep Factors - Types of Enuresis y Type I
y

Stable bladder with EEG response during enuresis Stable bladder with no EEG response during enuresis 80% change to I Unstable bladder with no EEG response during enuresis 20% change to IIa 60% change to I

y Type IIa
y y

y Type IIb
y y y

1/22/2012

Etiology
y Alteration in Vasopressin Secretion and Nocturnal

Polyuria
y High ADH as night leads to less urine production y Enuretics have stable ADH during the day and night
y y

larger amounts of dilute urine at night may be delayed development of the ADH circadian rhythm Bladder emptying may cause decreased nighttime ADH levels in enuretics

y ADH levels increase normally with bladder fullness

y

1/22/2012

Etiology
y Developmental Delay
y Altered urodynamic function, sleep and ADH secretion

occur normally in infants and young children y Nocturnal enuresis may be an arrest in development y Each physiologic alteration tends to resolve spontaneously y Neurologic disease is rare with monosymptomatic nocturnal enuresis

1/22/2012

Etiology
y Developmental Delay
y Stress has been shown to delay development of urinary

control
y

enuresis is 3 times higher when associated with stressful circumstances delay in development is not isolated to urinary control

y Associated with encopresis 10 - 25%

y

1/22/2012

Etiology
y Genetic Factors
y 33% fathers y 20% mothers y One parent enuretic - 44% y When mother and father were enuretics, 77% children

affected y 15% enuresis in children of nonenuretics

1/22/2012

Etiology
y Organic Urinary Tract Disease
y Enuretics are predisposed to UTIs
y y

especially girls many have diurnal symptoms due to bladder instability

y Most with monosymptomatic nocturnal enuresis do not have an

organic cause <10% y meatal stenosis is not a cause - meatotomy does not cure
y Increased incidence of organic abnormalities with diurnal symptoms
y y

These may need U/S to exclude obstruction - esp. boys controversial

1/22/2012

Evaluation
y Families with a history of enuresis await spontaneous

cure - more tolerant y Families without such a history can place great pressure on the physician to perform tests and produce a cure y Urologic tests are rarely indicated for monosymptomatic bedwetters
y Rarely find an organic lesion

1/22/2012

Evaluation
y Negative Screening Evaluation for Enuresis
y Prepubertal age y Lifelong enuresis y Nocturnal enuresis only y No daytime wetting, urgency, polyuria y No UTI y Negative UA and Culture y Normal PE - including neurologic exam

1/22/2012

Evaluation
y Screening creates 3 groups
y Children with nocturnal enuresis
y

no further evaluation full urologic workup

y Children with UTI or neuropathy

y

y Children without UTI or neuropathy with day and night

enuresis or dysfunctional voiding

y y

U/S to exclude anatomic abnormality Assesses hydro, bladder wall thickening, emptying

1/22/2012

Evaluation
y Screening creates 3 groups
y Normal U/S
y y

pharmacologic therapy is symptoms are not severe If dysfunction persists or is severe - Urodynamics to exclude neuropathy and guide further treatment

1/22/2012

Treatment
y Treatment is discouraged before age 7 y less successful y age when bedwetting interferes with social activities

1/22/2012

Treatment - Drug Therapy

y Anticholinergics y Only 5 - 40% effective (equal to placebo) in nocturnal enuretics y useful to eliminate bladder instability
y y

urgency, frequency, day and night incontinence (87%) more effective in urodynamically proven instability (90%)

1/22/2012

Treatment - Drug Therapy

y Reduction of Urinary Output y limiting fluids in the day is not effective y DDAVP - intranasal or oral
y y y y

significantly reduces number of wet nights only 25% dry for 14 or more consecutive days temporary treatment - only 33% cured may lead to hyponatremic seizures - limit fluids before administering dose not first-line treatment

1/22/2012

Treatment - Drug Therapy

y Imipramine y Cure > 50% Improvement - 80% y Discontinuation - 60% relapse y Peripheral action
y y

weak anticholinergic weak smooth muscle antispasmotic antidepressant activity not involved decreases REM early sleep - less enuresis early in the night and more common in the last third of sleep y does not lead to more awakenings at night y effect on sleep is independent of its effect on enuresis

y Central action
y y

1/22/2012

Treatment - Drug Therapy

y Imipramine y Recommended dosage
y y y

25 mg age 5-8 50 mg for older children results in optimal plasma levels in only 30% increased dosage not justified y toxicity y 25% are nonresponders despite higher doses adjust dosage and timing of administration weaning the drug reduces relapses

y 2 week trial
y

y Long-term effects not known in children

y

1/22/2012

Treatment - Behavior Modification

y When used in a motivated family, result in most

effective rate of sustained cure

y 1st line therapy in these patients

1/22/2012

Treatment - Behavior Modification

y Bladder Training y goal is to increase the time interval between voiding y enlarges functional capacity of bladder y Child is encouraged to retain urine after 1st urge y When combined with conditioning therapy, very successful

1/22/2012

Treatment - Behavior Modification

y Responsibility Reinforcement y motivation
y

child assumes responsibility for wet and credit for dry with progressively longer dry intervals as a consequence of rewards for behavioral changes

y reward
y

y response shaping
y

y reinforcment y Part of a multicomponent behavioral program

1/22/2012

Treatment - Behavior Modification

y Conditioning Therapy y Use of a urinary alarm is the most effective for nocturnal enuresis - 80% cure
y y

child wakes up and voids in toilet followed by sensation of a full bladder and production of the same inhibition as the alarm failure is often due to lack of parental understanding and cooperation may take months

1/22/2012

Treatment - Behavior Modification

y Conditioning Therapy y Once enuresis is cured (2 weeks dry) relapse is reduced by overlearning techniques
y

forcing fluids prior to bed - bladder overdistention provides a stronger conditioning stimulus reinforced by alarm sounding intermittently some nights but not others

y May be combined with pharmacotherapy

1/22/2012

Summary
y Exclude- infection, neuropathy, obstruction y Reassurance- harmless, perhaps genetic, high rate of

spontaneous resolution y Recognize- not all parents and children are ready for therapy y Begin with conditioning therapy and behavior modification y Add the use of medications as necessary

1/22/2012

SANAA EL SADEK

31