Incontinence in Children

WHAT WE ALREADY KNOW

A short review

Do I have enuresis?

The Boundary

We struggle to determine the age at which enuresis can be defined.

The age at which schooling starts is one determinant.

The age at which motivation and longer term goal setting is achievable.

Age related incidence of Enuresis

5 6 7 8 9 10 11 12 13 14 150.00

5.00

10.00

15.00

20.00

25.00

Incidence vs Age

Percent

Simple Measures

Trial removal of the trainer wheels (pull-ups).

Reward systems. Reassurance

Do Nots

Restrict fluids Lift child to toilet during night Punish Resort to medications without medical

assessment (including ‘alternative therapies’)

Desmopressin – indications limited

NZ Bedwetting GuidelinesBedwetting Assessment

Urinary Infection

Constipation

Mono symptomatic Nocturnal Enuresis

enuresis

Child less than 7 yrs

Not motivated

Treat as perUTI guidelines

Treat

Inform, Advise and Reassure

Episodic Needs (6 yrs or older) Offer

Desmopressin

Cure!

Complex Enuresis

Refer to Urologist or Paediatrician

Enuresis Alarm with support program

failed

Bedwetting persists

Relapse

Repeat

Spontaneous

Behavioural change using an Enuretic Alarm

A simple history will suffice for the majority of children. Invasive examination or investigations are not required.

Identification of those with small bladders or large nocturnal urine outputs has not given useful management prediction.

Alarm based treatments have proven efficacy and low relapse rates

Practical training points

Child and Parent buy in Goal setting and Progress

Charts Choice of alarms

PNE –a global problem

China

A randomized controlled clinical trial 2007 for treatment of 130 children with primary nocturnal enuresis

Physio-psychological treatment and drug treatment are suitable for Chinese enuretic children, both of them showed good curative effects.

Physio-psychological treatment is more suitable for widespread use to treat PNE in China

Germany

An evaluation of different modes of combined therapy in 43 children with enuresis Sept 2009

Comparison between alarm vs combined alarm and desmopressin therapy

Combined therapy proved effective in children with enuresis after 6 months, with no statistically significant differences between the two different orders of treatment

Turkey

Evaluation of the long-term success of the enuretic alarm device in 62 patients with monosymptomatic primary nocturnal enuresis

65.9% of the patients maintained a full response after enuretic alarm treatment in the 12 to 30 month follow-up.

Another 16% responded to combination therapy.

Slovakia

Combination desmopressin and oxybutinin therapy -60 children -2006

68% response rate to desmopressin Of those who did not respond to desmopressin

alone a further group responded to both desmopressin and oxybutinin

A response was a 50% decrease in wet nights No mention of relapse rates

Belgium

Adherence to Guidelines over a 4 month period -41 children 2009 Jrnl Paed Uro

1. Compliance with a drinking schedule 2. Going to the toilet with adequate body 3. Adherence to medication intake 4. Compliance with a voiding schedule

the authors were pleased to have achieved over 70% parental and child compliance.

Treatment results were not mentioned

Ireland

Landmark study Forsyth and Redmond. 1974 Royal Belfast

Children’s Hospital 1129 Irish bedwetters aged 5 and over Aim was to determine natural cure rates Intensive history, examination and

investigation A variety of treatments Results and conclusions still stand

Results

5 to 10% of enuretics have incidental urological abnormalities but less than 1% have an organic cause for enuresis

Rewards, lifting, exercises, psychotherapy and drugs trialled did not improve outcomes.

Treating UTIs does not cure enuresis In 830 children there was no correlation

between bladder size and enuresis Spontaneous cure rates are 14 to 16% 3 % still bed-wetting at age 20.

Doing nothing is not always an option

As the problem can become too big to ignore