Childhood EnuresisMaterial by : Dr Mohamed Yassin

Ass. Prof. Of urology Ain Shams university

Presentation by : Ahmed Tawfeek

Bedwetting Is Common

• 15 – 20% of over five year olds (1 in 6)• 7% of seven year olds (1 in 14)• 5% of ten year olds (1 in 20)• 2-3% of twelve-fourteen year olds (1 in 30)• 1-2% of over fifteen year olds

• Boys outnumber girls by nearly 2 to 1

What is Primary Nocturnal Enuresis?

• Child has never been reliably dry at night but is dry by day

• Absence of other urinary symptoms or signs of disease.

Primary Nocturnal Enuresis - Causes• Small functional bladder capacity• Decreased awareness of full bladder whilst asleep• Nocturnal polyuria• Genetic factors – (family history)• Stressful early life events

Some Other Causes of Enuresis• Secondary enuresis can be a manifestation of a

psychological cause• Detrusor instability / pelvic floor weakness• Urinary Tract Infection• Constipation • Diabetes (Mellitus & Insipidis)• Chronic Renal Failure• Congenital Abnormality e.g. ectopic ureter, posterior

urethral valves• Neurological causes

History

• Is it primary or secondary enuresis?• When? Night only? • Circumstances of enuresis i.e. one large patch of urine

on the sheets versus many small patches. • How many nights per week?

History

• Family history• Other symptoms e.g. constipation, polydipsia• Any emotional upsets / recent life events• Methods tried so far

Examination & Investigations

Examination: weight, blood pressure, abdomen, genitalia,neurological function

Investigations:Urine dipstix(If suspicious about physical cause: Ultrasound, bloods etc)

Management • Decide on diagnosis and treat cause accordingly• E.g. referral for any suspected underlying physical /

psychological condition or structural abnormality• Treat infection / constipation

Primary Nocturnal Enuresis- Management• Children will almost always grow out of bedwetting but

this can take years.• Simple strategies• Enuresis alarms• Dry bed training• Drug therapy

Management – Simple Methods• Explanation & reassurance.• Use of star charts and other methods of positive

reinforcement. Ignore wet nights.• Toileting immediately before bedtime.• Avoiding too many drinks close to bedtime (but do not

encourage dehydration).

Unhelpful Strategies

• Lifting – taking the child to the toilet and allowing the child to empty his bladder whilst still asleep. This may stop the bed from becoming soiled but does not teach the child to wake when the bladder becomes full.

Management - Alarms

• Sensor worn in the underpants or as a pad on the bed. When the child passes urine, an electrical circuit is completed and an alarm rings, waking the child.

• This method works by conditioning. i.e. if the child becomes used to waking at night to pass urine, they will eventually start to wake before they wet the bed.

Management - Alarms• Need to have supportive parents• Can be disruptive i.e. by waking up the household.• Some children can sleep through the alarm. In this case it

is important that the parents fully wake the child in order for the alarm be effective

Management – Dry Bed Training• Combination approach of enuresis alarms, waking

routines, positive encouragement, rewards for dryness, cleanliness training & bladder training

Management – Drug Therapy

• Desmopressin• Imipramine (& other tricyclics)• Oxybutanin

Management - Desmopressin

• Available as a nasal spray (Desmospray) or tablet (Desmotabs 200mcg – 400mcg at night)

• Mimics the action of anti-diuretic hormone and therefore makes urine more hypertonic & less vol.

• Useful for short-term relief from enuresis i.e. allowing the child to sleep away from home.

• Maximum length of treatment should be 3/12 and reassess

• Treats the symptom not the cause.• Should be used if diabetes insipidis is the cause.

Management - Imipramine• Tricyclic antidepressant• Mechanism of action in enuresis is not fully understood• Anticholinergic and antidiuretic properties• Treats symptom not cause therefore relapse on

discontinuation is common (BNF)• Maximum duration of treatment 3/12 before

reassessment

Management - Oxybutinin

• May have a role if detrusor overactivity is thought to be the cause

• Otherwise ineffective in primary nocturnal enuresis

Evidence Based Medicine• Children given alarms are 13 times more likely to

become dry than children without alarms. • 60-70% of children will succeed with an alarm• Dry bed training is effective but no more so than using an

alarm alone and is ineffective without an alarm.

Evidence Based Medicine

• Children given Desmopressin have, on average, 2.2 fewer wet nights per week than placebo and are 4.5 times more likely to become dry at night.

• However this improvement vanishes on discontinuing treatment compared to placebo.

Evidence Based Medicine

• Children receiving Imipramine have 1.3 fewer wet nights and are 4.2 times more likely to be dry than children given placebo.

• No reliable data on whether they remain dry after treatment

Evidence Based MedicineDesmopressin Vs Imipramine• Both drugs have comparable effects during treatment

and 6 weeks after treatment• However, Desmopressin has less potentially severe

adverse effects than Imipramine

Evidence Based MedicineConclusion• Enuresis alarms are the most effective treatment for

primary nocturnal enuresis with lasting effects.• Drug treatment can be useful for short term relief of

symptoms but consider potential adverse effects