Management of Primary nocturnal Enuresis

Jeetendra Bhandari

Patan Academy of Health Sciences-School of Medicine

Introduction

• Defines as reported voiding of urine into clothes or bed at least twice a week for at least 3 consecutive months in child who is >5 years

• Behaviour is not due to direct physiological effect of substance or any general medical condition

• Primary Enuresis:• Occurs in children who have never been consistently dry through night

• Nocturnal Enuresis:• Wetting during sleep

Epidemiology

• At age 5 yrs. 7% of boys and 3% girls have enuresis

• By age 10 yrs-3% of boys and 2% girls

• By age 18 yrs.- 1% men and <1% female

• Primary enuresis in 85% of cases

• Common in lower socioeconomic group

• Estimated spontaneous cure rate of 14-16% annually

Aetiology

• Maturational delay is most likely cause

• Anxiety producing during second to fifth years

• ADH, Circadian rhythms, high at night and at 4 and 8 am; failure lead to enuresis

• Lack of inadequate arousal is also believed to impair vasopressin secretion, leading to polyria

Evaluation

• <5% of cases with nocturnal enuresis have organic basis

• History and examination to differentiate primary and secondary enuresis

• Voiding diary with frequency and volume charting of urine output and fluid intake for at least 2 days

• Urinalysis rules out infection, proteinuria and glucosuria

Treatment

• Decision of starting therapy should be guided by degree of concern and motivation on part of child rather than parent

• Active treatment can be started after 6 yrs

• Caffeinated drinks should be avoided in evening

• Two type of methodology• Non Pharmacology Treatment(first line)

• Motivational Therapy

• Alarm Therapy

• Pharmacotherapy

Motivational Therapy

• Successful in curing enuresis in 25% patients

• Child is reassured and provided emotional support

• Attempt is made to remove any feeling of guilt

• Nature of disorder is explained to child and parent

• Child is encouraged to assume active responsibility, including • keeping dry night diary

• voiding urine before going to bed

• changing wet clothes and bedding

• Dry nights are credited with praise and encouraging words

Alarm therapy

• Best after 7 years of age

• Successful in 2/3rd of children

• Use of device to elicit conditioned response of awakening to sensation of full bladder

• Alarm device consists of sensor attached to child's underwear, or mat under bed sheet and an alarm attached to child’s collar or placed at bed side

• When child starts wetting bed, sensors activate, alarm ring

• Child wakes up and void and reattach the device

Pharmacological Therapy• Started if non pharmacological therapy fails

• Imapramine 1-2.5 mg/kg/day works by altering arousal sleep mechanism• Cardiac arrhythmia – adverse effect

• Anticholinergic drugs reduces uninhibited bladder contraction • 5mg of oxybutalin

• 2mg of tolterodine

• 0.4 mg/kg of properine at bed time

• Desmopressin(DDAVP, 10 microgram orally or intravenous reduce volume of urine

• Relapse rate is high

• Good for social propose due to rapid onset

Reference

• Enuresis, Ghai textbook of Pediatrics, 8th ed. Page: 504-5

• Enuresis, Nelson textbook of Pediatrics, 19th ed. Page: 71-3.

Thank you!!Have a good day..