Enuresis practical

Enuresis practical

guidlines

guidlines

Heba mohammed Heba mohammed bahbahbahbah

Micturation reflex

Micturation reflexMicturation reflex

The micturition reflex is overridden by voluntary

control. Descending pathways from the cerebral

cortex can inhibit parasympathetic neurons and

stimulate motor neurons that excite the external

urethral sphincter and thus inhibit the micturition reflex.

AgendaAgenda

•Definition

•Classification

•Prevalence

•Pathogenesis

•Assessment

•Treatment

•Conclusions

DefinitionsDefinitions

IcontinenceIcontinence:- :- Uncontrollable leakage of urineUncontrollable leakage of urine

Continuous intermittentContinuous intermittent

•Urine leakage in Urine leakage in discrete amounts discrete amounts • Applicable to Applicable to children more than children more than 5 years 5 years

Constant urine leakageConstant urine leakageApplicable to all agesApplicable to all agesAssociated with Associated with congenital congenital malformationsmalformations

Night -timeEnuresis

Day- time

Enuresis: Definition Enuresis: Definition

An involuntary wetting during sleep, at least An involuntary wetting during sleep, at least

twice a week, in children older than 5 years twice a week, in children older than 5 years

of age with no congenital or acquired of age with no congenital or acquired

defects of the central defects of the central nervousnervous system system

Enuresis: ClassificationEnuresis: Classification

Primary: Primary: The child has never achieved sustained The child has never achieved sustained continence at night for a period of at least 6 monthscontinence at night for a period of at least 6 months

Mono-symptomatic Without daytime symptoms

Non-mono-symptomatic With daytime symptoms

SecondarySecondary: Bedwetting occurs after the child has been dry at night for more than 6 months

PrevalencePrevalence

PathogenesisPathogenesis

High arousal threshold

Nocturnal polyuria due to nocturnal lack of ADH

Bladder dysfunction: A small bladder capacity or nocturnal detrusor overactivity

geneticsgenetics

Evaluation at the first visitEvaluation at the first visit

Primary with day-time symptoms

Primary without day-time symptoms

Secondary bed wetting

Duration

Daytim

e sym

ptoms

Day time symptoms

Holding manouver hesitancy

urgency frquancy

Urological proplems

Evaluation at the first visitEvaluation at the first visit

Primary with day-time symptoms

Primary without day-time symptoms

Secondary bed wetting

Assessment of Primary Assessment of Primary EnuresisEnuresis

The pattern of bedwettingThe pattern of bedwetting

Assessment of fluid intakeAssessment of fluid intake

Bladder diaryBladder diary

Bowel habitsBowel habits

Psychological assessmentPsychological assessment

comorbidities

The pattern of bedwettingThe pattern of bedwetting

How many nights a week does bedwetting occur?

How many times a night does bedwetting occur?

Does there seem to be a large amount of urine?

At what times of night does the bedwetting occur?

Does the child wake up after bedwetting

Functional bladder disorderWets the bed most nights Ever wets more than once a nightWets small volumes

Nocturnal polyuria Wets one or two nights Wet Large volumes

Assessment of fluid intakeAssessment of fluid intake

Age (years) Volume (mL/day)

Boys Girls

4-8 1000-1400 1000-1400

9-13 1400-2300 1200-2100

14-18 1400-2500 2100-3200

Bladder diaryBladder diary

Bladder capacity= 30+(30 × age )mL Low voided volumes [maximum voided volume <70% of the expected bladder capacity] Nocturnal urine production > 130% of the expected bladder capacity

Bowel habits Bowel habits

• Bowel movement frequency, stool consistencyBowel movement frequency, stool consistency

• Faecal incontinenceFaecal incontinence

Psychological assessmentPsychological assessment

Child

Behavioral problemsHow does the child view his/her enuresis

Parents

Difficulty to cope with the burden of bedwetting Anger, negativity, or blame towards the child

Psychological assessmentPsychological assessment

Child

Behavioral problemsHow does the child view his/her enuresis

Parents

Difficulty to cope with the burden of bedwetting Anger, negativity, or blame towards the child

Assessment of Primary Assessment of Primary EnuresisEnuresis

• Good historyGood history

• Physical examination Physical examination (bad general ,external (bad general ,external genitalial neurological(occult spina bifidagenitalial neurological(occult spina bifida))

Assessment of Primary Assessment of Primary EnuresisEnuresis

• Urine analysisUrine analysis

• Urine osmolalityUrine osmolality

• Lumbo-sacral x-rayLumbo-sacral x-ray

• Abdominal ultrasonographyAbdominal ultrasonography

• VCUGVCUG

• Urodynamic studyUrodynamic study

• Urine analysis Urine analysis (when):? (when):? if secondary , bad health, UTI?? if secondary , bad health, UTI??

• No radiologyNo radiology

• No urodynamic study No urodynamic study

Should a 5-year-old child be actively Should a 5-year-old child be actively treated for enuresis?treated for enuresis?

If primary nocturnal enuresis is not distressing to the child,

treatment is unnecessary, although parents should be reassured

about their child’s physical and emotional health and counseled

about eliminating guilt, shame, and punishment. (Grade B)

Response:14 consecutive dry nights or a 90% ↓in no of wet nights/ week

Partial response:Symptoms improved but 14 consecutive dry nights or a 90%↓in no of wet nights/ week has not been achieved

Children under 5 years

Children more than 5 years

Treatment of PrimaryEnuresisTreatment of PrimaryEnuresis

Treatment of Primary Treatment of Primary EnuresisEnuresis

Advice

First line

Second line

Third

General

Diet Fluid intake

Toilet pattern

Lifting and walking

Reward

advice

General

Diet Fluid intake

Toilet pattern

Lifting and walking

Reward

advice

•Not the child's fault•No punishment •Reassurance (dry after a given time) •Children change their bedding

Healthy diet with no restriction

Avoid caffeine-based drinks before going to bed

urinate at regular interval during the day and befor sleep

•Safe the bed only

positive rewards for agreed behaviour rather than dry nights( fluid-toilet –management)

First line treatment Alarm Desmopressin

an alarm is considered inappropriate, particularly if: ◆ bedwetting is very infrequent (that is, less than 1–2 wet beds per

week) ◆ the parents or carers are having emotional difficulty coping with the

burden of bedwetting

rapid-onset and/or short-term improvement in bedwetting is the priority of treatment or− an alarm is inappropriate or undesirable (see recommendation

Alarm is the first line for families who are well motivated and well informed

Do not exclude alarm treatment as an option for children and young people with:

● daytime symptoms as well as bedwetting

● secondary onset bedwetting

Start desmopressintreatment

Is complete drynessachieved after 1–2 weeks?

Assess response at4 weeks

Continue treatment for3 months Stop desmopressin for 1 week to check whether dryness has been achieved(grdual)

Consider increasing dose(240 –400)

assessment of factors associated with poor response (adhernce,30%sleep apnea ,constipation , underlying disease (urological proplems)or social and emotional factors

yes No

Response

Partial

Increase the dose Give the drug 1–2 hours before bedtime restrict fluid Continue treatment for another 6 months

No

Management of Management of RecurrencesRecurrences

• Another course of desmopressin (repeated courses may be Another course of desmopressin (repeated courses may be used)used)

• Regular withdrawal of desmopressin (for 1 week every Regular withdrawal of desmopressin (for 1 week every 3 months)3 months)

• Gradual withdrawal of desmopressin rather than stopping it Gradual withdrawal of desmopressin rather than stopping it suddenly (increase of 'no-medication days' over an 8-week suddenly (increase of 'no-medication days' over an 8-week period)period)

• Using an enuresis alarmUsing an enuresis alarm

Treatments Not Treatments Not Recommended Recommended

• strategies that interrupt normal passing of urine or encourage infrequent urination during the day

• dry-bed training with or without an alarm.

Second-Line TherapySecond-Line Therapy

Desmopressin or alarm + Anticholinergic drugs

Anticholinergic Drugs bedwetting that has partially responded to desmopressin alone bedwetting that has not responded to desmopressin alone

bedwetting that has not responded to an alarm combined with desmopressin

Do not use an anticholinergic:

● alone for children and young people with bedwetting without daytime symptoms● combined with imipramine

Oxybutynin: 5mg

assess 1–2 month?

Continue treatment for3 months with Gradual tapering

Response

Partial

Continue treatment for another 6 months

Have the greatest chance of success in the child with signs of detrusor overactivity, i.e. low daytime voided volumes. Repeated courses can be used Doses can be doubled in over 12 years childrenThe main side effects are dry mouth, headaches, constipation, retention of urine and very occasionally unusual behaviour or night terrors

Third-line Therapy

Desmopressin or alarm + Tricyclic anti-depressants

Tricyclic Tricyclic Antidepressants Antidepressants

• Significant anticholinergic effects and additional central effects

ImipramineImipramineHow Is It Given?How Is It Given?

• Start as a low dose (25 mg for children > 6 years, 50 to 75 mg for children > 11 years) and increase fortnightly to the maximum dose allowed for the age of the child (50 mg in children 7 to 12 years of age and up to 75 mg in older children)

• The single daily dose should be given around 3 hours before sleep

• A course of treatment should last for 3 months maximum before reducing the dose slowly and stopping it for a week or so to assess progress

Take Home MessegeTake Home Messege

• The initial evaluation of the enuretic child should focus on good history and with no radiology or invasive procedures

• The first step in assessment is to exclude underlying disorders, such as diabetes, kidney disease or urogenital malformations

• The main goals of treatment are to increase the number of dry night and to alleviate the emotional impact of enuresis

Take Home MessegeTake Home Messege

• Positive reward systems have a better impact on the enuretic child (Grade B)

• Bladder training, retention control training, and dry bed training are no longer recommended

Take Home MessegeTake Home Messege• Therapy is a stepwise process. Partial response is

better than no response

• The first-line treatment is the enuresis alarm or desmopressin

• In therapy resistant cases occult constipation needs to be ruled out

• The second line of therapy is anticholinergic treatment combined with desmopressin

Take Home MessegeTake Home Messege

• In situations when all other treatments have failed, imipramine treatment is warranted, provided the cardiac risks are taken into account