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National University of Rwanda Family and Community Medicine

Enuresis
KABERA Ren,MD Family and Community Medicine National University of Rwanda

Plan
Introduction Examination Causes Diagnosis Management

Introduction
The word enuresis is derived from a Greek word that means "to make water." Enuresis is the involuntary voiding of urine beyond the developmental age of anticipated control, usually 5 years for girls and 6 years for boys. Primary enuresis occurs in children who have never been dry for extended periods. Secondary enuresis is the onset of wetting after a continuous dry period of more than 6 months.

Introduction
Nocturnal (nighttime) enuresis is usually primary Diurnal (daytime) enuresis often indicates voiding dysfunction or significant underlying pathology The International Childrens Continence Society (ICCS) restricts the use of the term enuresis to wetting only at night. Enuresis can be divided into primary enuresis (PE) and secondary enuresis (SE).

Introduction
Psychological and social impact Children with enuresis are commonly punished and are at significant risk of emotional and physical abuse Primary Enuresis : Psychological problems are almost always the result and only rarely the cause Secondary Enuresis : Psychological problems are a possible but uncommon cause

Introduction
Genetics Enuresis is reported in 43% of children of enuretic fathers, 44% of children of enuretic mothers, and 77% of children when both the mother and father had enuresis. Enuresis is usually transmitted in an autosomal dominant fashion. The family history of enuresis does not seem to influence outcomes of any of the various treatments.

Introduction
Sex Enuresis is more common in males. Age The prevalence of enuresis gradually declines during childhood.

Diagnosis
Signs and symptoms Voiding pattern (intermittently continent or wet all the time) Inability to keep from urinating while asleep at least once per month. Diurnal enuresis : frequency, dysuria Withdraw and shy attitude Aggressive behaviors Feelings of embarrassment and anxiety Loss of self-esteem Poor school performance

Diagnosis
Laboratory Not usually needed for children Urinalysis and urine culture: UTI, pyuria, hematuria, proteinuria, glycosuria, and poor concentrating Blood urea nitrogen (BUN) and creatinine Urine cytology if carcinoma/CIS suspected

Causes
Causes of Primary Enuresis
Idiopathic Disorder of sleep arousal Nocturnal polyuria Small nocturnal bladder capacity Overactive bladder and dysfunctional voiding Cystitis Constipation Neurogenic bladder Urethral obstruction Psychological Ectopic ureter Diabetes insipidus

Causes of Secondary Enuresis


Idiopathic Disorder of sleep arousal Nocturnal polyuria Small nocturnal bladder capacity Overactive bladder and dysfunctional voiding Cystitis Constipation Psychological Acquired neurogenic bladder Seizure disorder OSA Diabetes mellitus Acquired diabetes insipidus Acquired urethral obstruction

Management
General measures Behavioral modifications Medical and surgical care Psychotherapy

Management
General measures Bladder training Enuresis alarms Diet: Restricting liquids after 6 PM, Avoid caffeinated beverages (diuretic effect)

Management
Behavioral modifications Self monitoring Motivation and responsibility training. Reward system for dry nights Penalty system for wet beds is not effective

Management
Medical care Anticholinergic: increases functional bladder capacity and aids in timed voiding. Oxybutynin (Ditropan, Ditropan XL, Oxytrol patch) Ditropan Adults and peds > 5 years - 5 mg po tid-qid; Peds 1-5 years - 0.02 mg/kg/dose bid-qid (syrup 5 mg/5 mL) Ditropan XL Adults 5 mg po qd; increase to 30 mg/d po (5 and 10 mg/tab) Oxytrol patch, Apply one patch every 3-4 days (3.9 mg/patch)

Management
Tricyclic antidepressant with anticholinergic effects Imipramine (Tofranil) Adults 25-75 mg po qhs Peds > 6 y: 10-25 mg po hs Increase by 10-25 mg at 1-2 wk intervals, treat for 2-3 mo, then taper, success rate of 25-30% when used > 3 months

Management
Synthetic analogue of vasopressin, a naturally occurring human ADH, decreases nocturnal urine output. Desmopressin (DDAVP) Intranasally 10-40 mcg. Peds > 6 years 20 mcg intranasally Tolterodine (Detrol, Detrol LA) - anticholinergic Detrol 1-2 mg po bid Detrol LA 2-4 mg/d

Management
Surgical care Secondary enuresis due to surgical cause (tethered cord, ectopic ureter, BPH) Psychotherapy

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