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Program MCPS/MRCGP/CEFM CME ©

Course Paediatrics

Module GI

Topic Nocturnal Enuresis and Encopresis

Credit Hours 1 CME credit hour

Total Educational hours 2 educational hours

MCPS-MRCGP[INT]-CEFM | Pediatrics | GI | Enuresis and Encopresis

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Prof. Nasir Shah
MCPS, FCPS, MRCGP [INT], FRCGP [INT]

Dean Family Medicine Faculty, College of Physicians and

Surgeons Pakistan

Convener National Family Medicine Committee of

Pakistan

MCPS-MRCGP[INT]-CEFM | Pediatrics | GI | Enuresis and Encopresis

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NOCTURNAL ENURESIS ®
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• Involuntary voiding of urine during sleep
• Affects 8% of children aged 4½y and 1.5% at 9 y
• M>F
• Tends to run in families
• Distressing for child and parents
• Effects on emotional and social well-being

MCPS-MRCGP[INT]-CEFM | Pediatrics | GI | Enuresis and Encopresis

TYPES OF NOCTURNAL ENURESIS ®

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Primary:
• Child has never been dry
• No cause

Secondary:
• Child was previously dry and newly develops enuresis
• Usual secondary causes like UTI, stress

MCPS-MRCGP[INT]-CEFM | Pediatrics | GI | Enuresis and Encopresis

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SECONDARY NOCTURNAL ENURESIS ®
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• Occasionally caused by emotional distress or recent illness

• Consider if the child has been dry for 6 months prior to onset

• Explore possible triggers that may need treating

MCPS-MRCGP[INT]-CEFM | Pediatrics | GI | Enuresis and Encopresis

NOCTURNAL ENURESIS: CAUSE ®

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Not fully understood:
• 1–2% have underlying abnormality: UTI, constipation, or DM

• Exclude with history, examination and urinalysis:

- If recent onset, daytime symptoms, or symptoms/signs of
ill health

MCPS-MRCGP[INT]-CEFM | Pediatrics | GI | Enuresis and Encopresis

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MALTREATMENT: NOCTURNAL ENURESIS ®
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• Maltreatment, particularly if parents blame/punish the child

MCPS-MRCGP[INT]-CEFM | Pediatrics | GI | Enuresis and Encopresis

NOCTURNAL ENURESIS: APPROACH ®

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1. Behavioral modification
2. Positive reinforcement
3. Alarm therapy or Desmopressin acetate
4. Imipramine

MCPS-MRCGP[INT]-CEFM | Pediatrics | GI | Enuresis and Encopresis

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NON-PHARMACOLOGICAL MANAGMENT ®
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• Reassure parents and children that enuresis is not the child’s
fault
• Advise:
1. That punitive measures should not be taken
2. Limit the impact of bedwetting, e.g., bed protection
3. Regular toileting 4–7 times per day and before bed
4. Avoid caffeine

MCPS-MRCGP[INT]-CEFM | Pediatrics | GI | Enuresis and Encopresis

LIFTING AND WAKING ®

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• Waking the child to go to the toilet several hours after going
to bed

• Useful in short term but will not promote long-term dryness

• Grown up children: self-waking with an alarm clock

MCPS-MRCGP[INT]-CEFM | Pediatrics | GI | Enuresis and Encopresis

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REWARD SYSTEMS ®
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Reward systems (positive reinforcement)

• For example, star chart

• Use for agreed behavior (e.g., going to the toilet before bed)
rather than a dry night

MCPS-MRCGP[INT]-CEFM | Pediatrics | GI | Enuresis and Encopresis

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MCPS-MRCGP[INT]-CEFM | Pediatrics | GI | Enuresis and Encopresis

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AT SCHOOL ®
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1. Children should be encouraged to void regularly (2-3/daily)
2. A note for the teacher should be written to ensure that the
child is allowed regular access to the bathroom
3. Children should not be expected to wait for scheduled breaks
to void
4. Holding the urine to the last minute must be discouraged

MCPS-MRCGP[INT]-CEFM | Pediatrics | GI | Enuresis and Encopresis

NO RESPONSE TO BEHAVIOR THERAPY ®

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• If no response to behavior therapy and positive reinforcement
in 3 months, then;

• Alarm therapy

MCPS-MRCGP[INT]-CEFM | Pediatrics | GI | Enuresis and Encopresis

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ALARM VERSUS PHARMCOLOGICAL TX ®
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• Neither therapy is superior to the other in efficacy

• Alarm superior in lower relapse and sustained response

• Choice should be dictated by the clinical setting, the family

preference, and the experience of the practitioner

MCPS-MRCGP[INT]-CEFM | Pediatrics | GI | Enuresis and Encopresis

NOCTURNAL ENURESIS | MANAGEMENT ®

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Enuresis alarms
• An alarm is triggered to wake the child when urine contacts a
sensor
• First-line treatment when advice/rewards fail
• Starts effect in <4wk
• May take months until the child is completely dry at night
• Children may relapse after successful treatment
• Restart as new course if relapses

MCPS-MRCGP[INT]-CEFM | Pediatrics | GI | Enuresis and Encopresis

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MCPS-MRCGP[INT]-CEFM | Pediatrics | GI | Enuresis and Encopresis

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MCPS-MRCGP[INT]-CEFM | Pediatrics | GI | Enuresis and Encopresis

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DURATION OF ALARM THERAPY ®
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• Parent should participate every night for at least 3 consecutive
months
• Monthly follow-up care
• Continue therapy 1 month after sustained dryness

• If no response in 3 months of consecutive use, discontinue

• Try again once the child is older and more motivated

MCPS-MRCGP[INT]-CEFM | Pediatrics | GI | Enuresis and Encopresis

DO CHILDREN WAKE UP WITH ALARM? ®

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• Most do not awaken to the alarm
• They often stop emptying the bladder
• When the alarm sounds, a parent must help the child wake to
full consciousness and attend to the bathroom to finish
voiding
• After the sheets and underwear or pajamas are changed, the
child should be returned to bed and the alarm reset.

MCPS-MRCGP[INT]-CEFM | Pediatrics | GI | Enuresis and Encopresis

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DESMOPRESSIN ®
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• Usually, specialist initiated
• Synthetic version of ADH, taken at night
• Side effects: Headache, nausea, nasal congestion, nosebleed,
sore throat, cough, flushing, and mild abdominal cramps
• Risk of water overload—advise only one mug of fluid from 1
hour before desmopressin dose to 8 hour afterwards
• Used when alarm is unsuccessful or unsuitable or in
combination with an alarm

MCPS-MRCGP[INT]-CEFM | Pediatrics | GI | Enuresis and Encopresis

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MCPS-MRCGP[INT]-CEFM | Pediatrics | GI | Enuresis and Encopresis

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DESMOPRESSIN ®
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• Taken 1 hour before bedtime
• Recommended starting dose for the tablet is 0.2 mg
• Titrated as to a maximum dose of 0.6 mg

MCPS-MRCGP[INT]-CEFM | Pediatrics | GI | Enuresis and Encopresis

COMBINATION OF ALARM THERAPY WITH

DESMOPRESSIN THERAPY ®
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• Combination of alarm therapy with desmopressin therapy has
been reported better than either therapy alone.

MCPS-MRCGP[INT]-CEFM | Pediatrics | GI | Enuresis and Encopresis

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NASAL MINIRIN?? ®
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• Because of the risk for severe
hyponatremia, the intranasal
formulation is no longer indicated
for primary enuresis.

MCPS-MRCGP[INT]-CEFM | Pediatrics | GI | Enuresis and Encopresis

IMIPRAMINE ®
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• Children treated with imipramine had one fewer wet night
per week.
• The relapse rate is high
• Taken 1-2 hours before bedtime
• Dose: 25 mg for patients aged 6-8 years and 50-75 mg for
older children and adolescents.

MCPS-MRCGP[INT]-CEFM | Pediatrics | GI | Enuresis and Encopresis

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MCPS-MRCGP[INT]-CEFM | Pediatrics | GI | Enuresis and Encopresis

IMIPRAMINE: ADVERSE EFFECTS ®

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1. Constipation
2. Difficulty initiating voiding
3. Drowsiness
4. Reduced appetite
5. Imipramine overdose can be fatal

• Because of the unfavorable adverse effect profile and the

significant risk of death with overdose, the World Health
Organization (WHO) does not recommend imipramine for the
treatment of enuresis

MCPS-MRCGP[INT]-CEFM | Pediatrics | GI | Enuresis and Encopresis

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BLADDER TRAINING EXERCISES ®
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• Not recommended (have not been shown to be effective)

MCPS-MRCGP[INT]-CEFM | Pediatrics | GI | Enuresis and Encopresis

ENCOPRESIS ®
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• Encopresis is the involuntary discharge of feces
• Also called fecal incontinence
• In most cases, consequence of chronic constipation and
resulting overflow incontinence
• No good data suggest that encopresis is primarily a behavioral
or psychological disorder
• The behavioral difficulties associated with encopresis are
most likely the result of the condition rather than its cause.

MCPS-MRCGP[INT]-CEFM | Pediatrics | GI | Enuresis and Encopresis

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ENCOPRESIS ®
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• Most children are continent of feces by 4 years
• Fecal soiling after this age usually occurs during the day
If:
• Soft stool oozes out, causing constant soiling, consider
overflow incontinence secondary to constipation
• A firm stool is passed occasionally in the toilet but usually in
the pants, developmental delay (either mental or social) is
likely

MCPS-MRCGP[INT]-CEFM | Pediatrics | GI | Enuresis and Encopresis

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MCPS-MRCGP[INT]-CEFM | Pediatrics | GI | Enuresis and Encopresis

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DIAGNOSIS OF ENCOPRESIS ®
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• Established with the history and physical examination
• Includes rectal examination

• Laboratory studies are rarely needed

MCPS-MRCGP[INT]-CEFM | Pediatrics | GI | Enuresis and Encopresis

PSYCHOLOGICAL ASPECTS ®
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• Children with encopresis are significantly more likely to have
attention-deficit disorder/hyperactivity (ADHD) than the
general population

• Low self-esteem or parent-child conflict as a result of the

disorder is common.
• Embarrassed youngsters also frequently deny having the
problem.

MCPS-MRCGP[INT]-CEFM | Pediatrics | GI | Enuresis and Encopresis

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TREATMENT OF ENCOPRESIS ®
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• Treatment remains largely experiential and consists of;

1. Demystification and education

2. Colonic dis-impaction
3. Routine laxative therapy
4. Toilet training

MCPS-MRCGP[INT]-CEFM | Pediatrics | GI | Enuresis and Encopresis

TREATMENT OF ENCOPRESIS ®
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• Dis-impaction by either oral cathartics or a series of enemas

• After the colon is evacuated, long-term laxative therapy is

generally started

• Virtually any laxative can be used as-long-as it is used in

sufficient quantity to produce 1-2 soft stools daily

MCPS-MRCGP[INT]-CEFM | Pediatrics | GI | Enuresis and Encopresis

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POLYETHYLENE GLYCOL 3350 ®
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MCPS-MRCGP[INT]-CEFM | Pediatrics | GI | Enuresis and Encopresis

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MCPS-MRCGP[INT]-CEFM | Pediatrics | GI | Enuresis and Encopresis

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MCPS-MRCGP[INT]-CEFM | Pediatrics | GI | Enuresis and Encopresis

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MCPS-MRCGP[INT]-CEFM | Pediatrics | GI | Enuresis and Encopresis

REFERENCES ®
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• https://www.nice.org.uk/guidance
• https://www.patient.co.uk
• https://www.aafp.org
• https://www.mayoclinic.org
• https://www.medscape.com
• https://www.who.int
• Oxford Handbook of General Medicine, 5th edition

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