BEDWETTING IN

CHILDREN

DR ANKIT MANGLA
HEAD OF DEPARTMENT PEDIATRIC NEPHROLOGY & CONSULTANT
PEDIATRIC INTENSIVIST
HOPE HOSPITAL
JAIPUR
DEVELOPMENT OF URINARY CONTROL

As voluntary bladder control matures bladder capacity also

Increases and voiding frequency decreases

ORDER OF CONTROL
• Control of bowel at night
• Control of bowel during the day
• Control of bladder during the day (by 2 ½ years)
• Control of bladder at night (by 3-4 years)
 INCONTINENCE
Uncontrolled leakage of urine at an inappropriate time and place after 5
years of age

CONTINUOUS INCONTINENCE INTERMITTENT INCONTINENCE

Always ORGANIC pathology

• Neurogenic Bladder
• Vesico-vaginal fistula
• Ectopic ureters
• Bladder exostrophy
DAY TIME Nocturnal Incontinence or
INCONTINENCE ENURESIS

Neveus T et al. The standardization of terminology of lower urinary tract function in children and adolescents: report from the Standardisation
Committee of the International Children's Continence Society. J Urol. 2006 ;176(1):314-24.
 SUBDIVISIONS OF ENURESIS

Primary Nocturnal enuresis is enuresis in a Secondary enuresis is enuresis in a child

child who has previously been dry for less who has previously been dry for at least 6
than 6 months months

Monosymptomatic enuresis is enuresis in a Non-monosymptomatic enuresis is enuresis in

child without any (other) a child with (other) lower urinary tract
lower urinary tract symptoms symptoms, such as daytime incontinence,
(80%) urgency, frequency, holding maneuvers
(20%)

Neveus T et al. The standardization of terminology of lower urinary tract function in children and adolescents: report from the Standardisation
Committee of the International Children's Continence Society. J Urol. 2006 ;176(1):314-24.
 MONOSYMPTOMATIC NOCTURNAL ENURESIS

 Monosymptomatic nocturnal enuresis (MNE) is defined as bedwetting in a child in the absence

of daytime bladder symptoms:

 Non-monosymptomatic nocturnal enuresis (NMNE) is present when one or more of the above
daytime symptoms occurs with nocturnal symptoms
• Urgency
• Incontinence
• Increased/decreased voiding frequency
• Voiding postponement
• Holding maneuvres
• Interrupted flow
OTHER SYMPTOMS : Holding maneuvers

• Standing on tip-toes
• Forcefully crossing legs and bending
forward at the waist (Vincent’s curtsy
sign)
• Squatting with hand/heel pressed into the
perineum
• Applying pressure to urethra with hands
ENURESIS

Prevalence
• 15% of 5 year olds
• 7% of 8 year olds
• 5% of 10 year olds
• 2% of 15 year olds
Fewer than 1/3rd of the parents of a bedwetting child consults a doctor.
SEVERITY OF BEDWETTING VERSUS AGE
‘WAIT AND WATCH’ MAY LEAD TO
UNNECESSARY DISTRESS

 If untreated, bedwetting can persist into adulthood1

 The negative impact of bedwetting on child and family

is considerable2

 Effective treatment can alleviate this burden,

allowing the child to enjoy normal social and emotional development 2

 Early treatment (from 5–6 years) can prevent prolonged distress during formative years and
should be initiated whenever the child is ready/wishes to be dry, especially if enuresis is severe
(spontaneous resolution unlikely)2

 Increasing age is correlated with reduced self-esteem and negatively correlated with QoL score

1. Yeung et al. BJU Int 2006;97:1069–1073; 2. Gozmen et al. Pediatr Nephrol 2008;23:1293–1296;
3. Ertan et al. Child Care Health Dev 2009;35:469–474
CHILDREN WHO BEDWET HAVE POOR SLEEP AROUSAL

 Children affected by bedwetting may have lighter and

poorer quality sleep than other children

 These children have lighter sleep with frequent cortical

arousals, but inability to awaken completely

 This may have implications for daytime functioning

 It is important to treat bedwetting and restore sleep

patterns to normal

Nevéus T. Pediatr Nephrol 2008;23:1201–1202

Primary Nocturnal Enuresis - Impact
Psychological well-being: Parental Concern:
• Emotional impact on child.
• Substantial feeling of
shame, anger and • Effect on the child’s social
inferiority relationships.
• Is the child normal?
• Dangerous impairment of
self-esteem. • Removing the smell from the bedroom

• Inability to socialize - • Keeping it a secret

Outdoor activities • The extra washing

• Fear of public discovery- • Is the parent to blame?

haunts sufferers
 IS GENETICS TO BE BLAMED IN CHILDREN WITH PRIMARY
MONOSYMPTOMATIC NOCTURNAL ENURESIS??

• A family history of bedwetting strongly predicts

bedwetting in children.
– 73% of children affected by bedwetting had first degree
relatives with a history of bedwetting1
– The age of attaining dryness was delayed by 1.5 years if
both parents had a history of bedwetting 2
– Risk of bedwetting was 5–7 times higher if one parent
had a history of bedwetting and 11.3 times higher if both
had3 Chromosome 8,12,13
ENURI 1 gene --AD
 CAUSES OF NOCTURNAL ENURESIS

• Maturational delay
• Food containing Diuretics- Cola, chocolate,
• Genetics
tea, coffee
• Small bladder capacity
• Urinary Tract Infection - May lead to
• Nocturnal polyuria
enuresis
• Role of ADH
• Sleep disordered breathing
• Constipation
 Habitual snoring
• ADHD
 Obstructive sleep apnea hypopnea
syndrome

Reddy NM et al. Nocturnal Enuresis in India: Are We Diagnosing and Managing Correctly? Indian Journal of Nephrology. 2017;
PRIMARY NOCTURNAL ENURESIS -
CAUSES
Reduced Vasopressin Production at night

• Enuretics do not show normal

nocturnal rise in plasma
vasopressin
• Urine production continues at the
same rate at night.
• Bladder reaches its functional
capacity long before morning
 KEY PATHOGENIC
MECHANISMS UNDERLYING MNE

Nocturnal Polyuria
• Nocturnal urine production >130% of expected bladder capacity
(EBC) for age (normally decreases to 50% of daytime)
+/-
Reduced or abnormal bladder reservoir function at night
Inability to wake in response to bladder signalling

Kamperis P et al. Optimizing response to desmopressin in patients with monosymptomatic nocturnal enuresis.
Pediatr Nephrol. 2016; 32(2):217-226
 Bladder Function Problems
• Functional bladder capacity (FBC) is vital for NE
• Bladder capacity : {Age (in years) + 2} x 30 ml
• In enuretics, night time BC is lower, but in non enuretics: 1.6 – 2 times larger than day time BC
• There can be detrusor over activity in absence of LUTS
• Constipation can cause detrusor over activity
• UTI can cause detrusor over activity
Evaluation & therapeutic
options for Bed wetting
 Approach to NE

• Detailed history through questionnaire

• Interpretation of the answers
• Examination of the child
• Relevant Investigations for that child
• Define broadly the type of NE
• Tailored therapy for that child & family
 History & Charting in Children
• Detailed questionnaire to rule out daytime voiding symptoms
• Chart the frequency & volume of Fluid intake & voided urine. Voiding
diary – non invasive representative record of child fluid intake, urine
output, frequency of micturition, pattern of voiding
• Charting must start and continue thru therapy
• Largest single micturition volume is FBC(MVV)
• Record wetness episodes during day & estimate overnight u/o
• Childs involvement in charting a must
• Ideal is a 2 day 3 night FVC record over a weekend
BLADDER DIARY FORMAT
 Investigations USG
 Bladder measurements: Full bladder
Max. length : LS
Max. transverse: TS
Max. Anteropost. : AP
Bladder Volume Index: BVI = LS X TS X AP
Empty bladder BVI

 Percentage: BVImax – BVI empty

BVI max
>90%: child judged to have emptied normally
<90%: incomplete emptying
Normal empty bladder thickness: up to 5 mm
Normal distended bladder thickness: up to 3 mm
 History & Charting in Children

Reddy NM et al. Nocturnal Enuresis in India: Are We Diagnosing and Managing Correctly? Indian Journal of
Nephrology. 2017; DOI: 10.4103/ijn.IJN_288_16
 Symptoms in NE
Pull up/plastic sheets
• Differentiate Primary & secondary NE
Clothes washed/diaper
• How family handles wet nights
Child punished
Teasing by sibs

• Dry spell – congratulate the child, signifies no structural GU anomaly

• Sleep hours, morning tiredness(teacher), s/o obstructive sleep apnea
• Tonsils & Adenoids a cause of OSA
• Mouth breathing snoring, restless sleep – OSA
• NE during afternoon nap too – s/o detrusor overactivity during sleep
 Rule out Urological Cause
• Abnormal Storage Symptoms
Increased frequency, urgency, urge incontinence
Continuous dribbling between voids
Stress incontinence
• Abnormal Voiding Symptoms
Voiding with poor stream
Bladder and/or
Straining to pass urine
Interrupted flow of urine Urethral problems
 CONSERVATIVE MANAGEMENT

• Timed voiding – voiding every 3-4 hours (discourage holding)

• Voiding immediately upon rising in morning and before bed
• Adequate hydration
• Distribute fluid intake (40% morning, 40% afternoon, 20% evening)
 CONSERVATIVE MANAGEMENT

• Treat constipation
• Proper positioning on the toilet seat
• Encourage child to take time on toilet to empty completely
• Encourage physical activity – discourage TV / Computer for long
duration
• Star charts : motivational therapy
ALARM THEARPY
 ALARM THERAPY

• 60-70% Effective but labour extensive

• Moisture sensor and alarm which rings when child wets
• Conditioning - teaches child to wake to a full bladder before
wetting
• May be used in combination with DDAPV and/or oxybutynin
• 30-40% discontinue therapy
NON PHARMACOLOGICAL MANAGEMENT OF
ENURESIS
Dry Bed training
 Waking the child on a schedule of decreasing intervals over several nights
 The child is made to change clothes and bedding (if wet), and walk to the toilet if voiding is
required

Motivational Therapy
Combination of providing reassurance, emotional support, eliminating guilt, and rewarding
the child for dry nights
 Cleaning after bedwetting should not be performed as a punishment
 Avoidance of dairy products, fruits juices, and fluids 2 hours before bedtime, voiding just
before bed
Reddy NM et al. Nocturnal Enuresis in India: Are We Diagnosing and Managing Correctly? Indian Journal of Nephrology. 2017
Jain S, Bhatt GC. Advances in the management of primary monosymptomatic nocturnal enuresis in children. Paediatrics and International Child
Health, 36:1, 7-14
 PHARMACOLOGICAL THERAPY OF
ENURESIS: ANTICHOLINERGICS
• Oxybutinin and Tolterodine

• Primarily to treat children with daytime urgency or frequency as well as night-time

enuresis
• Small capacity bladder when Neurogenic component is ruled out
• Children with PMNE only where primary treatment has failed
• Act mainly by suppressing detrusor over activity
Side effects include flushing, blurred vision, constipation, tremor, decreased
salivation and decreased ability to sweat
WHO & NICE has now endorsed that Imipramine cannot be recommended for
treatment of PNE

Jain S, Bhatt GC. Advances in the management of primary monosymptomatic nocturnal enuresis in children. Paediatrics and
International Child Health, 36:1, 7-14
PHARMACOLOGICAL THERAPY OF
ENURESIS: DESMOPRESSIN

• Pharmacologic therapies for nocturnal enuresis decrease the frequency of

enuresis and temporarily resolve symptoms until spontaneous resolution
occurs

• The response rate to desmopressin therapy is 60%–70%, but relapse rates are
high
The NE indication has been withdrawn from the intranasal spray in most
countries due to unpredictability of dosing and increased risk of hyponatremia

The combination of an enuresis alarm with desmopressin may be superior to the

use of an desmopressin alone

Reddy NM et al. Nocturnal Enuresis in India: Are We Diagnosing and Managing Correctly? Indian Journal of
Nephrology. 2017; DOI: 10.4103/ijn.IJN_288_16
 PATHOPHYSIOLOGY OF AVP IN ENURESIS

Children with Nocturnal Polyuria are most likely to benefit from

desmopressin since lower nocturnal vasopressin levels have been
demonstrated in a large percentage of patients , making substitution with
desmopressin, a rational first-line treatment for children with MNE and NP
 Overview of Different Treatment Modalities for
Enuresis

Jain S, Bhatt GC. Advances in the management of primary monosymptomatic nocturnal enuresis in children. Paediatrics and International Child
Health, 36:1, 7-14
 MELT TABS
Features Benefit
1 Dissolves instantly when placed under tongue Avoid water intake at bedtime
2 Dissolves instantly No taste or swallowing issues
3 Bioavailability 60% greater than tablet Equivalent to tablets at 40%
lower dose
4 Can be taken with food. It has a longer and more predictable Can be taken immediately post
action meals
5 Contains no lactose/starch Suitable for lactose intolerant
MEDICATIONS FOR COMORBIDITIES

• UTI’s – Antibiotic prophylaxis; rule out VUR

• Constipation - Laxatives
 MUST RULE OUT

• Constipation/Encoperesis • Spinal cord Examination

• Recurrent UTI’s : Reflux disorders • Spinal dysraphism / lower limb
weakness / patulous anus
• Abnormal urine analysis
• Failure to thrive : Renal tubular acidosis
• Sleep disorders : OSA
• Bony deformities : CKD / RTA
• Underlying DM / DI
• Deranged RFT
• Neuropsychiatric conditions
• USG KUB
• ADHD
• Learning disabilities • Hypertention
GREEN signal only if

• Normal physical examination

• Normotensive
• Normal Urinanalysis
• Normal USG KUB
• Normal Renal functions
THANK YOU