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Dr Dina Kamal Specialist Pediatrician in PFBS, Tabuk

1/22/2012

Enuresis
y Involuntary discharge of urine y Nocturnal enuresis - nighttime wetting y Diurnal enuresis - daytime wetting y 15% normal children have nocturnal enuresis at 5

years of age y 99% are dry by age 15 y Nocturnal enuresis is 50% more common in boys y More girls dry day and night by age 2

1/22/2012

Enuresis
y 80% enuretics are wet only at night y most are primary enuretics - never been dry y 25% are secondary enuretics y initially dry at night by age 12 y relapse for 2.5 years y may be associated with emotional stress y Only 10% who develop daytime dryness relapse wet for 1.2 years

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number of voidings decrease 1/22/2012 .Development of Urinary Control y Infant y spontaneous micturation as a spinal cord reflex y distention simulates a detrusor contraction y voluntary sphincter is integrated into the reflex y y y constricts to prevent incontinence relaxation during micturation low pressure voinding y As bladder capacity increases and fluid intake decreases.

Development of Urinary Control y Development of adult type control y Capacity of the bladder must increase y Voluntary control over the striated sphincter y usually complete by 3 years y Direct volitional control over the spinal micturition reflex to initiate or inhibit bladder contraction y Complete by age 4 1/22/2012 .

Rule of 15 s 1/22/2012 .

Development of Urinary Control y Order of Control y Control of bowel at night y Control of bowel during the day y Control of bladder during the day y Control of bladder at night 1/22/2012 .

60% y Bladder instability seen in many with day and night enuresis y y in children with daytime symptoms of frequency/urgency anticholinergics are helpful y Those with nocturnal enuresis do not have a higher incidence of daytime instability y y nighttime contraction is just as likely to wake the child as to cause wetting anticholinergics not effective 1/22/2012 .Etiology y Urodynamic Factors y Reduced bladder capacity by 50% y anticholinergics increase capacity by 25 .

Etiology y Sleep Factors y Theory that sleep disturbance causing the child to sleep too deeply or fail to awaken y Enuretics do not sleep more soundly than controls y Enuresis occurs in deep sleep and in REM sleep y Enuresis may be a developmental delay y perception and inhibition of bladder filling and contraction by the CNS 1/22/2012 .

Types of Enuresis y Type I y Stable bladder with EEG response during enuresis Stable bladder with no EEG response during enuresis 80% change to I Unstable bladder with no EEG response during enuresis 20% change to IIa 60% change to I y Type IIa y y y Type IIb y y y 1/22/2012 .Etiology y Sleep Factors .

Etiology y Alteration in Vasopressin Secretion and Nocturnal Polyuria y High ADH as night leads to less urine production y Enuretics have stable ADH during the day and night y y larger amounts of dilute urine at night may be delayed development of the ADH circadian rhythm Bladder emptying may cause decreased nighttime ADH levels in enuretics y ADH levels increase normally with bladder fullness y 1/22/2012 .

Etiology y Developmental Delay y Altered urodynamic function. sleep and ADH secretion occur normally in infants and young children y Nocturnal enuresis may be an arrest in development y Each physiologic alteration tends to resolve spontaneously y Neurologic disease is rare with monosymptomatic nocturnal enuresis 1/22/2012 .

Etiology y Developmental Delay y Stress has been shown to delay development of urinary control y enuresis is 3 times higher when associated with stressful circumstances delay in development is not isolated to urinary control y Associated with encopresis 10 .25% y 1/22/2012 .

77% children affected y 15% enuresis in children of nonenuretics 1/22/2012 .44% y When mother and father were enuretics.Etiology y Genetic Factors y 33% fathers y 20% mothers y One parent enuretic .

esp. boys controversial 1/22/2012 .meatotomy does not cure y Increased incidence of organic abnormalities with diurnal symptoms y y These may need U/S to exclude obstruction .Etiology y Organic Urinary Tract Disease y Enuretics are predisposed to UTIs y y especially girls many have diurnal symptoms due to bladder instability y Most with monosymptomatic nocturnal enuresis do not have an organic cause <10% y meatal stenosis is not a cause .

Evaluation y Families with a history of enuresis await spontaneous cure .more tolerant y Families without such a history can place great pressure on the physician to perform tests and produce a cure y Urologic tests are rarely indicated for monosymptomatic bedwetters y Rarely find an organic lesion 1/22/2012 .

urgency. polyuria y No UTI y Negative UA and Culture y Normal PE .Evaluation y Negative Screening Evaluation for Enuresis y Prepubertal age y Lifelong enuresis y Nocturnal enuresis only y No daytime wetting.including neurologic exam 1/22/2012 .

Evaluation y Screening creates 3 groups y Children with nocturnal enuresis y no further evaluation full urologic workup y Children with UTI or neuropathy y y Children without UTI or neuropathy with day and night enuresis or dysfunctional voiding y y U/S to exclude anatomic abnormality Assesses hydro. emptying 1/22/2012 . bladder wall thickening.

Evaluation y Screening creates 3 groups y Normal U/S y y pharmacologic therapy is symptoms are not severe If dysfunction persists or is severe .Urodynamics to exclude neuropathy and guide further treatment 1/22/2012 .

Treatment y Treatment is discouraged before age 7 y less successful y age when bedwetting interferes with social activities 1/22/2012 .

day and night incontinence (87%) more effective in urodynamically proven instability (90%) 1/22/2012 .40% effective (equal to placebo) in nocturnal enuretics y useful to eliminate bladder instability y y urgency.Drug Therapy y Anticholinergics y Only 5 .Treatment . frequency.

only 33% cured may lead to hyponatremic seizures .intranasal or oral y y y y y significantly reduces number of wet nights only 25% dry for 14 or more consecutive days temporary treatment .Treatment .limit fluids before administering dose not first-line treatment 1/22/2012 .Drug Therapy y Reduction of Urinary Output y limiting fluids in the day is not effective y DDAVP .

60% relapse y Peripheral action y y weak anticholinergic weak smooth muscle antispasmotic antidepressant activity not involved decreases REM early sleep .Drug Therapy y Imipramine y Cure > 50% Improvement .less enuresis early in the night and more common in the last third of sleep y does not lead to more awakenings at night y effect on sleep is independent of its effect on enuresis y Central action y y 1/22/2012 .80% y Discontinuation .Treatment .

Drug Therapy y Imipramine y Recommended dosage y y y 25 mg age 5-8 50 mg for older children results in optimal plasma levels in only 30% increased dosage not justified y toxicity y 25% are nonresponders despite higher doses adjust dosage and timing of administration weaning the drug reduces relapses y 2 week trial y y Long-term effects not known in children y 1/22/2012 .Treatment .

Treatment . result in most effective rate of sustained cure y 1st line therapy in these patients 1/22/2012 .Behavior Modification y When used in a motivated family.

very successful 1/22/2012 .Behavior Modification y Bladder Training y goal is to increase the time interval between voiding y enlarges functional capacity of bladder y Child is encouraged to retain urine after 1st urge y When combined with conditioning therapy.Treatment .

Behavior Modification y Responsibility Reinforcement y motivation y child assumes responsibility for wet and credit for dry with progressively longer dry intervals as a consequence of rewards for behavioral changes y reward y y response shaping y y reinforcment y Part of a multicomponent behavioral program 1/22/2012 .Treatment .

80% cure y y y y child wakes up and voids in toilet followed by sensation of a full bladder and production of the same inhibition as the alarm failure is often due to lack of parental understanding and cooperation may take months 1/22/2012 .Treatment .Behavior Modification y Conditioning Therapy y Use of a urinary alarm is the most effective for nocturnal enuresis .

bladder overdistention provides a stronger conditioning stimulus reinforced by alarm sounding intermittently some nights but not others y May be combined with pharmacotherapy 1/22/2012 .Behavior Modification y Conditioning Therapy y Once enuresis is cured (2 weeks dry) relapse is reduced by overlearning techniques y y forcing fluids prior to bed .Treatment .

infection.not all parents and children are ready for therapy y Begin with conditioning therapy and behavior modification y Add the use of medications as necessary 1/22/2012 . neuropathy.Summary y Exclude.harmless. high rate of spontaneous resolution y Recognize. perhaps genetic. obstruction y Reassurance.

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