Andrea Green

Grampians Regional Continence Service

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Enuresis

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Enuresis

Enuresis

Symptom and condition of intermittent incontinence that occurs

during sleep at the minimum age of 5 years

Minimum of one wet night per month

Minimum duration of three months

Monosymptomatic: incontinence during sleep in the absence of

lower urinary tract dysfunction

Non-monosymptomatic: incontinence during sleep in combination

with other bladder symptoms (urinary frequency, urge

incontinence)

Enuresis; primary and secondary

Primary; not yet achieving night dryness by the minimum age of 5

years

Secondary; enuresis after a period of 6 months dry at night. UTI,

constipation or other specific cause

Frequent; four nights or more per week

Infrequent; less than four nights per week

Austin et al. (2014) Rittig, S et al (2010)

Expected development - awareness

Newborn – reflex voiding at intervals with no voluntary

control

Awareness of being wet around 18 months

Awareness of urge around 2 years. Bladder volumes

increase and voiding frequency decreases

Ability to defer with urge around 3 years, able to inhibit

and initiate voiding

Ability to void on request (if urine in bladder) around 5

years, good bladder storage and response to sensation

Mechanisms

Incidence of enuresis

Second most common chronic condition in children aged

6 – 7 years

1 in 5 children of aged 5 - 7

1 in 15 children aged 7 - 10

1 in 20 children aged 10 - 15

1 in 50 children aged 15

Potential causes of enuresis

Hereditary

Overactive bladder

Poor arousal from the deep sleep phase

Delay in antidiuretic hormone secretion

Contributing factors such as faecal loading and bladderirritants

Other factors – jaw alignment, sleep apnoea etc Weider, W.W., SateiaM.J., & West R.P. 1991

Expected bladder volumes

30 ml per year of age, plus 30ml

5 years - 180ml

6 years - 210ml

7 years - 240ml

8 years - 250ml

Older - adult volumes

4 - 6 voids per day are expected

Estimating Fluid Requirements

Age: Fluid / kg of body weight:

3 months 125-150 ml

6 months 140-160 ml

6 months 130-155 ml

12 months 120-135 ml

2 years 15-125 ml

6 years 90-100 ml

10 years 70-85 ml

14 years 50- 60 ml

Depends which book you read… (look at the color of the urine)

General rule of thumb: 30 – 40ml per kg of body weight

Children 1000 - 1500ml per day

Adult 1500 - 2000ml per day

24ml/kg/day or 35 - 45ml/kg/day

Mahan I.K.,& Arlin M. (1992). Krause’s Food, Nutrition and Diet Therapy. 8th Ed. WB Saunders Co. Philadelphia

Assessment

Continence paediatric assessment tool. Look for red flags

Bladder diaries +/-

Uroflow +/-

Urinalysis +/-

Post void residual +/-

Trigger diary for the intermittent wetters and regressors +/-

Real time ultrasound – bowel, bladder wall thickness, PVR

symptoms (urinary frequency, urge incontinence) +/-

General advice

Push fluids early in the day

Ensure adequate fluid input over all

Urine color chart to guide fluid intake

24ml per kg of body weight as a minimum guide

If possible defer voiding a little, never go “just in case”,

except before bed

Good bowel habits

Trigger diary may be required – bladder irritants

Alarm Therapy

Alarm therapy has been considered first line

management for the treatment of bedwetting in

children. Alarms take longer to achieve dryness than

Desmopressin but results are longer lasting. Glazener, MA, et al,

Cochrane Systematic Review. 2005.

Bell and pad style alarms are most commonly used in

Australia

Success rates estimated at 60-75% Butler & Glasson, 2005

or at 76 – 87% Apos et.al., 2017

The Grampians Regional Continence Service recently

conducted a pilot study to compare the effectiveness

of bell and pad with the body worn alarms – more on

the study later…

Apos et al, 2017. Butler & Glasson, 2005. Berry, 2006. Tsuji, et al, 2018

Urotherapy

Alarm therapy

Information provision

Voiding habits

Voiding posture

Avoid holding manoeuvres

Regular bowel habits

Bladder and/or bowel diaries

Support

Research Project – Pilot Study 2017

GRCS conducted a Pilot Study comparing the bell and pad

alarm with the body worn device

Sample size was 86 children aged from 6 – 15 years

There was a random allocation of alarm type to participants

within the pilot study

Success criteria was as per ICCS guidelines – 14 consecutive

dry nights, maximum 16 weeks duration for therapy

Bell & Pad Body-Worn

Cost ~$1,800 ~$130

Therapy Success Rates ~60 - 85%

Accessibility (Time to Therapy)

Upwards of 6 months

Immediate

Clinician Involvement No Difference

Research project – pilot study

Bell & Pad Body-Worn p Value

Primary Measure(Dry ≥ 14 Nights)

64% 44% 0.056

Secondary Measure(Time to Dryness)

44 nights 46 nights 0.818

Other Measure (False Positive Alarms)

20% 43% 0.039

Other Measure (Alarm Woke Parent)

88% 62% 0.022

Other Measure (Child Turned Alarm Off –Back to sleep)

6% 36% 0.003

Results

Nocturnal polyuria

Nocturnal polyuria - nocturnal urine production greater than

130% of expected bladder capacity for age

Normal bladder reservoir function, maximum voided volume

greater than 70% of expected bladder capacity for age

Greater than 20 X (age + 9) in ml

Pharmaceuticals – how do they relate

to enuresis?

Oxybutynin, Ditropan, Vesicare – Anticholenergics

Betmiga – Beta antagonist

Minirin / Desmopressin

Hiprex, Vitamin C for prevention of urinary tract infection

Jain S, Bhatt GC.Advances in the management of primary monosymptomatic nocturnal enuresis in children. Paediatric Int Child Health. 2015 May

Bowel softeners - eg. OsmoLax / Movicol (iso-osmotic)

Lactulose (osmotic)

Bowel stimulants - eg. Dulcolax drops, Laxette chocolate

squares, Senokot tablets

Minirin - Desmopressin

Desmopressin is a synthetic replacement for the antidiuretic

hormone that reduces urine production during sleep. Children

taking Desmopressin are 4.5 times more likely to stay dry than

those taking a placebo. Melt and tablet are prescribed, nasal

spray is no longer recommended.

Other children who are likely candidates for desmopressin

treatment are those in whom alarm therapy has failed or those

considered unlikely to comply with alarm therapy. It is useful

for camps and sleepovers. Jain S, Bhatt GC. 2015 May

Desmopressin only for treatment of nocturnal enuresis is

associated with a high relapse rate. Thiedke CC, American Family Physician, 2003.

Anti-cholinergics - Ditropan, Vesicare

Muscularinic receptor antagonists

M3 selectivity - 3 fold selective

M3 receptors - bladder (desired therapeutic effect)

- salivary glands (dry mouth)

- GI tract (constipation)

Useful in non-monosymptomatic children with alarm

therapy

Not recommended as enuresis is a disorder of the central

nervous system and not that of the bladder Yucal, Kol, Guntekin, Baykara, 2011

Betmiga – Mirabegron

Beta-3 adrenoceptor agonist

Useful in non-monosymptomatic children with alarm

therapy

Not recommended as enuresis is a disorder of the central

nervous system and not that of the bladder

Hiprex – Methenamine

Vitamin C – Ascorbic Acid

Urinary tract infection management – preventative

Hiprex turns to formaldehyde, makes urine acidic and kills

bacteria

Ceased while on antibiotics then recommenced

Vitamin C can be prophylactic, converting nitrates to nitrites

Nitrites convert to nitrogen oxides that are toxic to bacteria BannwartC, Hagmaier V, Straumann E, Hofer H, Vuillemier JP, Rutishauser G, 1981

Bowel softeners

OsmoLax – Movicol – Macrogol 3350. Iso-osmotic

Lactulose - Actilax. Osmotic

Bowel stimulants

Senokot

Dulcolax drops

Laxette chocolate squares

Nocturnal Enuresis – adults

Group Prevalence, %

Age, years 16–20 21–25 26–30 31–35 36–40

All enuretics 2.6  2.2  2.1  2.4  2.2

male 3.3  2.2  2.2  2.5  2.8

female 1.9  2.3  2.1  2.3  1.7

Education Univ

Enuretics 7.7 34.2 40.3 6.6  11.2

Controls 3.7 16.1 46.8 10.7 22.7

Sleep disturbance

A B C D

Enuretics 49.5 48.9 45.4 39.9

Controls 33.1 27.4 33.8 25.8

Prevalence of monosymptomatic PNE in adults in Hong

Kong with age, education and sleep disturbance. Yeung C.K., Sihoe, F.D.Y., et al (2004)

Let’s talk about poo

Bowel management may be required

Faecal loading or constipation are space occupying in the

pelvis

Aim for a 5 minute toilet sit after the evening meal if bowels

have not been opened yet for the day

Teach toilet sitting position and pelvic floor relaxation

techniques

Manage stool type with softeners and stimulants as

appropriate

Client Centred Care

Is the child ready? Early treatment equates to better

outcomes

Are the parents ready?

Two household families – parents living separately

Compliance issues

Other factors:

Hot weather – sweating

Wet weather – getting the linen dry

Reflective listening

Motivational interviewing techniques

Establish goals and expectations

Provide effective solutions

Cost factors

Hire or purchase of alarms

Medication costs

Laundry costs

Pull ups and continence products

Time off work for appointments

Economic cost to the taxpayer – service provision, funding

schemes

Tom’s story

Tom is a 10 year old boy who originally presented with

monosymptomatic enuresis. There was no suggestion of any

other problem.

Tom had a failed alarm attempt and was lost to follow up for a

short time.

Tom re-attended the clinic for re-hire of bell and pad alarm for

a second try.

During the assessment it became clear that “something was

not right” when a small comment was made by Tom’s mother

(he had been wet during the day after a large void).

A uroflow and post void residual led to the discovery of

significant urinary retention. Alarm was not re-hired.

The lesson: Ask the questions, don’t blindly re-hire.

Josie’s story

Josie was 9 when we started to treat her enuresis.

Josie initially came along with significant faecal loading, not at

all toilet trained. Josie is deaf and has Down Syndrome.

We elected to use the pad and bell style alarm with the

vibrating disc attachment.

Josie’s mother responded as expected to the bell. Josie never

woke to the vibration of the disc but had her first dry night on

night 9 with the alarm. Josie achieved 14 consecutive dry

nights within 6 weeks and 5 days.

Several years later, Josie has had some intermittent bowel

problems but remains continent of urine both day and night.

Final thoughts…

Be a game changer

Sliding doors moments

It might be routine work for us, but to the client the

outcomes are important and life changing

References Apos, E., Schuster, S., Reece, J. Whitaker, S., Murphy, K., Golder, J., Leiper, B., Sullivan, L. & Gibb, S. (2017). Enuresis Management in Children: Retrospective Clinical Audit of 2861 Cases Treated with Practitioner-Assisted Bell-and-Pad Alarm, The Journal of Pediatrics, 193, 211-216.

Austin, P.F., Bauer, S.B., Bower, W., Chase, J., Franco, I., Hoebeke, P., Rittig, S., Vande Walle, J., Von Gontard, A., Write, A., Yang, S.S. & Neveus, T. (2014). The Standardization of Terminology of Lower Urinary Tract Function in Children and Adolescents: Update Report from the Standardization Committee of the International Children’s Continence Society.

Bannwart C, Hagmaier V, Straumann E, Hofer H, Vuillemier JP, Rutishauser G. [Modifi cation of urinary pH through ascorbic acid]. Helv Chir Acta1981; 48 (3-4): 425-428.

Berry, A.K. (2006) Helping Children with Nocturnal Enuresis: The wait-and-see approach may not be in anyone’s best interest, American Journal of Nursing, 106(8), 56-63.

Caldwell, P.H.Y., Deshpande, A., & Von Gontard, A. (2013), Clinical Review: Management of nocturnal enuresis. British Medical Journal, 347, 1-6.

Glazener, M.A., Evand J., Peto, R.E. (2005) Cochrane Systematic Review, 2005

Jain S, Bhatt G.C. Advances in the management of primary monosymptomatic nocturnal enuresis in children. Paediatric Child Health. 2015 May

Mahan I.K.,& Arlin M. (1992). Krause’s Food, Nutrition and Diet Therapy. 8th Ed. WB Saunders Co. Philadelphia

Rittig, S., Kamperis, K., Siggaard, C. et al.: Age related nocturnal urine volume and maximum voided volume in healthy children: reappraisal of International Children’s Continence Society definitions. J Urol, 183: 1561, 2010

Thiedke C.C, American Family Physician, April 2003

Tsuji, S., Suruda, C., Kimata, T, Kino, J., Yamanouchi, S. & Kaneko, K. (2018) The Effect of Family Assistance to Wake Children with Monosymptomatic Enuresis in Alarm Therapy: A Pilot Study, The Journal of Urology, 199 (4), April, pp.1056-1060

Weider D.J., Sateia M.J., West R.P. (1991) Nocturnal Enuresis in Children with Upper Airway Obstruction, 1991

Yeung, C.K., Sihoe, J.D.Y., Sit, F.K.Y., Bower, W., Sreedhar, W., Lau, J. (2004) Characteristic of Primary Nocturnal enuresis in Adults: an epidemiological study BJUI International

Yucal, S., Kol, A., Guntekin, E., & Baykara, M (2011). Anticholenergics do not improve cure rate of alarm treatment of monosymptomatic nocturnal enuresis. Urology, 77, 721-724.