CHILDHOOD ENURESIS

Dr. Majd Azez Resident at Urologist surgery of faculty of medicine of Damascus university

11-9-2014

BACKGROUND & DEFINITION The word enuresis is derived from a Greek word (enourein) that means “to void urine.” Enuresis may be 1. Primary (75%) Nocturnal urinary control never achieved 2. Secondary (25%) The child was dry at night for at least a

few months and then enuresis occurs

In PE, psychological problems are almost always the result of the condition and only rarely the cause. In SE, however, psychological problems are a possible cause, albeit not a common one.

The comorbidity of behavioral problems is 2-4 times higher in children with enuresis.

Enuresis can be further divided into the following 3 subtypes on the basis of the time of occurrence : Nocturnal (ie, during sleep) Diurnal (ie, during waking hours) Nocturnal and diurnal (also known as

nonmonosymptomatic enuresis)

The International Children’s Continence Society [ICCS] restricts the term to wetting that occurs at night

75% of children with enuresis are wet only at night 25% are wet day and night By 5 yr of age, 90-95% are nearly completely

continent during the day and 80-85% are continent at night

DEVELOPMENT OF CONTINENCE In infants , void 20 times a day Over the next 2 years, 11 times . Around this time that children also begin to recognize

symptoms of bladder fullness . 3 years of age, children have some conscious control and

most have daytime control with occasional accidents Most children are dry by day and night by the age of 4

years .

Maturation of communication between : pontine micturition centre pontine storage centre, cerebellum, which receives sensory input from the bladder and

pelvic floor the basal ganglia frontal lobes

EPIDEMIOLOGY

Approximately 60% of children with nocturnal enuresis are boys.

Family history is also important and is positive in 50% of cases.

Although primary nocturnal enuresis may be polygenetic, candidate genes have been localized to chromosomes 12 and 13.

If one parent was enuretic, each child has a 44% risk of enuresis;

If both parents were enuretic, each child has a 77% likelihood of enuresis.

Nocturnal enuresis without overt daytime voiding symptoms affects up to 20% of children at the

age of 5 yr It ceases spontaneously in approximately 15% of

involved children every year thereafter. Its frequency among adults is less than 1%.

ETIOLOGY

Idiopathic Disorder of sleep arousal Nocturnal polyuria Small nocturnal bladder capacity Overactive bladder or dysfunctional voiding Cystitis Psychological causes Sleep-disordered breathing Urethral obstruction Seizure disorder Ectopic ureter : 3-4 times more common in girls

than in boys and causes incontinence only in females.

Diabetes mellitus Diabetes insipidus

CLINICAL MANIFESTATIONS AND DIAGNOSIS

Careful History should be obtained, especially with respect to fluid intake at night and pattern of nocturnal enuresis.

Children with diabetes insipidus, diabetes mellitus, and chronic renal disease may have a high obligatory urinary output and a compensatory polydipsia.

CLINICAL MANIFESTATIONS AND DIAGNOSIS

The family should be asked whether the child snores loudly at night.

A complete physical examination should include palpation of the abdomen and rectal examination after voiding to assess the possibility of a chronically distended bladder.

The child with nocturnal enuresis should be examined carefully for neurologic and spinal abnormalities.

There is an increased incidence of bacteriuria in enuretic girls, and, if found, it should be investigated and treated .

CLINICAL MANIFESTATIONS AND DIAGNOSIS Laboratory Studies :

Urinalysis is the most important screening test in a child with enuresis .

cystitis usually have white blood cells (WBCs) or bacteria evident in the microscopic urinalysis.

If the urinalysis findings suggest cystitis , a clean-catch urine specimen should be sent for culture and sensitivity.

Urethral obstruction may be associated with red blood cells (RBCs) in the urine.

The presence of glucose suggests diabetes mellitus.

A random or first-morning specific gravity greater than 1.020 excludes diabetes insipidus.

Blood tests usually are not needed.

CLINICAL MANIFESTATIONS AND DIAGNOSIS

Ultrasonography :

Diagnostic imaging studies are not routinely indicated; however, patients with coincidental daytime voiding symptoms should undergo ultrasonography of the bladder and kidneys.

In patients with significant daytime symptoms whose ultrasonograms are normal, more invasive investigations should be deferred for 3 months, during which period the voiding routine and emptying are improved, cystitis is treated or prevented, and bowel health is improved.

The residual volume of urine is normally less than 5 mL.

CLINICAL MANIFESTATIONS AND DIAGNOSIS

Voiding Cystourethrography Plain Radiography :

If the bladder wall is thickened or trabeculated or a significant postvoid residual volume of urine is noted, voiding cystourethrography (VCUG) should be considered.

VCUG is warranted for patients in whom a neurogenic bladder

is suspected. The lumbosacral spine should be visualized during the procedure to look for sacral agenesis or spinal dysraphism. VCUG is also warranted when urethral obstruction is suspected on the basis of an abnormal urinary stream or abnormal ultrasonography findings.

If obstructive sleep apnea (OSA) is suspected, consider lateral radiography of the neck or referral to a pediatric otolaryngologist for direct visualization of the nasopharynx should be considered.

CLINICAL MANIFESTATIONS AND DIAGNOSIS

MRI :

MRI of the spine is indicated in any patient with any of The following :

An abnormal neurologic examination finding of the lower extremities

A visible defect in the lumbosacral spine The triad of encopresis, gait abnormality, and daytime

symptoms

MRI should be considered in patients with significant daytime voiding dysfunction that does not improve with treatment, even if neurologic and orthopedic examination findings are normal.

CLINICAL MANIFESTATIONS AND DIAGNOSIS

Urodynamic Studies and Cystoscopy :

Urodynamic studies help clarify the diagnosis of neurogenic bladder.

A video urodynamic study measures both filling-phase parameters (eg, bladder capacity, presence or absence of unstable detrusor contractions, bladder compliance, and the state of the bladder neck) and voiding-phase parameters (eg, voiding pressures, bladder emptying, and the state of the external urethral sphincter).

Urodynamic studies and cystoscopy should be reserved for patients with urethral obstruction and neurogenic bladder and for patients with dysfunctional voiding who do not improve after 3 months of therapy.

CLINICAL MANIFESTATIONS AND DIAGNOSIS

Uroflowmetry

Uroflowmetry is a simple, noninvasive measurement of urine flow that is helpful in screening patients for neurogenic bladder and urethral obstruction .

Patients with dysfunctional voiding, urethral obstruction, or neurogenic bladder have prolonged curves or an interrupted series of curves and low peak and average urine flow rates.

TREATMENT

The best approach to treatment is to reassure parents that the condition is self-limited and to avoid punitive measures that may affect the child's psychologic development adversely.

Specific treatment is generally discouraged before the age of 7 years

The only therapies that have been shown to be effective in randomized trials are alarm therapy and treatment with desmopressin acetate or imipramine.

Nonmonosymptomatic enuresis may be more difficult and time-consuming to treat

Bladder training exercises are not recommended

Enuresis is not a surgically treated condition. However, ectopic ureter and obstructive sleep apnea (OSA) respond to specific surgical interventions.

o Supportive management :

Supportive therapy as an initial management carries a high grade of recommendation.

Explaining the condition to the child and his parents

Eating and drinking habits should be reviewed,

stressing normal fluid intake during day and reducing fluid intake in the hours before sleep

Certain measures are sensible in all patients with nocturnal enuresis: void just before getting into bed, avoid huge fluid loads during the evening hours, and avoid caffeine after 3:00 pm

Keeping a chart depicting wet and dry nights has been shown to be successful.

Alarm Therapy :

It is reported to improve bedwetting by encreasing nocturnal bladder capacity or by enhanced arousal; it does not reduce nocturnal urine output.

Although most children with enuresis do not awaken to the alarm, they often stop emptying the bladder.

Some improve within the first 2 weeks of treatment, and others improve only after several months. A Cochrane review of 56 randomized trials involving 3257 children concluded that alarm therapy is beneficial. About two thirds of children on alarm therapy were dry, but about half relapsed, so that only about a third remained dry at 6-month follow-up.

In successfully treated children, alarm therapy should be continued for at least 3 months and for 1 month after sustained dryness.

Relapses are common, developing in 29-66% of children, and sometimes respond to further alarm therapy. If the child is still wet after a minimum of 3 months of consecutive use, alarm therapy can be discontinued and considered unsuccessful.

PHARMACOLOGIC THERAPY Desmopressin acetate : Antidiuretic , analog of ADH , increases renal

reabsorption of water, reducing urine output in patients with a decreased nocturnal peak in ADH .

success rates of 70% , relapse rates are high It is currently given orally 1 hour before bedtime The recommended starting dose for the tablet is 0.2

mg, a maximum dose of 0.6 mg. The equivalent starting dose for the orally

disintegrating tablet is 120 µg, and the maximum dose is 360 µg.

A nasal spray is no longer recommended due to an increased risk of overdosing and severe hyponatremia

Combination of alarm therapy with desmopressin therapy has been reported to result in dryness not achievable with either therapy alone.

Anticholinergic agents “ Oxybutynin ” :

helpful in some patients, especially those with overactive bladder, dysfunctional voiding, or neurogenic bladder.

reduce uninhibited detrusor contractions, increase the threshold volume at which an uninhibited detrusor contraction occurs, and enlarge the functional bladder capacity.

Anticholinergic adverse effects include dry mouth, blurred vision, facial flushing, constipation, poor bladder emptying, and mood changes. Constipation as an adverse event is especially problematic in that it might increase the risk for wetting.

Anticholinergic medications should not be administered during a fever, because an anticholinergic effect is a decrease in sweating

Oxybutynin is given in a dose of 2.5-5 mg administered at bedtime. A long-acting preparation is available but has not been approved for use in children.

Tolterodine is not approved for use in children younger than 12 years.

Flavoxate, a urinary spasmolytic, might be helpful in some patients with overactive bladder and dysfunctional voiding but is approved only for children older than 12 years.

The combination of desmopressin acetate and oxybutynin chloride might be efficacious in children with overactive bladder or dysfunctional voiding who respond to anticholinergic therapy with improved daytime symptoms but who continue to wet at night.

Imipramine “TCA” :

A Cochrane review of 58 randomized trials concluded that imipramine is effective in reducing bedwetting; children treated with imipramine had 1 fewer wet night per week .

The relapse rate is high when the medication is discontinued.

The usual dose, taken 1-2 hours before bedtime, is 25 mg for patients aged 6-8 years and 50-75 mg for older children and adolescents.

Adverse effects include constipation, difficulty initiating voiding, irritability, drowsiness, reduced appetite, and personality changes .

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.

THANKS