Obstructive uropathy presenting as primary
enuresis - A case report
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Case Report
Obstructive uropathy presenting as primaryenuresis e A case report
Kiran Prakash Sathe*
Associate Consultant, Division of Pediatric Nephrology, Sir HN Reliance Foundation Hospital & Research Centre,
Mumbai, India
a r t i c l e i n f o
Article history:
Received 8 October 2014
Accepted 8 November 2014
Available online xxx
Keywords:
Bedwetting
Diurnal symptoms
Urgency
Frequency
Bladder dysfunction
* Block No 8, Bldg C-3, “SUMAN NAGAR”, VE-mail address: [email protected]
Please cite this article in press as: SathMedicine (2014), http://dx.doi.org/10.1016
http://dx.doi.org/10.1016/j.apme.2014.11.0040976-0016/Copyright © 2014, Indraprastha M
a b s t r a c t
An adolescent male presented with persistent nocturnal bedwetting. Confounding family
history of nocturnal enuresis lead to delay in seeking medical attention. Careful history
and investigations confirmed underlying obstructive uropathy and bladder dysfunction.
Primary enuresis presenting beyond childhood period should be investigated to look for
underlying organic cause.
Copyright © 2014, Indraprastha Medical Corporation Ltd. All rights reserved.
1. Introduction
Family history of nocturnal enuresis can be a misleading
factor while evaluating caseswith primary enuresis persisting
beyond childhood. Correct history and simple bedside evalu-
ation can help in identifying underlying organic cause.
2. Case report
A 14 year old adolescent male presented with primary
enuresis. He had persistent nocturnal bedwetting with a fre-
quency of once to twice weekly episodes since childhood. He
had a normal development and was well grown for his age.
There were no psychosocial stressors. There was history of
nocturnal enuresis in his father and paternal grandfather
N Purav Marg, Chembu.
e KP, Obstructive uropa/j.apme.2014.11.004
edical Corporation Ltd. A
which subsided by 13 years of age. Presuming the same con-
dition in the patient, the family never sought a medical
opinion and hence never investigated for his symptoms. He
had a normal urine stream. There was no history of recurrent
urinary tract infections (UTI) or constipation. There was no
history of excessive water intake. On direct questioning, there
was history of occasional day time enuresis in addition to the
nocturnal bedwetting. There was history of urge to void
frequently during the daytime. Despite attempts at holding
voiding, he had to rush to the toilet each time. On examina-
tion, he was adequately grown for his age. He was normo-
tensive without pallor or edema. There was phimosis but no
evidence of renal lump or palpable bladder. There was no
obvious evidence of spina bifida. Neurological examination in
the lower limbs was normal with normal anal reflex and
bulbocavernosus reflex.
r, Mumbai 400071, India. Tel.: þ91 9821673216 (mobile).
thy presenting as primary enuresis e A case report, Apollo
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A 36-hours voiding diary suggested frequent voiding and
suboptimal bladder capacity without polyuria. Urinalysis
suggested pH 6.5, specific gravity 1025 without evidence of
abnormal sediment, glucosuria or proteinuria. Serum creati-
nine was 0.7 mg/dL. Renal ultrasound reported right kidney
9.7 � 3.9 cm; left kidney 9.4 � 4.9 cm with mild left pelvica-
lyceal fullness without dilated ureters. There was evidence of
trabeculated and thickened bladder wall measuring 4.4 mm
with significant post void residue of 45 cc. MRI revealed
normal vertebral bodies, normal spine without evidence of
tethering. Micturating cystourethrogram (MCU) revealed
dilated & elongated posterior urethra without associated
vesicoureteric reflux. An invasive urodynamic study (UDS)
was performed. Filling phase study revealed decreased
compliance of bladder. There was severe degree of detrusor
over activity beyond 80 ml capacity with detrusor pressures
ranging between 104 and 184 cm H20 resulting in severe urge
to void and profuse pericatheter leakage. Maximum bladder
capacity recorded was 211 cc. During the voiding phase, he
could initiate prompt voiding on command with leak point
pressure of 62 cm H20. At the end of the study there was no
significant residual volume. Simultaneous electromyography
revealed normal coordinated and relaxed pelvic floor.
Cystoscopy with circumcision although advised was how-
ever refused by the patient. He was explained about the pos-
sibility of mechanical obstruction in the urinary outflow tract
resulting in bladder dysfunction. Meanwhile the patient was
started on oxybutynin at dose of 2.5 mg twice daily. This was
later increased to 2.5mg thrice daily whichwaswell tolerated.
He was advised restriction of oral fluids after late evening and
double voiding. Within the next two months of starting oxy-
butynin, there was improvement in his symptoms of urgency
and frequency with no further bedwetting.
3. Discussion
Presence of daytime symptoms of enuresis, urgency, fre-
quency and holding tendency in addition to the nocturnal
bedwetting clearly suggested abnormal lower urinary tract
symptoms suggestive of abnormal voiding. The symptoms
were wrongly presumed to be related to familial autosomal
dominant nocturnal enuresis leading to delayed presentation.
Voiding diary was a useful bedside test to arrive at a probable
diagnosis of detrusor over activity and suboptimal bladder
capacity resulting in above symptoms. Both neurogenic
bladder and obstructive uropathy may present with a signifi-
cant post void residue and trabeculated bladder. Normal
neuroimaging ruled out the possibility of neurogenic bladder
and MCU confirmed the bladder outlet obstruction most
probably posterior urethral valves. However the exact nature
and extent of obstruction could not be ascertained as cystos-
copy could not be done. Bladder dysfunction was secondary to
chronic bladder outlet obstruction and manifested with
symptoms of detrusor over activity as described earlier,
incomplete voiding, and reduced bladder compliance. These
functional symptoms including bedwetting resolved after
starting oxybutynin consequent to amelioration of the
detrusor over activity. Absence of VUR and recurrent urinary
Please cite this article in press as: Sathe KP, Obstructive uropaMedicine (2014), http://dx.doi.org/10.1016/j.apme.2014.11.004
tract infections helped to preserve normal renal function.
However, the high pressure detrusor over activity with
bladder outlet obstruction confirmed on UDS puts him at risk
for late deterioration of renal function. Relief of underlying
primary mechanical obstruction would be necessary to avoid
the long term damage.
Conventionally, diagnosis of PUV is made antenatally or in
infancy. Late detection of PUV has been reported in about 10%
cases.1 Bladder dysfunction resulting from high pressure
bladder outlet obstruction can present as nocturnal enuresis
in 60% cases.2 Abnormal voiding pattern, recurrent UTI or
renal failure could be the presentation in occasional cases.1e3
A simple bedside test such as voiding diary can be useful in
arriving at diagnosis and in guiding further investigations.
Diagnosis can be easily missed and such cases may present
late if MCU is not included as a part of work up for enuresis in
older boys.4 Identifying the symptoms of bladder dysfunction
is critical in suspecting such cases.
In conclusion, enuresis persisting into adolescence should
be investigated regardless of family history. Careful history
and voiding diary helps to identify underlying bladder
dysfunction in enuretic children. MCU should be a part of
work up of enuresis persisting beyond childhood period to
identify underlying obstructive uropathy.
Contributors
The author was involved in the concept and design, acquisi-
tion of data, analysis and interpretation of data, drafting the
manuscript, critical revision of the manuscript for important
intellectual content and final approval of the version to be
published.
Conflicts of interest
The author has none to declare.
Acknowledgement
Dr Shirish Yande, Dr Dashmit Singh, Dr Kumud P Mehta.
r e f e r e n c e s
1. Nobrega de Jesus C, Filho J, Goldberg J. Late presentation ofposterior urethral valve: two case reports. Sao Paulo Med J.2008:126e127.
2. Bomalaski MD, Anema JG, Coplen DE, Koo HP, Rozanski T,Bloom DA. Delayed presentation of posterior urethral valves: anot so benign condition. J Urol. 1996;162:2130.
3. Lal R, Bhatnagar V, Mitra DK. Urinary continence followingposterior urethral valves treatment. Indian J Pediatr.1999;66:49e54.
4. Vanwaeyenbergh J, Libert MH, Keuppens FI. Endoscopicresection as treatment of enuresis with posterior urethralvalves. Acta Urol Belg. 1990;58:133e137.
thy presenting as primary enuresis e A case report, Apollo
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