EnuresisEnuresis

Ali Derakhshan MDAli Derakhshan MD

Shiraz University of Medical Sciences,Shiraz University of Medical Sciences,Shiraz-IranShiraz-Iran

ENURESIS: SOME GENERAL POINTSENURESIS: SOME GENERAL POINTS

DEF: Wetting twice a week for 3 consecutive monthsDEF: Wetting twice a week for 3 consecutive monthsChronological age: 5-6 yearsChronological age: 5-6 years The disorder : either The disorder : either primaryprimary or or secondarysecondary Primary enuresisPrimary enuresis 85% 85%Secondary enuresisSecondary enuresis dryness for at least 6 months then dryness for at least 6 months then resumed wetting 15%resumed wetting 15%Nocturnal only, diurnal only, nocturnal Nocturnal only, diurnal only, nocturnal &diurnal&diurnalPrevalence different in diff. countriesPrevalence different in diff. countries

Epidemiology of EnuresisEpidemiology of Enuresis15 to 20 % of children night 15 to 20 % of children night time wetting at five years of time wetting at five years of ageageThe spontaneous resolution The spontaneous resolution rate is15%/yr rate is15%/yr At 8 yr 7% of childrenAt 8 yr 7% of childrenAt age 15 only 1 %At age 15 only 1 %Boys wet the bed twice > than Boys wet the bed twice > than girls till 11 yr then equal.girls till 11 yr then equal.EN more common 1EN more common 1stst child, low child, low socioec.., disease 1socioec.., disease 1stst 4 4 yr,large size familyyr,large size family Daytime control is typically Daytime control is typically accomplished by the age of 3 accomplished by the age of 3 or 4.or 4.Nighttime dryness expected by Nighttime dryness expected by 6yrs6yrsOf children with En Of children with En 22%day,17%day and night and 22%day,17%day and night and 61%night61%night11STST bowel control at night, bowel control at night, then day, then day time then day, then day time urine control then night…urine control then night…

Rule of 15’sRule of 15’s

Factors That May Contribute To Enuresis

Genetic factors Family history of enuresis Delayed maturation A stressful life event, such as the birth of a sibling, Delayed arousal from sleep Malfunction of detrusor muscle Chronic constipation can irritate the bladder and ↓functional volume Sleep apnea (periods of non-breathing during sleep) Urinary tract infection High urine production during the night

Enuresis: Genetic BasesEnuresis: Genetic Bases

• Genetic: higher incidence of enuresis in Genetic: higher incidence of enuresis in children whose parents were enureticchildren whose parents were enuretic

• In families where In families where both parentsboth parents have a history have a history of enuresis, of enuresis, 7777 % of children will have % of children will have enuresis.enuresis.

• when when one parent one parent has had enuresis, has had enuresis, 4444 % of % of children will be affected;children will be affected;

• Homozygote twins Homozygote twins 6868%,Hetrozygote …%,Hetrozygote …3636%%• 74% of boys with EN ,58% girl one or both 74% of boys with EN ,58% girl one or both parentsparents

• In only In only 1515 % of children family history is % of children family history is negativenegative

• nocturnal enuresis was associated with 2 markers, 13q13 & nocturnal enuresis was associated with 2 markers, 13q13 & 13q14.2, on long arm of chromosome 1313q14.2, on long arm of chromosome 13

• An autosomal dominant pattern has been reportedAn autosomal dominant pattern has been reported

Enuresis and Upper Airway Enuresis and Upper Airway ObstructionObstruction

Nocturnal enuresis association with upper Nocturnal enuresis association with upper airway obstructionairway obstruction

In these instances, surgical relief of the In these instances, surgical relief of the obstruction by tonsillectomy, adenoidectomy or obstruction by tonsillectomy, adenoidectomy or both has been reported to diminish nocturnal both has been reported to diminish nocturnal enuresis in up to 76 percent of patients. enuresis in up to 76 percent of patients.

Enuresis and Anatomic FactorsEnuresis and Anatomic Factors

In Isolated primary enuresis, usually no In Isolated primary enuresis, usually no anatomic abnormalities anatomic abnormalities

ADH secretion

Normal childrenNormal children have a diurnal rhythm of plasma have a diurnal rhythm of plasma vasopressin and urinary output with a nocturnalvasopressin and urinary output with a nocturnal increase increase in in ADH decreasedecrease in urinary excretion rate, and in urinary excretion rate, and increaseincrease in urine in urine osmolarityosmolarityEnureticsEnuretics have an have an abnormal rhythmabnormal rhythm of plasma vasopressin of plasma vasopressin

and urinary output with nocturnal low vasopressin, large and urinary output with nocturnal low vasopressin, large

urinary excretion rate, and lower urinary osmolarityurinary excretion rate, and lower urinary osmolarity The relationship between ADH secretion and nighttime urinary flow rates remains controversial.abnormalities in ADH secretion appear to play a role in at least some patients with nocturnal enuresis.

OTHER POSSIBLE ETIOLOGICAL OTHER POSSIBLE ETIOLOGICAL FACTORS: BEHAVIORAL FACTORSFACTORS: BEHAVIORAL FACTORS

Enuresis Enuresis psychological problemspsychological problems

psychological problem 2psychological problem 2ndnd enuresisenuresis

Behavioral regression due to stress Behavioral regression due to stress (divorce, abuse, school trauma, (divorce, abuse, school trauma, hospitalization) does seem to be hospitalization) does seem to be involved in involved in many cases of secondary many cases of secondary enuresis.enuresis.

ORGANIC CAUSESORGANIC CAUSES

UTIUTI

DMDM

DIDI

CRFCRF

Secondary Nocturnal EnuresisSecondary Nocturnal Enuresis

Psychological factors: stress, anxiety, Psychological factors: stress, anxiety, depressiondepressionNeurogenic detrusor underactivity and Neurogenic detrusor underactivity and overflow incontinenceoverflow incontinenceDysfunctional voidingDysfunctional voidingUrinary tract infectionUrinary tract infectionBladder outlet obstructionBladder outlet obstructionDM,DI,CRFDM,DI,CRF

Diurnal enuresisDiurnal enuresis

Detrusor instability is commonly foundDetrusor instability is commonly found

Urgency frequency and urge incontinenceUrgency frequency and urge incontinence

Pelvic floor spasticity and dysfunctional Pelvic floor spasticity and dysfunctional voidingvoiding

May be associated with constipation or May be associated with constipation or fecal incontinence fecal incontinence

UTI AND ENURESISUTI AND ENURESIS

• IN 15% of children with UTI EN is 1IN 15% of children with UTI EN is 1stst symptom symptom

•EN is common in children with EN is common in children with asymptomatic bacteriuriaasymptomatic bacteriuria•UTI more common in EN childrenUTI more common in EN children•Treatment of UTI improved EN in 30%Treatment of UTI improved EN in 30%•Girls with diurnal and nocturnal EN 50% Girls with diurnal and nocturnal EN 50% chance of UTIchance of UTI

EVALUATION

History

Physical examination

INVESTIGATIONS

CLINICAL AND PARACLINICAL CLINICAL AND PARACLINICAL EVALUATIONEVALUATION

HISTORY: birth Hx, developmental milestones, HISTORY: birth Hx, developmental milestones, previous control, social setting, inside toilet, voiding previous control, social setting, inside toilet, voiding pattern, wetting episodes, bowel control, fecal soiling, pattern, wetting episodes, bowel control, fecal soiling, incontinence, UTI, primary or secondary? Drinking incontinence, UTI, primary or secondary? Drinking habitshabits

Family HistoryFamily History

Previous treatment, Motivation for Rx Previous treatment, Motivation for Rx

Complete PE: child developmentComplete PE: child development

INVESTIGATIONS

1-Primary EN: Urinalysis/ specific gravity, Ca/Cr,U/C if indicated

-Imaging studies not indicated2-2nd Enuresis more investigations -U/A, U/C, BUN, Cr, if UTI US and

VCUG and…..3-incontinence, abnormal neurological signs:

US ,VCUG and Urodynamic study

TREATMENT OF NE

-treatment of organic conditions if any General measures - Restrict fluid 3-4 hours before bedtime

-Empty bladder before sleep -Salt restriction

- Encourage child to make bedtime resolution- Keep a chart of wet and dry nights- Reward for dry nights

-Avoid punishment & criticism

TREATMENT OF NENon-pharmacological

- Reassurance and counselling

- Bladder training programme

- Enuresis alarm

Pharmacological

-Desmopressin

-Oxybutynin

- Imipramine

Pharmacological treatment

Bell and Pad>7 yr 70-90% response,10%recurrenceBell and Pad>7 yr 70-90% response,10%recurrenceImipramine- rarely used now in children

Used in children over 6- can TX for 3-6 mo effective in 50-60% (author 24%), 25%remain dry 60%relapse Side effects-, toxicity, sleep and appetite dry mouth

Desmopressin - DDAVP Synthetic analog of antidiuretic hormone vasopressin Spray and Tablet forms* Rapid response 40-70% response but 50%- 90% relapse Side effects- HA, convulsion due to water intoxication

Oxybutynine + imipramine or Oxybutynine + Desmopressin Alarm RxAlarm Rx++ Desmopressin Imipramine and desmopressin may be combinedImipramine and desmopressin may be combined

*Black box warning

Evidence Based Medicine

Enuresis alarms are the most effective treatment for primary nocturnal enuresis with lasting effects.

Drug treatment can be useful for short term relief of symptoms but consider potential adverse effects

Conclusions

Nocturnal enuresis is multifactorial

A 15% annual spontaneous cure rate

Treatment should match to etiologies

Balance between bladder functional capacity and nocturnal urine output appear to be the most important

The EndThe EndTHE END