PEDBASE.org - The Pediatric Database - Detailed information of ENURESIS

ENURESIS

DEFINITION:

The involuntary voiding of urine after the age of 6 years.

EPIDEMIOLOGY:

incidence: 25-33% of 4 year old children, 15% of 5-6 year olds, 5-7% of 7 year olds, 1% of 15 year olds
age of onset:
- by definition after the age of 6
risk factors:
- family history
  - 75% if both parents affected
  - 40% if one parent affected
- sex
  - M > F (nocturnal)
  - F > M (diurnal)

DIFFERENTIAL DIAGNOSIS:

1. Organic

bladder instability
constipation
Diabetes Mellitus or Insipidus
renal (medullary) damage
urinary tract infection
neurologic dysfunction

2. Non-Organic

deep sleeper
emotional disturbance
excessive water drinking
learned ("holding-on") behaviour
mental retardation
sexual abuse

DEFINITIONS:

Nocturnal: nighttime bedwetting
Diurnal: daytime wetting +/- nighttime bedwetting
Primary: has never been dry for longer than 6 months
Secondary: wetting after a minimal 6 month period of dryness (less common than primary enuresis)
Relapse: more than 2 wet nights in 2 weeks
Initial Success: 14 consecutive dry nights within a 16 wk treatment
Continued Sucess: no relapse in the 6 months after initial success
Complete Success: no relapse in the 2 years after initial success

PATHOGENESIS:

1. Development of Bladder Control

babies - void 12-16 times per day
1-2 years - develop an awareness of a full bladder
2-4 years - recognize the sensation of voiding
- develop the ability to "hold-on"
4-5 years - can initiate voiding voluntarily (even before the bladder is full)
6-7 years - can hold as necessary and void at any degree of filling

2. Nocturnal Enuresis

a developmental issue
delay in the development of the nocturnal release of ADH

3. Diurnal Enuresis

a behavioural issue
"holding-on" -> overflow incontinence

CLINICAL FEATURES:

1. History

primary or secondary
nocturnal or diurnal
frequency
- # of times per week
- # of times per night
risk factors
- family history
- recurrent UTI (frequency, dysuria)
- constipation or encopresis
- neurologic defects
- diabetes mellitus (polyuria, polydypsia)
"holding-on" behaviour
- squatting
- squirming
- dancing
- starer
"holding-on" features
- do not void when first arise in the morning
- void only 2-3 times per day (normal 5-7 times/day)
- short bathroom duration
motivation of child and family

2. Physical Examination

growth parameters
blood pressure
genital examination
neurologic examination
- reflexes
- abnormalities of extremities or spine
rectal examination (constipation)

INVESTIGATIONS:

1. First Line

1. Primary Enuresis

complete urinalysis
- R & M, C & S, osmolality (day & night)

2. Secondary Enuresis

complete urinalysis
renal ultrasound

2. Second Line

1. Imaging Studies

renal ultrasound
VCUG - measures bladder capacity
cystoscopy

2. Osmolality

9 urine samples over 3 consecutive days at 1600, 2200 and 1st am samples while the child is fluid restricted to 25cc/ kg/day

3. Bladder Capacity

normal capacity in average child is age + 2 = ounces (i.e., 6 year old will have a bladder capacity of 8 ozs.)

MANAGEMENT:

1. Patient and Family Counselling

to provide reassurance and emotional support
describe scope of enuresis in society
explain correctable organic causes of enuresis
explain that enuresis is a self-resolving condition and not a disease
explain that child has no control over condition

2. Correct any underlying causes

UTI (antibiotics prophylaxis for recurrent UTI - Septra qhs)
constipation

3. Manage daytime wetting before nighttime wetting

4. Principles of therapy (3)

1. Increase Bladder Capacity

for daytime wetting
double fluid intake in order to make "holding-on" more difficult
oxybutynin or an anticholinergic agent to control bladder instability

2. Establish Circadian Rhythm of Serum ADH

DDAVP (desmopressin)
- an analogue of antidiuretic hormone (ADH)
- acts by duplicating the normal nighttime increase in
- ADH
- initially use 10 ug intranasally qhs x 3 nights and if no effect increase to 20 ug intranasally qhs x 3 nights and if no effect increase to 30 ug intranasally qhs x 3 nights and if no effect increase to 40 ug intranasally qhs x 3 nights

high rate of recurrence once terminated (not curative)
works best in those older than 8 years
response within 1 week

3. Patient Conditioning

Alarm Systems
- Palco
- works best in older children ( > 6 years)
- 10% spontaneous remission but 30% non-responders
- child and family must be motivated for this to work
- expect response over 3-4 weeks with low relapse rate
  - if 2 wks dry -> challenge
  - if 2 wks dry on challenge -> cured
Reward System
- child takes responsibility for problem - changes sheets, star system

5. Others

1. Imipramine

an antidepressant thought to decrease the level of sleep in those children who are deep sleepers
initial dose of 25 mg po qhs; may be increased to 50 then 75 mg po qhs
dose dependent and once dryness achieved a gradual withdrawal over a few months is necessary
effectiveness is not related to serum levels

2. Voiding Routine

void q1.5-2h

Pediatric Database - ENURESIS

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