Transcript Enuresis - OU Medicine

Enuresis
Stephen Confer, MD
Ben O. Donovan, MD
Brad Kropp, MD
Dominic Frimberger, MD
University of Oklahoma
Department of Urology
Section of Pediatric Urology
Enuresis
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Involuntary discharge of urine
Nocturnal enuresis - nighttime wetting
Diurnal enuresis - daytime wetting
15% normal children have nocturnal
enuresis at 5 years of age
• 99% are dry by age 15
• Nocturnal enuresis is 50% more common in
boys
• More girls dry day and night by age 2
Enuresis
• 80% enuretics are wet only at night
– most are primary enuretics - never been dry
• 25% are secondary enuretics
– initially dry at night by age 12
– relapse for 2.5 years
– may be associated with emotional stress
• Only 10% who develop daytime dryness relapse
– wet for 1.2 years
Rule of 15’s
Development of Urinary Control
• Infant
– spontaneous micturation as a spinal cord reflex
– distention simulates a detrusor contraction
– voluntary sphincter is integrated into the reflex
• constricts to prevent incontinence
• relaxation during micturation
• low pressure voinding
– As bladder capacity increases and fluid intake
decreases, number of voidings decrease
Development of Urinary Control
• Development of adult type control
– Capacity of the bladder must increase
– Voluntary control over the striated sphincter
• usually complete by 3 years
– Direct volitional control over the spinal micturition
reflex to initiate or inhibit bladder contraction
• Complete by age 4
Development of Urinary Control
• Order of Control
– Control of bowel at night
– Control of bowel during the day
– Control of bladder during the day
– Control of bladder at night
Etiology
• Nocturnal enuretics
– normal psychologically and physiologically
– fail to awaken when bladder is full or contracts
– unknown etiology
Etiology
• Urodynamic Factors
– Reduced bladder capacity by 50%
• anticholinergics increase capacity by 25 - 60%
– Bladder instability seen in many with day and night enuresis
• in children with daytime symptoms of frequency/urgency
• anticholinergics are helpful
– Those with nocturnal enuresis do not have a higher incidence
of daytime instability
• nighttime contraction is just as likely to wake the child as to cause
wetting
• anticholinergics not effective
Etiology
• Sleep Factors
– Theory that sleep disturbance causing the child to
sleep too deeply or fail to awaken
– Enuretics do not sleep more soundly than controls
– Enuresis occurs in deep sleep and in REM sleep
– Enuresis may be a developmental delay
• perception and inhibition of bladder filling and
contraction by the CNS
Etiology
• Sleep Factors - Types of Enuresis
– Type I
• Stable bladder with EEG response during enuresis
– Type IIa
• Stable bladder with no EEG response during enuresis
• 80% change to I
– Type IIb
• Unstable bladder with no EEG response during enuresis
• 20% change to IIa
• 60% change to I
Etiology
• Alteration in Vasopressin Secretion and
Nocturnal Polyuria
– High ADH as night leads to less urine production
– Enuretics have stable ADH during the day and night
• larger amounts of dilute urine at night
• may be delayed development of the ADH circadian
rhythm
– ADH levels increase normally with bladder fullness
• Bladder emptying may cause decreased nighttime ADH
levels in enuretics
Etiology
• Developmental Delay
– Altered urodynamic function, sleep and ADH
secretion occur normally in infants and young
children
– Nocturnal enuresis may be an arrest in development
– Each physiologic alteration tends to resolve
spontaneously
– Neurologic disease is rare with monosymptomatic
nocturnal enuresis
Etiology
• Developmental Delay
– Stress has been shown to delay development of
urinary control
• enuresis is 3 times higher when associated with stressful
circumstances
– Associated with encopresis 10 - 25%
• delay in development is not isolated to urinary control
Etiology
• Genetic Factors
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33% fathers
20% mothers
One parent enuretic - 44%
When mother and father were enuretics, 77%
children affected
– 15% enuresis in children of nonenuretics
Etiology
• Organic Urinary Tract Disease
– Enuretics are predisposed to UTIs
• especially girls
• many have diurnal symptoms due to bladder instability
– Most with monosymptomatic nocturnal enuresis do not have an organic
cause <10%
• meatal stenosis is not a cause - meatotomy does not cure
– Increased incidence of organic abnormalities with diurnal symptoms
• These may need U/S to exclude obstruction - esp. boys
• controversial
Evaluation
• Families with a history of enuresis await
spontaneous cure - more tolerant
• Families without such a history can place great
pressure on the physician to perform tests and
produce a cure
• Urologic tests are rarely indicated for
monosymptomatic bedwetters
– Rarely find an organic lesion
Evaluation
• Negative Screening Evaluation for Enuresis
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Prepubertal age
Lifelong enuresis
Nocturnal enuresis only
No daytime wetting, urgency, polyuria
No UTI
Negative UA and Culture
Normal PE - including neurologic exam
Evaluation
• Screening creates 3 groups
– Children with nocturnal enuresis
• no further evaluation
– Children with UTI or neuropathy
• full urologic workup
– Children without UTI or neuropathy with day and
night enuresis or dysfunctional voiding
• U/S to exclude anatomic abnormality
• Assesses hydro, bladder wall thickening, emptying
Evaluation
• Screening creates 3 groups
– Normal U/S
• pharmacologic therapy is symptoms are not severe
• If dysfunction persists or is severe - Urodynamics to
exclude neuropathy and guide further treatment
Treatment
• Treatment is discouraged before age 7
– less successful
– age when bedwetting interferes with social activities
Treatment - Drug Therapy
• Anticholinergics
– Only 5 - 40% effective (equal to placebo) in
nocturnal enuretics
– useful to eliminate bladder instability
• urgency, frequency, day and night incontinence (87%)
• more effective in urodynamically proven instability (90%)
Treatment - Drug Therapy
• Reduction of Urinary Output
– limiting fluids in the day is not effective
– DDAVP - intranasal or oral
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significantly reduces number of wet nights
only 25% dry for 14 or more consecutive days
temporary treatment - only 33% cured
may lead to hyponatremic seizures - limit fluids before
administering dose
• not first-line treatment
Treatment - Drug Therapy
• Imipramine
– Cure > 50% Improvement - 80%
– Discontinuation - 60% relapse
– Peripheral action
• weak anticholinergic
• weak smooth muscle antispasmotic
– Central action
• antidepressant activity not involved
• decreases REM early sleep - less enuresis early in the
night and more common in the last third of sleep
– does not lead to more awakenings at night
– effect on sleep is independent of its effect on enuresis
Treatment - Drug Therapy
• Imipramine
– Recommended dosage
• 25 mg age 5-8
50 mg for older children
• results in optimal plasma levels in only 30%
• increased dosage not justified
– toxicity
– 25% are nonresponders despite higher doses
– 2 week trial
• adjust dosage and timing of administration
– Long-term effects not known in children
• weaning the drug reduces relapses
Treatment - Behavior Modification
• When used in a motivated family, result in most
effective rate of sustained cure
• 1st line therapy in these patients
Treatment - Behavior Modification
• Bladder Training
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goal is to increase the time interval between voiding
enlarges functional capacity of bladder
Child is encouraged to retain urine after 1st urge
When combined with conditioning therapy, very
successful
Treatment - Behavior Modification
• Responsibility Reinforcement
– motivation
• child assumes responsibility for wet and credit for dry
– reward
• with progressively longer dry intervals
– response shaping
• as a consequence of rewards for behavioral changes
– reinforcment
– Part of a multicomponent behavioral program
Treatment - Behavior Modification
• Conditioning Therapy
– Use of a urinary alarm is the most effective for
nocturnal enuresis - 80% cure
• child wakes up and voids in toilet
• followed by sensation of a full bladder and production of
the same inhibition as the alarm
• failure is often due to lack of parental understanding and
cooperation
• may take months
Treatment - Behavior Modification
• Conditioning Therapy
– Once enuresis is cured (2 weeks dry) relapse is
reduced by overlearning techniques
• forcing fluids prior to bed - bladder overdistention
provides a stronger conditioning stimulus
• reinforced by alarm sounding intermittently some nights
but not others
– May be combined with pharmacotherapy
Adult Enuresis
Occurs in 2 cases
– Persistent primary enuresis - 1% of the population
• More have urodynamic abnormalities (30 - 70%)
• Not due to anatomic abnormality - same as in children
• Treatment similar to that of children
– Secondary adult onset enuresis
• Requires anatomic investigation, neurologic evaluation
and urodynamics
• Occurs with obstructive sleep apnea
– increased atrial natriuretic peptide and activation of reninangiotensin system
Summary
• Exclude- infection, neuropathy, obstruction
• Reassurance- harmless, perhaps genetic,
high rate of spontaneous resolution
• Recognize- not all parents and children are
ready for therapy
• Begin with conditioning therapy and
behavior modification
• Add the use of medications as necessary