Transcript Enuresis 2010

Nocturnal
Enuresis
Elizabeth H. Kwon, MD, MPH
DEFINITIONS
• In 2006, the International
Children’s Continence Society
published new standardization
for the terminology of enuresis to
help clarify day and night
wetting.
Incontinence
• Incontinence is defined as the
uncontrollable leakage of urine that may
be intermittent or continuous and occurs
after continence should have been
achieved.
• Continuous incontinence constant urine
leakage (eg. Ectopic ureter, iatrogenic damage to
external sphincter)
• Intermittent incontinenceurine leaking
in discrete amounts during day, night, or
both.
Definitions continued
• Enuresisany urinary wetting that
occurs during the night
• Daytime incontininence urinary
leakage that occurs during the day (no
longer called diurnal enuresis)
• Dysfunctional voiding inappropriate
muscle contraction during voiding that is
usually associated with constipation and
is referred to as dysfunctional elimination
syndrome.
PRIMARY NOCTURNAL ENURESIS
Nocturnal wetting in a child who has never
been dry on consecutive nights for longer
than 6 months in children ages 6 and
older.
SECONDARY NOCTURNAL ENURESIS
-New-onset nighttime wetting on consecutive
nights after a 6-month or greater period of
dryness.
-Usually not due to an organic cause.
-In some cases, a stressful event, such as a birth of
a sibling, a move or the death of a parent or
grandparent, is the source.
-Should be evaluated and treated like primary
without need for additional lab work or studies.
Epidemiology of Nocturnal
Enuresis
• AGE:
– 7 years old: 10%-15 % prevalence
– Each subsequent year, 15% of bed
wetters become dry
– By 15 years of age, only about 1% of
adolescents remain enuretic
Epidemiology of Nocturnal
Enuresis
• SEX:
– Nocturnal enuresis: Boys>girls
– Daytime wetting: Girls>boys
• SOCIOECONOMIC
– Enuresis occurs more frequently in lower
socioeconomic populations and in larger
families
Etiology of Nocturnal Enuresis
Only 3% of nocturnal enuresis has an
organic etiology
Examples of organic symptoms:
– Polyuria
• Diabetes insipidus
• Diabetes mellitus
• Isothenuria (Sickle Cell Disease)
• Alcohol, caffeine, medications
• Habit polydispsia
Examples of organic symptoms (cont’d):
–Urgency/Frequency
• UTI
• bladder calculus from
hypercalciuria or bladder foreign
body
• fecal impaction (impinges on
bladder’s space) leading to
incomplete bladder filling
• lower urinary tract obstruction,
neurogenic bladder or
dysfunctional voiding leading to
incomplete bladder emptying
Sleep Apnea can cause enuresis
• Recent studies have shown that patients
with sleep apnea have increased atrial
natriuretic factor which inhibits the reninangiotensin-aldosterone pathway leading to
increased diuresis.
Tonsillectomy, adenoidectomy or both have
been shown to cure enuresis significantly in
this group of patients.
Etiology of Nocturnal Enuresis
• Since only 3% of nocturnal enuresis is caused by
an organic disease state, most nocturnal enuresis
is caused by a multifactorial combination of the
following:
– Genetics
– Sleep arousal dysfunction
– Urodynamics
– Nocturnal Polyuria
– Psychological Components
– Maturational Delay
Genetics
– If both parents were bedwetters-->77%
chance offspring would have enuresis
– If one parent was a bedwetter--> 45%
chance offspring would have enuresis
– If neither parent--> 15% chance
– Concordance for enuresis is 68% for
identical twins vs 36% for fraternal twins
– Thus, parental age of resolution often
predicts when the child’s enuresis should
resolve.
Sleep Arousal Dysfunction
• By age 5, most (85%) children can associate
between the presence of a full bladder and the
sensation in the brain from a full bladder.
• Daytime urination control is achieved first
followed by the ability to wake up in the night
to the sensation of a full bladder.
• Anecdotally, parents report that the bedwetting
episodes occur with their children who are
difficult to arouse from sleep. However sleep
studies HAVE NOT found an association from
sound sleep cycles and bedwetting.
Nocturnal Polyuria
• There are some children who may have an
abnormal circadian release of ADH. Normally,
based on circadian rhythms, nocturnal urine
production is approximately 50% less than
daytime urine production but this may be
altered in some children who suffer from
enuresis.
• Nocturnal polyuria may also be exacerbated by
caffeine, alcohol, medications, irregular drink
intake, staying up late or its most common
cause—habit polydipsia. The patient must try
to modify these factors.
Psychological Factors
• Children with ADHD have a 30%
increased chance for enuresis vs. controls.
• Enuresis itself clearly also increases
psychosocial problems for the enuretic
child such as poor self-esteem , family
stress and social isolation.
• Enuretic children have lower self-esteem
than children with chronic, debilitating
illnesses.
• Important to assess the psychosocial
symptoms in the patient and family to
decide on the aggressiveness of treatment.
Bladder Dysfunction
• Nocturnal enuresis patients have both
– Smaller-than normal functional bladder
capacities at night
– Higher bladder instability at night compared
with during the day based on urodynamic
studies.
Thus diminished bladder capacity and
abnormal urodynamics may play a role
in some nocturnal enuresis patients.
Maturational Delay
• Children with enuresis have more
– fine and gross motor delays,
– Perceptual dysfunction
– Speech defects.
However, most enuretic children
eventually are cured with or
without treatment.
Maturational Delay
Thus, maturational delay as a hypothesis for the
cause of enuresis may be the most unifying of
theories.
Perhaps the best way to think about the cause of
nocturnal enuresis is a delay in the
– maturation of CNS recognition pathways to
full bladder sensation,
– maturation of circadian rhythms
– maturation of nocturnal ADH surges, &
– maturation of size of the bladder and
bladder stability
Evaluation of Nocturnal Enuresis
• Who should be evaluated?
• Usually, enuresis at 5 years old concerns
parents.
• It does not concern children usually until
around age 7…
• So generally, at age 6, evaluation should
start.
History
1) Primary or Secondary
2) Family history
3) SymptomsPolyuria, Polydipsia, Urgency,
Frequency, Dysuria, Abnormal Urine
Stream, Constant wetness
4) PMHXUTI, Bowel complaints (15 % with
enuresis have encopresis), Sleep Apnea
Symptoms, Sleep Disorders,
Developmental delay, ADHD
Evaluation of Nocturnal Enuresis
• Physical Exam—most will have a normal exam
– Genitalia
• Ectopic ureter, labial adhesions, urethral
abnormalities, traumatized urethra
– Abdomen
• Distended bladder vs. fecal impaction
– Upper airway
• Mouth breathing secondary to adenoidal
hypertrophy
– Neurologic
• Lumbrosacral exam to r/o overlying midline defect
(sacral dimples, hair patches, vascular birthmarks)
• Gait, muscle tone, strength, DTRs and cremasteric,
anal, abdominal reflexes.
– Direct observation of urinary stream if hx. suggests
Evaluation of Nocturnal Enuresis
• Laboratory Tests ( for all workups )
– Urinalysis
• +/- glucosuria r/o diabetes mellitus
• <1.015 specific gravity--r/o diabetes insipidus
– Urine Culture if screening UA shows signs of UTI
• Radiographic tests ( only if has history of UTI )
– Voiding Cystourethrogram and Renal Ultrasound-if symptoms or signs suggest urinary tract obstruction
or neurogenic bladder or history of UTI
– Bladder Ultrasonography (pre- and post- voiding)-to rule out partial emptying
• Sleep studies (if indicated by history)
– To rule out sleep disorders or sleep apnea
Management Principles
• Primary Goal:
protect the child’s self-esteem
“ I knew that bedwetting was a) wicked and b)
outside my control….It was therefore possible to
sin without knowing you committed it, without
wanting to commit it, and without being able to
avoid it….The double beating was a turning
point for it brought home to me for the first time
the harshness of the environment into which I
had been flung…. I had a conviction of sin and
folly and weakness such as I don’t remember to
have had before.”
--George Orwell
Management Principles
In general:
• No punishment.
• Parents should be REASSURED that
bedwetting is due to maturational delay and is
not intentional.
• At ages 6-8 y.o. emotional harm can come from
being different. Children at this age are often
embarrassed and ashamed. They are at an age
when peers begin to sleep away from home. It
is a family secret. Thus, targeted intervention
should be at age 8 at the latest and prior to that
should parents/children request it.
Management Principles
• If there is any other comorbid conditions that
can lead to enuresis, they must be treated
first…
– constipation--stool softeners to have daily
bowel movements
– urinary tract infection---prophylactic
antibiotics
– sleep apnea—adenoidectomy and
tonsillectomy
Treatment
At ages 6 or 7 all that may be needed to decrease the
psychological burden on child and family is to:
-describe the condition,
-provide medical explanations,
-discuss the family history of enuresis
-outline its age-specific prevalence
However, after age 6, if children and family are
bothered by the enuresis and request further
intervention, treatment options should be discussed
and begun.
At age 8, interventions should be actively encouraged
since enuresis is having at least a negative effect on
the child’s self esteem.
Treatment
For maximum efficacy of the treatment program
the child must accept and be motivated to
comply with treatment
AND
the parent must also fully support the child
and the treatment program.
Otherwise the treatment is likely to fail and may lead
only to further frustration and disappointment.
Treatment of Nocturnal Enuresis
MOTIVATIONAL THERAPY
• 1) MAKE SURE THE CHILD WANTS TO DO THIS
– Remove responsibility from parent
– If the child does not want to do the treatment—then
wait til he/she is ready to be an active participant
2)MAKE THE GOAL: WAKE UP EACH NIGHT
AND USE THE TOILET
& forget “hold it til morning” and “make less urine”
– The smaller the bladder, the more important to learn to
wake up.
– The child must do three things: 1)wake up by himself,
2)find the toilet and 3)urinate there.
Motivational Treatment(cont’d)
• 2)MAKE THE TOILET EASY ACCESS
– Nightlight in bathroom
– Portable potty in child’s bedroom
– Bucket or bottle for boys
• 4)AVOID EXCESS FLUIDS 2 HOURS QHS
– No caffeine -- Normal fluid intake is fine
5) LIMIT DAIRY 4 hours QHS
-- to decrease urine output from osmotic diuresis
• 6)EMPTY BLADDER PRIOR TO BEDTIME
– Parental reminders or signs
• 7)NO DIAPERS OR PULLUPS
– Maintain message: no wetting bed
– Makes morning cleanup harder and thus, increase motivation to
wake up at night.
– Use plastic protective mattress cover.
MotivationalTreatment (cont’d)
• 8)INCLUDE CHILD IN MORNING CLEANUP
– Make child strip sheets, stick it in the washing machine
and replace new sheets in a nonpunitive fashion—it’s
just part of the natural consequence of bedwetting.
– Be sure child takes shower to prevent odor
• 9)REMIND PARENTS TO PROVIDE
ENCOURAGEMENT TO THE CHILD
– Provide information sheets to help parents
– Parents must remind and support children with the
belief that they will eventually be dry
• 10) USE A DIARY/CHART
– Reward the child for a dry night--including for waking
up and going to the bathroom
Motivational Treatment (cont’d)
• Success rates with only motivational treatment:
– 25% completely cured
– 70% have a decrease in number of wet nights
– Once cured—relapse rate is low.
– If unsuccessful after 3 to 6 months, a different
treatment program should be tried.
Enuresis Alarms
Alarms are small, portable alarms worn on the
body at bedtime that provide an audio or
tactile alarm in response to wetness—likely a
conditioned response
Goal is to “beat the buzzer” and wake up when
the bladder feels full before the alarm goes off
Enuresis Alarms
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Enuresis Alarms (Cont’d)
• REASONS FOR FAILURE (20-30%)
– Parents d/c too soon—must thoroughly counsel
parent in advance the need to be motivated and to use
nightly x 3 months for effective treatment.
– Child does not hear alarm—
• try tactile alarm
• parents must hear the alarm themselves and wake
the child up and walk with them to the bathroom.
Do not carry child to toilet—the child must be at
least somewhat awake for success.
– Child is scared of dark--use nitelight/flashlight
– Child does not want to use alarm – then use other
techniques.
Enuresis Alarms (Cont’d)
Success is when the child has not triggered the alarm for 1
month because he/she has remained dry.
• ADVANTAGES
– Highest cure rate (~70%) / relapse(~10%) retx.
– No adverse effects
DISADVANTAGES
--Time-consuming-- need to use 2-3 months
--Needs motivated parents to keep reminding
--Not covered by medical insurances costs $80$100
--May disturb sleep for all family
Pharmacologic Therapy
Used to treat---not to cure while
awaiting natural resolution from
maturation.
• 2 MAIN MEDICATIONS:
–DDAVP
– Imipramine
DDAVP (Desmopressin) is the
FIRST LINE CHOICE
– Mechanism of action:
• Synthetic analogue of ADH.
• Decreases urine production by increasing distal
tubule water resorption and urine concentration
overnight.
– Comes in nasal pump and tablets
• Nasal pump not recommended for treatment of
enuresis secondary to reports of severe
hyponatremia leading to seizures and death.
– Use tablets for enuresis
DDAVP (cont’d)
– Dosage: start at 2mg. (one tablet). Increase 2 mg. q
2weeks (max. of 6 mg. qhs)
-- Must limit H20 intake to prevent risk of hyponatremia
– Duration of action: 9 hours
(try to wake kids who sleep longer than that to see if that
helps efficacy)
– Efficacy: “Either works or it doesn’t”—since it only
controls one factor the volume of nocturnal urine
output
DDAVP (cont’d)
– Problem: 94.3% relapse (since it is only a treatment
not a cure)
– Side effects: rare
– Contraindications: habit polydipsia
(hyponatremia)—, hypertension or heart disease
– Cost: Expensive but covered by medicaid/insurance
– General use: Increase dose every 2 weeks to
minimal effective dose, use for 6 months. Then try
off for 2 weeks to see if patient has outgrown the
problem.
Pharmacologic Tx. (Cont’d)
• IMIPRAMINE
– Mechanism of action: anticholinergic effect
increases bladder capacity and norardrenergic
effect decreases bladder detrusor excitability
– Dosage: 25 mg 1 hour qhs (max. 50 mg for
6-12y.o. and 75mg. for >12 y.o.)
– Efficacy: 10-60% but relapse rate off tx. is 90%
– Disadvantages: low toxic/therapeutic ratio
• easy to overdose (#1 fatal poisoning in Britain)
• OD sx.:ventricular tachycardia, coma, seizures
• Mild side effects found in 20% of patients on correct
dose: anxiety, nervousness, constipation, crying,
dizziness, dry mouth and anorexia.
– Cost: Inexpensive--$5/month
Pharmacologic Tx. (Cont’d)
• How to use pharmacologic treatments?
1)Intermittent use for children> 8 years old for special
occasions (camp, trips, vacations)
2)Nightly therapy
3) Combination therapy Use for children>8 years old
with frequent enuresis (>4x/week)
• Children with frequent enuresis and their parents
may become disillusioned by frequent rings of the
alarm and lack of rapid improvement.
• Since there is an earlier increase in the number of
dry nights, combination tx. may increase motivation.
Pharmacologic Tx. (Cont’d)
• Combination Treatment
– Study by Bradbury and Meadow
• 36 patients used 40mcg. DDAVP qhs until success
or maximum of 6 weeks in combo with alarm.
• 35 patients used alarm alone until success or til the
end of the study period.
• Success (14 consecutive dry nights) rate was
significantly greater for the combo tx. (n=27 )
versus the single tx. group (n=13)
• Same number of relapses (2 wet nights in two
weeks after dry for 4 weeks) seen during 6 month
period.
• Similar success and relapse rates in 30 children
subgrouped as having family or behavior problems.
Conclusions
• Physiologic nocturnal enuresis is a primary care
pediatrician problem, and most do not need
urology referral or expensive enuresis programs.
AGE –RELATED TREATMENTS
<8years—motivational and alarm only with intermittent medication
>8 years– continuous medication OR combination alarm and
medication
If patients relapse after being dry for 1 month, then try again with the prior
effective therapy.