Childhood enuresis

1. Childhood Enuresis
Material by : Dr Mohamed Yassin
Ass. Prof. Of urology
Ain Shams university
Presentation by : Ahmed Tawfeek

2. Bedwetting Is Common
• 15 – 20% of over five year olds (1 in 6)
• 7% of seven year olds (1 in 14)
• 5% of ten year olds (1 in 20)
• 2-3% of twelve-fourteen year olds (1 in 30)
• 1-2% of over fifteen year olds
• Boys outnumber girls by nearly 2 to 1

3. What is Primary Nocturnal
?Enuresis
• Child has never been reliably dry at night but is dry by
day
• Absence of other urinary symptoms or signs of disease.

4. Primary Nocturnal Enuresis -
Causes
• Small functional bladder capacity
• Decreased awareness of full bladder whilst asleep
• Nocturnal polyuria
• Genetic factors – (family history)
• Stressful early life events

5. Some Other Causes of
Enuresis
• Secondary enuresis can be a manifestation of a
psychological cause
• Detrusor instability / pelvic floor weakness
• Urinary Tract Infection
• Constipation
• Diabetes (Mellitus & Insipidis)
• Chronic Renal Failure
• Congenital Abnormality e.g. ectopic ureter, posterior
urethral valves
• Neurological causes

6. History
• Is it primary or secondary enuresis?
• When? Night only?
• Circumstances of enuresis i.e. one large patch of urine
on the sheets versus many small patches.
• How many nights per week?

7. History
• Family history
• Other symptoms e.g. constipation, polydipsia
• Any emotional upsets / recent life events
• Methods tried so far

8. Examination & Investigations
Examination:
weight, blood pressure, abdomen, genitalia,
neurological function
Investigations:
Urine dipstix
(If suspicious about physical cause: Ultrasound, bloods etc)

9. Management
• Decide on diagnosis and treat cause accordingly
• E.g. referral for any suspected underlying physical /
psychological condition or structural abnormality
• Treat infection / constipation

10. Primary Nocturnal Enuresis
- Management
• Children will almost always grow out of bedwetting but
this can take years.
• Simple strategies
• Enuresis alarms
• Dry bed training
• Drug therapy

11. Management – Simple
Methods
• Explanation & reassurance.
• Use of star charts and other methods of positive
reinforcement. Ignore wet nights.
• Toileting immediately before bedtime.
• Avoiding too many drinks close to bedtime (but do not
encourage dehydration).

12. Unhelpful Strategies
• Lifting – taking the child to the toilet and allowing the
child to empty his bladder whilst still asleep. This may
stop the bed from becoming soiled but does not teach
the child to wake when the bladder becomes full.

13. Management - Alarms
• Sensor worn in the underpants or as a pad on the bed.
When the child passes urine, an electrical circuit is
completed and an alarm rings, waking the child.
• This method works by conditioning. i.e. if the child
becomes used to waking at night to pass urine, they will
eventually start to wake before they wet the bed.

14. Management - Alarms
• Need to have supportive parents
• Can be disruptive i.e. by waking up the household.
• Some children can sleep through the alarm. In this case it
is important that the parents fully wake the child in
order for the alarm be effective

15. Management – Dry Bed
Training
• Combination approach of enuresis alarms, waking
routines, positive encouragement, rewards for dryness,
cleanliness training & bladder training

16. Management – Drug Therapy
• Desmopressin
• Imipramine (& other tricyclics)
• Oxybutanin

17. Management - Desmopressin
• Available as a nasal spray (Desmospray) or tablet
(Desmotabs 200mcg – 400mcg at night)
• Mimics the action of anti-diuretic hormone and therefore
makes urine more hypertonic & less vol.
• Useful for short-term relief from enuresis i.e. allowing the
child to sleep away from home.
• Maximum length of treatment should be 3/12 and
reassess
• Treats the symptom not the cause.
• Should be used if diabetes insipidis is the cause.

18. Management - Imipramine
• Tricyclic antidepressant
• Mechanism of action in enuresis is not fully understood
• Anticholinergic and antidiuretic properties
• Treats symptom not cause therefore relapse on
discontinuation is common (BNF)
• Maximum duration of treatment 3/12 before
reassessment

19. Management - Oxybutinin
• May have a role if detrusor overactivity is thought to be
the cause
• Otherwise ineffective in primary nocturnal enuresis

20. Evidence Based Medicine
• Children given alarms are 13 times more likely to
become dry than children without alarms.
• 60-70% of children will succeed with an alarm
• Dry bed training is effective but no more so than using
an alarm alone and is ineffective without an alarm.

21. Evidence Based Medicine
• Children given Desmopressin have, on average, 2.2 fewer
wet nights per week than placebo and are 4.5 times
more likely to become dry at night.
• However this improvement vanishes on discontinuing
treatment compared to placebo.

22. Evidence Based Medicine
• Children receiving Imipramine have 1.3 fewer wet nights
and are 4.2 times more likely to be dry than children
given placebo.
• No reliable data on whether they remain dry after
treatment

23. Evidence Based Medicine
Desmopressin Vs Imipramine
• Both drugs have comparable effects during treatment
and 6 weeks after treatment
• However, Desmopressin has less potentially severe
adverse effects than Imipramine

24. Evidence Based Medicine
Conclusion
• 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