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Enuresis

Management of Enuresis in children. Adapted from Dr Anne Wright's paper.
by

Krishnan Balasubramanian

on 21 June 2010

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Transcript of Enuresis

Management History Definitions 3 System Model Enuresis Dr K Balasubramanian
Paediatric Consultant
Maidstone Hospital
Any type of wetting episode that occurs in discrete amount during sleep in a child >5 years of age.


Long standing no bladder control attained


Had a dry period at night for at least 6 months


Only have enuresis as a single symptom


Have additional lower urinary tract symptoms +/- bladder dysfunction
Enuresis Primary Secondary Monosymptomatic Non-monosymptomatic Epidemiology Why? Nocturnal polyuria
Urine production normally falls at night to <50% of daytime levels

Definition: >130% of expected bladder capacity

EBC 2-12 yrs:
(age in years x 30) + 30 ml
Lack of arousal
Fundamental problem for all

Not because of deep sleep

Can occur at any stage of sleep

Disorder of brainstem arousal
Reduced bladder capacity
Overactive bladder
Constitutionally small bladders

< 65% of EBC

Spontaneous involuntary detrusor contraction during filling/ storage phase

Lower urinary tract symptoms +


Hereditory
Stress
Infections – UTI
Metabolic -DI / DM ,hypercalciuria
Ectopic ureter, Neurogenic bladder
Obstructive uropathy
Other causes Enuresis profile Severity
Primary / Secondary

Child ever wakes to stimuli?

Early wetting, large amount, more than once

Single void, late at night, dry if sleeps shorter

Daytime symptoms – urgency, frequency
Wets more than once at night, small amounts
Wakes up after wetting


Lack of arousal Polyuria Small Bladder / Arousal Overactive bladder Symptoms of bladder dysfunction Complications Difficulty to initiate void
Stop-start stream
Dribbling
Abdominal straining
Need to sit to void in boys
Discomfort Known renal tract anomalies
Recurrent UTI
Constipation +/- soiling
OSA /Sickle cell disease Neuro Developmental issues Motor disorder
Learning difficulties
ADHD
ASD
Child & Family
factors Child's motivation
Parents'tolerance
Child's drinking / voiding patterns
Bedtime routines
Sleeping arrangements
Family h/o enuresis
? NAI What is it? Examination &
Investigations BP
Abdomen: bladder/ faecal mass

Spina bifida
Urethral meatus, urinary leakage, excoriation

Urine dipstick

USG – KUBU (pre & post voiding)
Uroflowmetry
Treatment General measures
6-8 drinks a day (1500ml/m2)
6 voidings a day
Avoid tea, coffee, coke, blackcurrant
Avoid drinks 1-2 hrs before going to bed

Easy access to bathroom, lighting
Not to use nappies but mattress protectors, duvet/ pillow covers
Not to lift child while sleep

Encourage regular bowel opening
Star chart / positive reward
Specific measures
Nocturnal polyuria Desmopressin
Tablets / melts
Start at low dose
Avoid drinks 1hr before and 8 hrs after

Responds quickly
Relapse rates high

Can be used for long term with a break of 1 week every 3/12
Overactive bladder Bladder retraining
Anti-cholinergics Oxybutynin /Tolteridine

Makes dysfunctional voiding worse
Lack of arousal Enuresis alarm Oldest specific treatment

Body warn / bed alarm / wireless
Children have to wet to trigger the alarm

Alerts who are able to wake
Needs at least 12-16 week to work

Provided in the community
Reference: Evidence based assessment and management of Childhood enuresis.
Anne Wright, Paediatrics and child health 18:12 ? Thank you I
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