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					 NOCTURNAL
 ENURESIS

DR DORIS M.WANJIRU KINUTHIA.
 CONSULTANT PAEDIATRICIAN
     & NEPHROLOGIST
DEFINITION OF NOCTURNAL ENURESIS

 Repeated voiding of urine ,whilst asleep in a
  child 5 years or more.
 Voiding may be involuntary or intentional
 May occur at least twice weekly in 3
  consecutives weeks
 Child may have significant distress
DEFINITION OF NOCTURNAL ENURESIS

NOCTURNAL ENURESIS-Nocturnal Incontinence
Category of Enuresis
 MONOSYMPTOMATIC
        Night time symptoms only (80%).

 NON-MONOSYMPTOMATIC
        Day and night-time symptoms (20%).
     DEFINITION OF NOCTURNAL ENURESIS


 PRIMARY
  Child has never been dry for an extended
  time(3-6 months).
 SECONDARY
 Incontinence that begins after a child has
  been dry for 3-6 months.
SEVERITY
     STAGE 111: At least once a month
     STAGE1V: At least twice a week
Epidemiology: Prevalence of
Nocturnal Enuresis
 Age 2 years: 82%
 Age 3 years: 49%
 Age 4 years: 26%
 Age 5 years: 15-25%
 Age 12 years:         Boys: 8%;   Girls: 4%
 Age 18 years:         Boys: 1%;   Girls: rare
  CAUSES OF URINARY INCONTINENCE

WITHOUT POLYURIA
 Primary noctural enuresis
 Dysfunctional voiding syndromes
 Spinal cord abnormalities.
 Neurogenic bladder
 Seizure Disorders
 Anatomical defects of the urinary tract.
 Posterior urethera valves in boys
 Ectopic Ureter in girls
CAUSES OF URINARY INCONTINENCE

WITH POLYURIA
 METABOLIC DISORDERS
   Diabetes Melittus or Central Diabetes
   Insipidus.Hypercalcemia or Hypokalemia
 MEDICATION (e.g. Diuretics)
 RENAL CONCENTRATING DEFECT
  Nephrogenic diabetes(genetic or secondary)
  Deranged circadian
                               Developmental
    ADH secretion
                                   Delay


                                           Psychosomatic
                                           manifestation

    Genetic         PRIMARY NOCTURNAL
 predisposition          ENURESIS
                                            Sleep arousal
                                             disturbance



   Deranged                   Dertrusor/sphincter
Bladder reservoir                Dysfunction
NOCTURNAL ENURESIS
 SLEEP AROUSAL DISTURBANCE
 UNDERLIES MOST CASES OF
 NOCTURAL ENURESIS
MICTURATION REFLEX



 A two phase cycle
 Is a protective mechanism for the kidneys
 Consists of Filling (storage) Phase and
  Emptying Phase
 Micturation Reflux is uninhibited in newborn
 Control or inhibition of this reflex is learnt
  as we grow
INNERVATION OF THE BLADDER
CONTROL OF THE MICTURATION REFLE



Dependent upon two systems:
1. RECEPTORS AND CHEMICALS
   To maintain a delicate balance for proper
   muscle operation
2. AN INTACT NEUROSENSORY PATHWAY
   between the brain, spinal cord and bladder.

RECEPTORS in the bladder communicate with
RECEPTORS in the brain via the spinal cord.
INNERVATION OF THE BLADDER
Pathophysiology and
Physiology
Maturity delay:

 Enuresis Prevalence decreases with age


 “Bladder full” signal does not yet work
PATHOPHYSIOLOGY OF ENURESIS


                            REDUCED
   SLEEP                    BLADDER
 POLYURIA                   CAPACITY

             FULL BLADDER
              WAKING UP?
     YES                       NO

  NOCTURIA                  ENURESIS
PNE & Impaired Arousal response

 Elevated Arousal threshold= reduced startle
  in enuretics ?? pontine dysfunction.
 Arousal disturbances & reduced ability to
  inhibit bladder activities & micturation during
  sleep may arise from a brainstem
  dysfunction.
DIURNAL VARIATION IN PLASMA
VASOPRESSIN &URINE PRODUCTION
 ADH-Vasopressin controls water reabsoption
 Norgaard et al were the first to report absence of
  expeced nocturnal ADH production in children with
  noctural enuresis (NE)
 Low nocturnal ADH secretion is present in some
  not all children with NE
 Bladder distension increases nocturnal ADH
  production
LOW NOCTURNAL BLADDER CAPACITY

 Some children with NE have low nocturnal
  functional bladder capacities.
 This leads to contraction of the detrusor
  muscles at lower volumes.
 Low nocturnal activity of the external
  urethral sphincter may trigger the detrusor
  contraction.
HISTORY TAKING



Voiding History (Voiding diary helpful)

 Does child meet STAGE IV criteria for enuresis above?


 Has the child ever been dry? (primary or secondary)


 Is there daytime enuresis?   (complicated enuresis)
HISTORY TAKING


Bowel or bladder habit changes

 Dysuria


 Infrequent or difficult stool passage


 Encopresis
HISTORY TAKING


Functional bladder disorder signs

 Voids >7 per day with urgency, and small volumes


 Withholding urine last minute


 Wets more than once nightly
HISTORY


Nocturnal Polyuria

 Enuresis on only a few nights per week


 Voids large volumes when enuresis occurs
 Nocturnal urine volume >130%x EBC
 Expected Bladder Capacity EBC (Hjalmas formula)
             =Age in years x30mls+30mls
Other related history



 Birth complications
 Neurologic disorders
 Genitourinary surgeries
 Family History of enuresis
PHYSICAL EXAMINATION




 Gait Evaluation for neurologic dificits
 Abdominal and flank exam
   • Costovertebral angle tenderness (CVA
     tenderness)
   • Abdominal masses
   • Bladder enlargement
    Back examination
   • Spinal Dysraphism signs
LAB URINALYSIS



 Signs of Urinary Tract Infection


 Urine Specific Gravity (to exclude diabetes insipidus)


 Urine Glucose( to exclude diabetes mellitus)
IMAGING STUDIES

 For exclusion of functional or structurual obstructive
    lesions.
   Micturating Cystourethrogram
   Urodynamic Studies for diagnosis of neurogenic
    bladders
   Magnetic Resonance Imaging of Spine
   If triad exists Encopresis,Gait abnormality and
    bedtime wetting
Other Imaging Studies


 Uroflowometry
  -    Measurement of urine flow.
  -    Useful in Neurogenic bladder and urethral
  obstruction.

 Electrocardiography
  -    If heart block is suspected.
Management: General

  Reassure parent with age-related norms
  Assess for organic causes.
  Complete history and physical with
   Urinalysis
  No further evaluation necessary if normal
   results
  Counsel family regarding conflict surrounding
   enuresis
General Recommendations


 Enlist support and co-operation of child
 Older children launder their own soiled clothes


   -    Should not be punishment
   -    Allows child’s participation and responsibility
MEDICAL-SURGICAL TREATABLE CAUSES OF
NOCTURNAL ENURESIS




 Ectopic Ureter
 Lower Urinary Tract Obstruction Neurogenic Bladder
 Bladder calculus or foreign body
 Sleep Apnea secondary to large adenoids
MEDICALLY TREATABLE CAUSES OF
NOCTURNAL ENURESIS

Psychiatric illness (in only 20%)
 More common in enuretic girls
 Suggested by enuresis both night and dayMore likely if enuresis
  in older child

Regressive enuresis (occurs after being dry)
 Associated with stressful environment even
 Children with HYPERACTIVITY ATTENTION DEFICIENT
  SYDROME often have NE
NE Management: Non-
Pharmacologic Therapies

Appropriate Toilet Training:
 Scheduled voiding times (especially in evening)
 Behaviour Modification
   •   Bed-Wetting Alarm (Most effective treatment for
       nocturnal enuresis)
   •   Visualization techniques
   •   Void just before bedtime
   •   Limit fluids 1 hour before bedtime
   •   Scheduled awakening during night to void
       ( Not recommended by some)
Positive reinforcement system


 Charts the child’s progress of dry nights


 Child is given stickers on calendar or points per
   dry night
BEHAVIORAL THERAPY



Directions: Tell the child to:
 Lie on your bed with your eyes closed.
 Pretend it’s the middle of the night.
 Pretend your bladder is full.
 Pretend it is starting to ache.
 Pretend it is trying to wake you up.
 Pretend it is saying, “Get up before it’s too late”

The child then gets up, walks to the bathroom
and urinates.
USE OF SIGNAL ALARM IN PNE &
MECHANISM OF ACTION

 Alarm is worn near genitals
 It is a moisture sensing device
 It is triggered by the wetness
 Evokes behaviour conditionng
 Two thirds become dry during treatment
 One half remain dry after treatment
Management: Pharmacologic
Therapies

Try to avoid medications if possible

 Medications are only effective briefly
 Drug torelance is common
 Symptoms are exacerbated after drug is discontinued
 Adverse effects are common
 If used, avoid in under age 6 years
Management: Pharmacologic
Therapies
Medications

dDAVP (Desmopressin, Intranasal ADH) or tablets
 For intermittent use on overnights or summer
  camp
 Nasal irritation or Epistaxis commonly occur
 Uncommon risk of water intoxication (use caution)
 Effective but high relapse rate
DESMOPRESSIN THERAPY


Desmopression (DDAVP)

 It is a Vasopressin analog
 Increase cellullar permeability of collecting fluid
 Leads to reabsorpsion of water by kidney
 Reduces urine outflow


(Availability as tablets and nasal spray)
DESMOPRESSIN PAEDIATRIC DOSAGE


Tablets or Nasal spray
 < 6 years Not Recommended
 Tabs 6 years 0.2mg per oral nocte.Titrate upwards
 max dose 0.6mg Po. (OD)
 Nasal spray10-40mcg 1-4 sprays of 100mcg/ml
 Restrict fluid intake in the evening 100mls.
 No fluid 2 hours prior to bedtime
 Adverse effects
 Fluid intoxication .Hyponatraemia
ANTICHOLINERGIC DRUGS


For children with small bladder capacities:
 Day time wetting OXYBUTYNIC (DITROPAN)


Paediatric dose - Nocturnal Enuresis
 0.1 mg/kg at night
 Max 5mg/dose
 Day and night Enuresis
 0.1mg/lg BD
Adverse Effects
 Constipation HOT flashes
 Blurred vision, interferes with perspiration
ANTICHOLINERGIC DRUGS


Tolterodine Detrol

For small capacity bladders

 12 years 0.5 – 1mg PO (OD or BD)
 Caution in liver or renal impairment.
Imipramine (Trofranil)

 Facilitates urine storage by decreasing bladder
  contractility and increase outlet resistance.
 Inhibits uptake of norepinephrine or serotonin at
  presynaptic neuron.
 6-12 years 25mg to 50mg PO nocte
 12 years 25-50mg PO nocte
Adverse effects
 Overdose maybe fatal--cardiac arrhythmias
 Cardiac conduction disturbances
PROGNOSIS OF NOCTURNAL ENURESIS


 Treatment restores self-esteem
 Secondary psychological and behaviour proteins
   1are eradicated.
 Spontaneous cure rate of NE is 15% per year.
Treatment with DDAVP leads to dryness in 75%
of children
When NE occurs with daytime symptoms,
prognosis depends on underlying cause.
REFERENCES NOCTURNAL ENURESIS


 Cendron (1999) Am Fam Physician 59(5): 1205-20
 Evans (2001) West J Med 175: 108-11
 Redsell (2001) child Care Health Dev 27(2): 149-62
 Thiedke (2003) Am Fam Physician 67(5): 1007-18
 Ullom (1996) Am Fam Physician 54(7): 2259-71
 Wan (1997) Pediatr Clin North Am 44:1117-31
THANK YOU FOR YOUR
ATTENTION

				
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