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					  The ICCS MNE standardisation document



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These slides are produced by the International Children’s
Continence Society (ICCS) and may be freely used for
educational purposes as long as they are not altered and
the source is acknowledged.

The originals can be found at the ICCS website:
www.i-c-c-s.org


     Evaluation and treatment of monosymptomatic enuresis - a standardisation docu-
     ment from the International Children’s Continence Society (ICCS).
     Nevéus T, Eggert P, Evans J, Macedo Jr A, Rittig S, Tekgül S, Vande Walle J, Yeung
     CK, Robson L. 2009
   The ICCS MNE standardisation document

An attempt to reach a consensus on recommended
evaluation and treatment of children with
monosymptomatic nocturnal enuresis, based on the
evidence and experience available in 2009

Authors:
T Nevéus (Sweden), P Eggert
(Germany), J Evans (UK), A Macedo Jr
(Brazil), S Rittig (Denmark), S Tekgül
(Turkey), J Vande Walle (Belgium),
CK Yeung (Hong Kong), L Robson (Canada)

Endorsement also from the AAP, ESPU and ICS

       Evaluation and treatment of monosymptomatic enuresis - a standardisation docu-
       ment from the International Children’s Continence Society (ICCS).
       Nevéus T, Eggert P, Evans J, Macedo Jr A, Rittig S, Tekgül S, Vande Walle J, Yeung
       CK, Robson L. 2009
                             Background: definitions

   Enuresis:
   Intermittent (i.e. not continuously dribbling) incontinence
   while asleep in a child at least five years of age*

   Monosymptomatic nocturnal enuresis (MNE):
   Enuresis in children without any other lower urinary tract
   symptoms*

   But:
   Pathogenesis, evaluation and treatment overlap between
   MNE and non-monosymptomatic nocturnal enuresis (NMNE)
* Nevéus T, von Gontard A, Hoebeke P, Hjälmås K, Bauer S, Bower W, et al. The standardisation of
terminology of lower urinary tract function in children and adolescents: report from the standardisation
committee of the International Children’s Continence Society (ICCS). J Urol. 2006; 176(1): 314-24

            Evaluation and treatment of monosymptomatic enuresis - a standardisation docu-
            ment from the International Children’s Continence Society (ICCS).
            Nevéus T, Eggert P, Evans J, Macedo Jr A, Rittig S, Tekgül S, Vande Walle J, Yeung
            CK, Robson L. 2009
       Background: pathogenesis, comorbidity

Etiology
Often inherited

Pathogenesis
Nocturnal polyuria and/or detrusor overactivity and high
arousal thresholds. Thus: inability to awaken from sleep in
spite of nocturnal bladder (over-)filling and/or nocturnal
detrusor contractions.

Comorbidity
Constipation and/or psychiatrical comorbidity not uncommon
(but this is more typical for NMNE than for MNE)

     Evaluation and treatment of monosymptomatic enuresis - a standardisation docu-
     ment from the International Children’s Continence Society (ICCS).
     Nevéus T, Eggert P, Evans J, Macedo Jr A, Rittig S, Tekgül S, Vande Walle J, Yeung
     CK, Robson L. 2009
Background: epidemiology and prognosis


    %
    14
    12
    10                   Wet occasionally
    8
    6
             Wet
    4
             every
    2        night

            2    4   6     8   10 12 14 16 18 20              Age




Evaluation and treatment of monosymptomatic enuresis - a standardisation docu-
ment from the International Children’s Continence Society (ICCS).
Nevéus T, Eggert P, Evans J, Macedo Jr A, Rittig S, Tekgül S, Vande Walle J, Yeung
CK, Robson L. 2009
              Primary evaluation: case history
General
Health and development. Weight loss? Excessive thirst? UTIs?
Timeframe
Primary/secondary enuresis? Frequent/sporadic accidents?
Bladder
Daytime bladder symptoms, now or previously? Voiding frequency.
Bowel
Constipation symptoms, fecal incontinence?
Behaviour
Problems at home or at school? Distressed by enuresis?
Previous treatment strategies
Which strategies have been used? Have they been used correctly?
Other
Enuresis in the family? Difficult to arouse from sleep?

     Evaluation and treatment of monosymptomatic enuresis - a standardisation docu-
     ment from the International Children’s Continence Society (ICCS).
     Nevéus T, Eggert P, Evans J, Macedo Jr A, Rittig S, Tekgül S, Vande Walle J, Yeung
     CK, Robson L. 2009
      Primary evaluation: examinations and tests

Physical examination
(usually unexceptional in pure MNE)
Height, weight, blood pressure, general neurological exam
Genital inspection. Consider rectal exam if constipation suspected

Urine tests
Dipstick test: glucose, leukocytes, protein, erythrocytes and bacteria

Blood tests, radiology, urodynamics
Not indicated in uncomplicated MNE

Bladder diary/voiding charts
Strongly recommended


      Evaluation and treatment of monosymptomatic enuresis - a standardisation docu-
      ment from the International Children’s Continence Society (ICCS).
      Nevéus T, Eggert P, Evans J, Macedo Jr A, Rittig S, Tekgül S, Vande Walle J, Yeung
      CK, Robson L. 2009
             Primary evaluation: voiding charts

Why?
Objectifies history data. Detects NMNE. Detects children who need
extra evaluation. Detects polydipsia. Gives prognostic information.
Detects families with poor compliance.



Recommended
charts can be
found at the ICCS
website!
www.i-c-c-s.org



      Evaluation and treatment of monosymptomatic enuresis - a standardisation docu-
      ment from the International Children’s Continence Society (ICCS).
      Nevéus T, Eggert P, Evans J, Macedo Jr A, Rittig S, Tekgül S, Vande Walle J, Yeung
      CK, Robson L. 2009
                              Warning signs

Enuresis in a previously dry child
Comorbidity (somatic or psychiatric) more common.
Daytime incontinence or other micturition symptoms
NMNE. Voiding charts mandatory. Treat daytime symptoms first.
Weak stream, straining to void, interrupted micturitions
Suspect neurogenic/anatomic bladder problem. Consult urologist.
Weight loss, excessive thirst, nausea
Exclude diabetes or kidney disease without delay.
Glucosuria, proteinuria
Exclude diabetes or kidney disease without delay.
Significant problems with peer relations
Suspect psychiatric comorbidity.


      Evaluation and treatment of monosymptomatic enuresis - a standardisation docu-
      ment from the International Children’s Continence Society (ICCS).
      Nevéus T, Eggert P, Evans J, Macedo Jr A, Rittig S, Tekgül S, Vande Walle J, Yeung
      CK, Robson L. 2009
                   Primary treatment strategy

General advice* given to all children:
Explanation, demystification, removal of guilt
Regular voiding. Sufficient, but non-excessive fluid/solute intake.
Active treatment with the enuresis alarm or desmopressin offered
to children age 6 years or older who are bothered by their condition
   Alternative strategies for the choice of the first therapy

 Present the assets and                      Measure nocturnal urine produc-
                                             tion. Offer desmopressin to
 drawbacks of the alarm and
                                             children with nocturnal polyuria
 desmopressin and let the                    + normal voided volumes. Offer
 family choose                               the alarm to the rest

*Experience based. Evidence level IV
      Evaluation and treatment of monosymptomatic enuresis - a standardisation docu-
      ment from the International Children’s Continence Society (ICCS).
      Nevéus T, Eggert P, Evans J, Macedo Jr A, Rittig S, Tekgül S, Vande Walle J, Yeung
      CK, Robson L. 2009
              First-line therapy: the enuresis alarm*


Assets: Curative potential. Cheap. Harmless
Drawbacks: Requires time, motivation and hard work
Prognostic indicators: best effect in motivated families

Practicalities
Information, motivation and early follow-up are essential!
The parents need to help the child to wake up
Use consistently every night without interruptions
Use until either 14 consecutive dry nights or 2-3 months without effect

New attempts recommended if enuresis recurs
*Evidence level Ia
         Evaluation and treatment of monosymptomatic enuresis - a standardisation docu-
         ment from the International Children’s Continence Society (ICCS).
         Nevéus T, Eggert P, Evans J, Macedo Jr A, Rittig S, Tekgül S, Vande Walle J, Yeung
         CK, Robson L. 2009
                First-line therapy: desmopressin*

Assets: Easy to use. Quick effect. Harmless if not combined with
excessive fluid intake
Drawbacks: Low curative potential
Prognostic indicators: best effect if nocturnal polyuria present and
daytime voided volumes normal

Practicalities
Dosage: oral tablets 0.2-0.4 mg or oral lyophilisate 240-480 ug,
taken 30-60 minutes before going to sleep
Keep evening fluid intake below 2 dL/6 oz, and no nighttime drinking
Stop treatment if no effect within two weeks
Continuous treatment or on ”important nights” only are both OK
 *Evidence level Ia
       Evaluation and treatment of monosymptomatic enuresis - a standardisation docu-
       ment from the International Children’s Continence Society (ICCS).
       Nevéus T, Eggert P, Evans J, Macedo Jr A, Rittig S, Tekgül S, Vande Walle J, Yeung
       CK, Robson L. 2009
         Therapy-resistant enuresis: evaluation

These children should see a pediatrician or pediatric urologist

Case history
Was the alarm correctly used?
Exclude occult constipation. Is there heavy snoring?

Extra evaluations
Voiding charts (if not already performed)
Measurement of nocturnal urine production
Ultrasound (increased bladder wall thickness? Rectal distension?)
Uroflowmetry with measurement of residual urine (recommended)
Consider psychiatric/psychological evaluation



      Evaluation and treatment of monosymptomatic enuresis - a standardisation docu-
      ment from the International Children’s Continence Society (ICCS).
      Nevéus T, Eggert P, Evans J, Macedo Jr A, Rittig S, Tekgül S, Vande Walle J, Yeung
      CK, Robson L. 2009
            Therapy-resistant enuresis: treatment

First line
New attempt with the alarm if incorrectly used
Combine alarm and desmopressin if nocturnal polyuria present
Exclude/treat constipation if present
Consider correction of airway obstruction in heavy snorers
New attempt with the alarm approximately every 2nd year
Second line
Anticholinergics*, with or without desmopressin
First exclude residual urine and/or constipation
Third line
Imipramine**, with or without desmopressin
Please note: cardiotoxic if overdosed! Only to be used by specialists!

 *Evidence level Ib ** Evidence level Ia
        Evaluation and treatment of monosymptomatic enuresis - a standardisation docu-
        ment from the International Children’s Continence Society (ICCS).
        Nevéus T, Eggert P, Evans J, Macedo Jr A, Rittig S, Tekgül S, Vande Walle J, Yeung
        CK, Robson L. 2009
                          Further information

The document is scheduled for publication in the Journal of Urology
February/March 2010, and will be made freely available on the ICCS
website 6 months later

An extended draft version of the document is available for paying
members on the ICCS website

ICCS-approved voiding charts, minimal evaluation protocols and
other materials are available for paying members on the ICCS
website

               ICCS website: www.i-c-c-s.org

      Evaluation and treatment of monosymptomatic enuresis - a standardisation docu-
      ment from the International Children’s Continence Society (ICCS).
      Nevéus T, Eggert P, Evans J, Macedo Jr A, Rittig S, Tekgül S, Vande Walle J, Yeung
      CK, Robson L. 2009