Chapter 24: Enuresis and Urinary Tract Infections​​​​​​​

Chapter 24: Enuresis and Urinary Tract Infections​​​​​​​

Enuresis is uncontrolled or unintentional urination that occurs after a child is beyond an age at which bladder control is achieved.

A urinary tract infection (UTI) is an infection in any portion of the urinary tract.

Primary Enuresis

Never achieved bladder control

Secondary Enuresis

Bedwetting after bladder control

Enuresis

Involuntary urination at least twice a week for three consecutive months in a child aged 5 years or older.

Types

• Primary: Never achieved bladder control

• Secondary: Bedwetting after bladder control

Risk Factors:

• Family history

• Twin siblings

• Bladder dysfunction disorders

• Assigned sex at birth: males

• Emotional stressors (e.g., new sibling, divorce)

• Behavioral disorders (e.g., ADHD, anxiety)

Complications: Low self-esteem, body image concerns, social isolation, fear.

• Listen to concerns, correct misperceptions.

• Involve the child in education and management.

• Refer to support groups or counseling if needed.

• Help the child and family understand emotional aspects of enuresis.

• Early intervention can prevent long-term emotional issues.

Enuresis S/S

History of toilet training issues or bowel movement patterns

Chronic or acute illnesses (e.g., UTI, diabetes, sickle cell disease, neurological deficits)

Increased fluid intake, especially in the evening

Restlessness, urinary frequency, urgency

Enuresis Dx

Physical examination to rule out other medical causes

Bladder capacity test

• Expected bladder capacity (ounces) = child’s age + 2 (up to 14 years old)

Pattern record

Enuresis Management & Discharge

Behavioral Therapy

• Reward system – Reward dry nights to reinforce behavior.

• Kegel/pelvic exercises – Strengthens bladder control (for daytime enuresis).

• Retention control training

  • Encourage holding urine to stretch bladder capacity.

• Wake schedules – Wake child at scheduled times to void at night.

Conditioning Therapy

• Urine sensor alarms – Moisture-sensitive device that wakes the child when urination begins.

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Assess the child's self-esteem and coping strategies.

Evaluate family coping and available support systems.

Educate child and family on enuresis management:

• Urinate before bedtime.

• Restrict fluids at least 2 hours before bedtime.

• Avoid caffeinated drinks in the afternoon.

• Use positive reinforcement; avoid punishment or teasing.

• Keep a calendar of wet and dry nights.

• Allow child to help change bed linens after accidents.

• Wake child at scheduled intervals during the night to void.

• Administer prescribed medications.

• Ensure regular, soft, and formed stools.

• Provide emotional support.

Enuresis Medications

Antidiuretic Hormone

Desmopressin acetate – Reduces urine volume.

• Administer orally (not intranasally due to risk of hyponatremia and seizures).

• Monitor intake & output (I&O).

• Monitor electrolytes

• Restrict fluids after dinner.

• Take at bedtime.

• Possible side effects: Headache, nausea.

Tricyclic Antidepressants

Imipramine hydrochloride – Inhibits urination.

• Monitor for suicidal tendencies.

• Treatment duration: 4-6 months, taper gradually.

• Monitor heart rate and blood pressure.

• Take 1 hour before bedtime.

• Give with food to reduce gastric irritation.

• Monitor mood and suicidal tendencies.

• Avoid sun exposure.

Anticholinergics

Oxybutynin chloride – Reduces bladder contractions.

• Monitor effectiveness of therapy.

• Watch for dry mouth and constipation as side effects.

UTI

Bacteriuria (Bacteria in Urine):

• Asymptomatic: No symptoms.

• Symptomatic: Shows symptoms.

Types:

• Recurrent: Multiple episodes of bacteriuria (with or without symptoms).

• Persistent: Bacteriuria not resolved by antibiotics.

• Febrile: With fever.

  • Urosepsis: With systemic infection.

Risk Factors

• Urinary stasis

• Urinary tract anomalies

• Reflux in the urinary tract

• Constipation

• Toilet training onset

• Uncircumcised penis

• Assigned sex at birth: Female (shorter urethra, proximity to rectum)

• Bubble baths

• Sexual activity

• Catheterizations

Complications

• Progressive kidney injury

• Pyelonephritis (kidney infection)

• Urosepsis (systemic infection from UTI)

Specific Infections

Cystitis: Bladder inflammation.

Urethritis: Urethra inflammation.

Pyelonephritis: Infection in upper urinary tract and kidneys.

UTI S/S (Children <2 years old)

Nonspecific symptoms

Jaundice, tachypnea, cyanosis, hypothermia, fever

Poor feeding

Vomiting

Diarrhea

Irritability, lethargy

Frequent urination

Fever

UTI S/S (Children >2 years old)

Vomiting

Enuresis, frequent urination, dysuria

Blood in urine

Constipation

Chills, fever

Malodorous urine

Abdominal or flank pain

UTI Labs/Dx

Urinalysis and Urine Culture

• Most accurate methods

  • Sterile catheterization or suprapubic aspiration (for children <2 years).

• Alternative: Clean-catch urine sample (for cooperative children).

• Avoid excessive fluid intake before sample collection to prevent false-negative bacterial count.

• Send urine specimen immediately for culture.

• Use urinary dipstick for preliminary screening.

Findings Indicative

• Urine culture: Positive for bacteria (E. coli, Proteus, Pseudomonas, Klebsiella, etc.).

• Microscopic examination: Positive for pyuria and bacteria.

• Urinalysis/dipstick:

  • Appearance: Cloudy, hazy, mucus, pus, odor.

  • pH: Alkalemia.

  • Leukocytes: Positive.

  • Nitrites: Positive.

  • RBC: Positive.

  • Protein, glucose, ketones: Negative.

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Used to identify anatomic defects contributing

• Ultrasound: Evaluates kidney and bladder structure.

• Voiding cystourethrogram (VCUG): Assesses urinary reflux.

  • Educate the child and caregivers about the procedure.

  • Prepare the child if catheterization is required.

  • Monitor the child post-procedure per protocol.

UTI Management & Discharge

Nursing Care

• Encourage frequent voiding and complete bladder emptying.

• Promote hydration by encouraging fluids.

• Monitor urine output for changes.

• Prepare for diagnostic tests as needed.

• Administer acetaminophen for pain management.

Medications

• Antibiotics based on urine culture & sensitivity (penicillins, sulfonamides, cephalosporins, nitrofurantoin).

• Route of administration: PO or IV, depending on severity.

• Monitor for allergic reactions to antibiotics.

• Complete the full course of antibiotics, even if symptoms improve.

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Monitor for recurrence: dysuria, frequency, urgency.

Preventive measures:

• Wipe front to back after toileting.

• For uncircumcised clients, retract and clean foreskin before replacing.

• Change diapers frequently.

• Use cotton underwear for breathability.

• Hydrate adequately with caffeine-free beverages.

• Avoid bubble baths, which can irritate the urethra.

• Encourage frequent voiding and complete bladder emptying.

• Prevent constipation by increasing fiber intake.

• Sexually active individuals should void immediately after intercourse.

• Recurrent history

  • Follow up with a repeat urinalysis 7 days after treatment.