Enuresis

What is enuresis?

involuntary urination

What is nocturnal enuresis?

bed wetting/weeing during the night

What is diurnal enuresis?

inability to control bladder function during the day

What is primary nocturnal enuresis?

where the child has never managed to be consistently dry at night

What is the most common cause of primary nocturnal enuresis?

variation of normal development, particularly if the child is <5 years old

What can be causes of primary nocturnal enuresis?

• overactive bladder- frequent small volume urination prevents development of bladder capacity

• fluid intake prior to bedtime

• failure to wake due to underdeveloped bladder signals and deep sleep

• psychological stress

What are secondary causes of primary nocturnal enuresis?

constipation

UTIs

learning disability

cerebral palsy

How is primary nocturnal enuresis investigated?

2 week diary of toileting, fluid intake, bowel openings, and bedwetting episodes to establish any patterns

history and examination to exclude physical or psychological causes

How is primary nocturnal enuresis managed?

• if <5 reassure that it will likely resolve

• lifestyle changed, eg: reduced fluid intake in the evenings

• encourage, avoid blame and punishment

• treat underlying causes, eg: constipation

• enuresis alarms

• pharmacological management

What are enuresis alarms?

a moisture detecting pad can be placed in the bed, and an alarm goes off when it gets wet. This wakes up the child, and helps them to associate the feeling of a full bladder, with having to wake up. These alarms make children 13x more likely to stop bed wetting, however there is a high relapse rate (up to 50%) and treatment regimens often have to be repeated.

What pharmacological treatments can be used for primary nocturnal enuresis?

desmopressin

oxybutinin

imipramine

What is desmopressin?

synthetic analogue of vasopressin (anti-diuretic hormone) that reduced volume of urine produced by the kidneys. Fluid restricted one hour before taking and eight hours after, so given at bedtime.

small risk of hyponatremia

higher relapse rate than enuresis alarms

What indicated further investigation for primary nocturnal enuresis?

primary enuresis with daytime symptoms - do urine MC+S

What questions are asked for primary enuresis?

• How many times a week?

• At what time does bedwetting occur?

  • Is there a pattern?

• Does the child wake after the wetting

• What is the daytime toilet use pattern?

  • If there are daytime symptoms – consider screening for UTI

• Any constipation?

• Fluid intake

• Any other developmental problems?

• Why have they presented at this particular time?

  • School trip

  • Sleepover

  • Family troubled by the problem

What is secondary nocturnal enuresis?

where a child begins bed wetting when they have been dry for at least 6 months. Normally indicative of something underlying

What are causes of secondary nocturnal enuresis?

• UTI

• constipation

• T1DM

• psychological problems

• maltreatment

safeguarding and abuse are important considerations

What can be asked about for secondary enuresis?

• When did it start?

• Does this correlate with any other changes in the child’s life?

• Bedwetting pattern

  • How often?

  • How may nights per week

  • Any pattern?

  • Does the child wake after bedwetting

What examinations should be done for enuresis?

• Abdominal examination

  • May elicit an enlarged bladder (outflow obstruction), or a mass consistent with faecal loading (constipation)

• Spine – spina bifida

• Lower limb neurological examination – neurological cause

• Perineum

• Urine dipstick (UTI, diabetes)

What are further investigation for secondary enuresis?

• Urine MC+S

• Assessment of constipation

• Blood sugar for diabetes

• Behaviours / emotional issues

• Consider child abuse

• Ask the child if they think it is a problem and what the cause is

What are indications for a paediatric referral for enuresis?

• persistent symptoms despite use of an alarm

• day time enuresis when secondary causes have been ruled out

• history of recurrent UTI

• diabetes identified

• emotional or psychosocial problems

What is the aetiology of enuresis?

• more common in boys and obese children

• frequency tends to correlate with severity

• often FH

• associations with sleep apnoea

• associations with global development delay

What are types of diurnal enuresis?

urge incontinence- overactive bladder that gives little warning before emptying

stress incontinence- leakage of urine during physical exertion, eg: coughing or laughing

What is oxybutinin?

anticholinergic medication reducing contractility of the bladder which can help if there is an overactive bladder causing urge incontinence

What is imipramine?

tricyclic antidepressant- not routinely recommended