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Enuresis practical
Enuresis practical
guidlines
guidlines
Heba mohammed Heba mohammed bahbahbahbah
Micturation reflex
Micturation reflexMicturation reflex
The micturition reflex is overridden by voluntary
control. Descending pathways from the cerebral
cortex can inhibit parasympathetic neurons and
stimulate motor neurons that excite the external
urethral sphincter and thus inhibit the micturition reflex.
AgendaAgenda
•Definition
•Classification
•Prevalence
•Pathogenesis
•Assessment
•Treatment
•Conclusions
DefinitionsDefinitions
IcontinenceIcontinence:- :- Uncontrollable leakage of urineUncontrollable leakage of urine
Continuous intermittentContinuous intermittent
•Urine leakage in Urine leakage in discrete amounts discrete amounts • Applicable to Applicable to children more than children more than 5 years 5 years
Constant urine leakageConstant urine leakageApplicable to all agesApplicable to all agesAssociated with Associated with congenital congenital malformationsmalformations
Night -timeEnuresis
Day- time
Enuresis: Definition Enuresis: Definition
An involuntary wetting during sleep, at least An involuntary wetting during sleep, at least
twice a week, in children older than 5 years twice a week, in children older than 5 years
of age with no congenital or acquired of age with no congenital or acquired
defects of the central defects of the central nervousnervous system system
Enuresis: ClassificationEnuresis: Classification
Primary: Primary: The child has never achieved sustained The child has never achieved sustained continence at night for a period of at least 6 monthscontinence at night for a period of at least 6 months
Mono-symptomatic Without daytime symptoms
Non-mono-symptomatic With daytime symptoms
SecondarySecondary: Bedwetting occurs after the child has been dry at night for more than 6 months
PrevalencePrevalence
PathogenesisPathogenesis
High arousal threshold
Nocturnal polyuria due to nocturnal lack of ADH
Bladder dysfunction: A small bladder capacity or nocturnal detrusor overactivity
geneticsgenetics
Evaluation at the first visitEvaluation at the first visit
Primary with day-time symptoms
Primary without day-time symptoms
Secondary bed wetting
Duration
Daytim
e sym
ptoms
Day time symptoms
Holding manouver hesitancy
urgency frquancy
Urological proplems
Evaluation at the first visitEvaluation at the first visit
Primary with day-time symptoms
Primary without day-time symptoms
Secondary bed wetting
Assessment of Primary Assessment of Primary EnuresisEnuresis
The pattern of bedwettingThe pattern of bedwetting
Assessment of fluid intakeAssessment of fluid intake
Bladder diaryBladder diary
Bowel habitsBowel habits
Psychological assessmentPsychological assessment
comorbidities
The pattern of bedwettingThe pattern of bedwetting
How many nights a week does bedwetting occur?
How many times a night does bedwetting occur?
Does there seem to be a large amount of urine?
At what times of night does the bedwetting occur?
Does the child wake up after bedwetting
Functional bladder disorderWets the bed most nights Ever wets more than once a nightWets small volumes
Nocturnal polyuria Wets one or two nights Wet Large volumes
Assessment of fluid intakeAssessment of fluid intake
Age (years) Volume (mL/day)
Boys Girls
4-8 1000-1400 1000-1400
9-13 1400-2300 1200-2100
14-18 1400-2500 2100-3200
Bladder diaryBladder diary
Bladder capacity= 30+(30 × age )mL Low voided volumes [maximum voided volume <70% of the expected bladder capacity] Nocturnal urine production > 130% of the expected bladder capacity
Bowel habits Bowel habits
• Bowel movement frequency, stool consistencyBowel movement frequency, stool consistency
• Faecal incontinenceFaecal incontinence
Psychological assessmentPsychological assessment
Child
Behavioral problemsHow does the child view his/her enuresis
Parents
Difficulty to cope with the burden of bedwetting Anger, negativity, or blame towards the child
Psychological assessmentPsychological assessment
Child
Behavioral problemsHow does the child view his/her enuresis
Parents
Difficulty to cope with the burden of bedwetting Anger, negativity, or blame towards the child
Assessment of Primary Assessment of Primary EnuresisEnuresis
• Good historyGood history
• Physical examination Physical examination (bad general ,external (bad general ,external genitalial neurological(occult spina bifidagenitalial neurological(occult spina bifida))
Assessment of Primary Assessment of Primary EnuresisEnuresis
• Urine analysisUrine analysis
• Urine osmolalityUrine osmolality
• Lumbo-sacral x-rayLumbo-sacral x-ray
• Abdominal ultrasonographyAbdominal ultrasonography
• VCUGVCUG
• Urodynamic studyUrodynamic study
• Urine analysis Urine analysis (when):? (when):? if secondary , bad health, UTI?? if secondary , bad health, UTI??
• No radiologyNo radiology
• No urodynamic study No urodynamic study
Should a 5-year-old child be actively Should a 5-year-old child be actively treated for enuresis?treated for enuresis?
If primary nocturnal enuresis is not distressing to the child,
treatment is unnecessary, although parents should be reassured
about their child’s physical and emotional health and counseled
about eliminating guilt, shame, and punishment. (Grade B)
Response:14 consecutive dry nights or a 90% ↓in no of wet nights/ week
Partial response:Symptoms improved but 14 consecutive dry nights or a 90%↓in no of wet nights/ week has not been achieved
Children under 5 years
Children more than 5 years
Treatment of PrimaryEnuresisTreatment of PrimaryEnuresis
Treatment of Primary Treatment of Primary EnuresisEnuresis
Advice
First line
Second line
Third
General
Diet Fluid intake
Toilet pattern
Lifting and walking
Reward
advice
General
Diet Fluid intake
Toilet pattern
Lifting and walking
Reward
advice
•Not the child's fault•No punishment •Reassurance (dry after a given time) •Children change their bedding
Healthy diet with no restriction
Avoid caffeine-based drinks before going to bed
urinate at regular interval during the day and befor sleep
•Safe the bed only
positive rewards for agreed behaviour rather than dry nights( fluid-toilet –management)
First line treatment Alarm Desmopressin
an alarm is considered inappropriate, particularly if: ◆ bedwetting is very infrequent (that is, less than 1–2 wet beds per
week) ◆ the parents or carers are having emotional difficulty coping with the
burden of bedwetting
rapid-onset and/or short-term improvement in bedwetting is the priority of treatment or− an alarm is inappropriate or undesirable (see recommendation
Alarm is the first line for families who are well motivated and well informed
Do not exclude alarm treatment as an option for children and young people with:
● daytime symptoms as well as bedwetting
● secondary onset bedwetting
Start desmopressintreatment
Is complete drynessachieved after 1–2 weeks?
Assess response at4 weeks
Continue treatment for3 months Stop desmopressin for 1 week to check whether dryness has been achieved(grdual)
Consider increasing dose(240 –400)
assessment of factors associated with poor response (adhernce,30%sleep apnea ,constipation , underlying disease (urological proplems)or social and emotional factors
yes No
Response
Partial
Increase the dose Give the drug 1–2 hours before bedtime restrict fluid Continue treatment for another 6 months
No
Management of Management of RecurrencesRecurrences
• Another course of desmopressin (repeated courses may be Another course of desmopressin (repeated courses may be used)used)
• Regular withdrawal of desmopressin (for 1 week every Regular withdrawal of desmopressin (for 1 week every 3 months)3 months)
• Gradual withdrawal of desmopressin rather than stopping it Gradual withdrawal of desmopressin rather than stopping it suddenly (increase of 'no-medication days' over an 8-week suddenly (increase of 'no-medication days' over an 8-week period)period)
• Using an enuresis alarmUsing an enuresis alarm
Treatments Not Treatments Not Recommended Recommended
• strategies that interrupt normal passing of urine or encourage infrequent urination during the day
• dry-bed training with or without an alarm.
Second-Line TherapySecond-Line Therapy
Desmopressin or alarm + Anticholinergic drugs
Anticholinergic Drugs bedwetting that has partially responded to desmopressin alone bedwetting that has not responded to desmopressin alone
bedwetting that has not responded to an alarm combined with desmopressin
Do not use an anticholinergic:
● alone for children and young people with bedwetting without daytime symptoms● combined with imipramine
Oxybutynin: 5mg
assess 1–2 month?
Continue treatment for3 months with Gradual tapering
Response
Partial
Continue treatment for another 6 months
Have the greatest chance of success in the child with signs of detrusor overactivity, i.e. low daytime voided volumes. Repeated courses can be used Doses can be doubled in over 12 years childrenThe main side effects are dry mouth, headaches, constipation, retention of urine and very occasionally unusual behaviour or night terrors
Third-line Therapy
Desmopressin or alarm + Tricyclic anti-depressants
Tricyclic Tricyclic Antidepressants Antidepressants
• Significant anticholinergic effects and additional central effects
ImipramineImipramineHow Is It Given?How Is It Given?
• Start as a low dose (25 mg for children > 6 years, 50 to 75 mg for children > 11 years) and increase fortnightly to the maximum dose allowed for the age of the child (50 mg in children 7 to 12 years of age and up to 75 mg in older children)
• The single daily dose should be given around 3 hours before sleep
• A course of treatment should last for 3 months maximum before reducing the dose slowly and stopping it for a week or so to assess progress
Take Home MessegeTake Home Messege
• The initial evaluation of the enuretic child should focus on good history and with no radiology or invasive procedures
• The first step in assessment is to exclude underlying disorders, such as diabetes, kidney disease or urogenital malformations
• The main goals of treatment are to increase the number of dry night and to alleviate the emotional impact of enuresis
Take Home MessegeTake Home Messege
• Positive reward systems have a better impact on the enuretic child (Grade B)
• Bladder training, retention control training, and dry bed training are no longer recommended
Take Home MessegeTake Home Messege• Therapy is a stepwise process. Partial response is
better than no response
• The first-line treatment is the enuresis alarm or desmopressin
• In therapy resistant cases occult constipation needs to be ruled out
• The second line of therapy is anticholinergic treatment combined with desmopressin
Take Home MessegeTake Home Messege
• In situations when all other treatments have failed, imipramine treatment is warranted, provided the cardiac risks are taken into account
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