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National University of Rwanda

Family and Community Medicine

Enuresis

KABERA Ren,MD

Family and Community Medicine

National University of Rwanda

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Plan

Introduction

Examination

Causes

Diagnosis

Management

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Introduction

The word enuresis is derived from a Greek word that means

"to make water." Enuresis is the involuntary voiding of urine beyond the

developmental age of anticipated control, usually 5 years for

girls and 6 years for boys.

Primary enuresis occurs in children who have never been dry

for extended periods.

Secondary enuresis is the onset of wetting after a continuous

dry period of more than 6 months.

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Introduction

Nocturnal (nighttime) enuresis is usually primary

Diurnal (daytime) enuresis often indicates voiding dysfunctionor significant underlying pathology

The International Childrens Continence Society (ICCS) restricts

the use of the term enuresis to wetting only at night. Enuresis can be divided into primary enuresis (PE) and

secondary enuresis (SE).

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Introduction

Psychological and social impact

Children with enuresis are commonly punished and are atsignificant risk of emotional and physical abuse

Primary Enuresis : Psychological problems are almost always

the result and only rarely the cause Secondary Enuresis : Psychological problems are a possible

but uncommon cause

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Introduction

Genetics

Enuresis is reported in 43% of children of enuretic fathers,44% of children of enuretic mothers, and 77% of children

when both the mother and father had enuresis.

Enuresis is usually transmitted in an autosomal dominantfashion.

The family history of enuresis does not seem to influence

outcomes of any of the various treatments.

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Introduction

Sex

Enuresis is more common in males.

Age

The prevalence of enuresis gradually declines during childhood.

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Diagnosis

Laboratory

Not usually needed for children

Urinalysis and urine culture: UTI, pyuria, hematuria,

proteinuria, glycosuria, and poor concentrating

Blood urea nitrogen (BUN) and creatinine Urine cytology if carcinoma/CIS suspected

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CausesCauses of Primary Enuresis Causes of Secondary EnuresisIdiopathic IdiopathicDisorder of sleep arousal Disorder of sleep arousalNocturnal polyuria Nocturnal polyuriaSmall nocturnal bladder capacity Small nocturnal bladder capacityOveractive bladder and dysfunctional voiding Overactive bladder and dysfunctional voidingCystitis CystitisConstipation ConstipationNeurogenic bladder PsychologicalUrethral obstruction Acquired neurogenic bladderPsychological Seizure disorderEctopic ureter OSADiabetes insipidus Diabetes mellitus

Acquired diabetes insipidusAcquired urethral obstruction

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Management

General measures

Behavioral modifications

Medical and surgical care

Psychotherapy

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Management

General measures

Bladder training

Enuresis alarms

Diet: Restricting liquids after 6 PM, Avoid caffeinated

beverages (diuretic effect)

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Management

Behavioral modifications

Self monitoring

Motivation and responsibility training.

Reward system for dry nights

Penalty system for wet beds is not effective

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ManagementMedical care

Anticholinergic: increases functional bladder capacity and aids in

timed voiding.

Oxybutynin (Ditropan, Ditropan XL, Oxytrol patch)

Ditropan

Adults and peds > 5 years - 5 mg po tid-qid;Peds 1-5 years - 0.02 mg/kg/dose bid-qid (syrup 5 mg/5 mL)

Ditropan XL

Adults 5 mg po qd; increase to 30 mg/d po (5 and 10 mg/tab) Oxytrol patch,

Apply one patch every 3-4 days (3.9 mg/patch)

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ManagementTricyclic antidepressant with anticholinergic effects

Imipramine (Tofranil)

Adults 25-75 mg po qhs

Peds > 6 y: 10-25 mg po hs

Increase by 10-25 mg at 1-2 wk intervals, treat for 2-3 mo, then

taper, success rate of 25-30% when used > 3 months

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ManagementSynthetic analogue of vasopressin, a naturally occurring human

ADH, decreases nocturnal urine output. Desmopressin (DDAVP)

Intranasally 10-40 mcg.

Peds > 6 years 20 mcg intranasally

Tolterodine (Detrol, Detrol LA) - anticholinergic

Detrol 1-2 mg po bidDetrol LA 2-4 mg/d

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ManagementSurgical care

Secondary enuresis due to surgical cause (tethered cord, ectopicureter, BPH)

Psychotherapy

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Thank you