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MANAGEMENT AND ASSESSMENT OF WETTING ISSUES IN CHILDREN;
ENURESIS
Dr Fiona CameronCommunity Paediatrician
Motherwell
Enuresis
• Definitions
• Aetiology
• Anatomy and physiology
• Impact
• Assessment
• Treatment options
• Summary
DEFINITIONS IN ENURESIS
Definitions; ICCS
THE INTERNATIONAL CHILDRENS CONTINENCE SOCIETY
The journal of Urology July 2006
Volume 176. number 1. New definitions and standardised
terminology in the field of the lower urinary tract
URINARY INCONTINENCE
Continuous incontinence
Intermittent incontinence
Day-time incontinence
Nocturnal incontinence,
Enuresis
Definition ENURESIS
Intermittent incontinence whilst sleeping
This is regardless of whether voiding is normal or not, what the suspected cause is, or the presence or absence of daytime
wetting
• PRIMARY ENURESIS; A child who has never been dry for more than six months
• SECONDARY ENURESIS; A child who has previously been dry for more than six months
• MONO-SYMPTOMATIC ENURESIS Enuresis in a child with no day time
bladder symptoms,
• NON MONO-SYMPTOMATIC ENURESIS Enuresis in a child with day time
bladder symptoms,
Prevalence in school children Yeung et al. BJU Int 2006;97:1069–73
0
5
10
15
20
25
5 6 7 8 9 10 11 12 13 14 15 16 17 18 19
Age (years)
Pre
vale
nc
e (
%)
Male (n=7455)
Female (n=9057)
All (n=16512)
PREVALENCE ACCORDING TO AGE:
At 5 years = 16.1%
At 7 years = 10.1%
At 9 years = 3.1%
At 19 years = 2.2%
SPONTANEOUS REMISSION RATE
15% PER YEAR
AETIOLOGY
• GENETICS
• EXPERIENCES
• PSYCHOLOGICAL DISTURBANCE
AETIOLOGY OF ENURESIS
• 15% risk where there is no parental history of enuresis
• 40% if siblings also had PNE
• 43% risk where only one parent had been enuretic as a child
• 77% risk where both parentshad been enuretic as a child
AETIOLOGY; FAMILY HISTORYAETIOLOGY; FAMILY HISTORY
Bakwin. Am J Dis Child 1971;121;222–5; Jarvelin et al. Acta Paediatr Scand 1988;77:148–53
AETIOLOGY;
• Formula feeding and low birth weight • UTI• Developmental delay• Emotional upset• Urinary tract abnormalities• Diabetes Mellitus• Recurrent UTI• Kidney disease• ADHD and other behavioural difficulties• Sleep Apnoea (Snoring)
HOW THE CHILD VIEWS ENURESIS
1998 Study youngsters aged 8–16 years rated bedwetting as the third most traumatic event following divorce and parental fighting.
ALSPAC study 8580 9 year old children were asked to rate difficulty of life events Enuresis was rated fourth out of twenty one .
ALSPAC • The Avon Longitudinal Study of Parents and Children
(ALSPAC) was formerly called the Avon Longitudinal Study of Pregnancy and Childhood.
• ALSPAC is also known locally as Children of the 90s.• ALSPAC recruited more than 14,000 pregnant women
with estimated dates of delivery between April 1991 and December 1992. These women, the children arising from the index pregnancy and the women's partners have been followed up since then and detailed data collected throughout childhood.
• ALSPAC is a two-generational resource available to study the genetic and environmental determinants of development and health.
• http://www.bristol.ac.uk/alspac
IMPACT OF ENURESIS
IMPACT
These are potential effects and by no means universal
Some children are not adversely affected and have no long term sequelae
However some do….
IMPACT ON CHILD
THE CHILD CAN
• Feel ashamed • Fear bullying
• Feel guilty
this can lead to restriction in activities no sleepovers or with only certain family members
No school trips
IMPACT ON CHILD
• Impaired self image and self esteem• Impaired emotional state• Avoidance behaviour• Attention span,• Achievement• Performance IQ
Children with non mono-symptomatic enuresis are more vulnerable to adverse psychological effects.
IMPACT ON PARENTS
• Feel helpless
• Worry about health of child
• Upset about impact on child’s life
• Upset about impact on their life
• Significant financial cost
• Last straw……
IMPACT ON FAMILY RELATIONSHIPS
STRESS ON CHILD AND FAMILY CAN LEAD TO….
• PARENTAL INTOLERENCE where the child is seen as lazy and disinterested
• CHILD ABUSE
EFFECTS OF TREATMENT
• THERE ARE A RANGE OF EVIDENCE BASED TREATMENTS AVAILABLE
• SIGNIFICANT IMPROVEMENT in psychological functioning follows treatment
• ALL ASPECTS BENEFIT from treatment; attention, achievement, Social, emotional, avoidance behaviours, low self esteem
Treatment is for Everyone
SPECIAL NEEDS
For the majority of children with mild to moderate learning difficulties in the absence of any neurological difficulties there is no reason why they should not be toilet trained and even those with more severe problems have been found to respond to training (Louiselli, 1994)
ANATOMY AND PHYSIOLOGY IN ENURESIS
URINARY TRACT
KIDNEY; FUNCTION
• BLOOD is brought to the kidneys through the renal arteries
• KIDNEYS filter blood at a rate of a litre a minute (20% of blood circulating volume per minute.)
• THE FILTRATE is then modified by the kidneys depending on the requirements of preservation or excretion of the body
• URINE REGULATION a minimum urine production is an absolute necessity
URINE PRODUCTION
KIDNEYS; regulate urine production to maintain disposal of waste products and maintain fluid
balance in the face of…..• OSMOTIC PULL e.g. naturesis, acid base
balance, fluid load etc• HYPOTHALAMUS/PITUITARY who maintain
water regulation• ALDOSTERONE which maintains salt regulation• etc etc etc
NEPHRON STRUCTURE
CONCENTRATION OF URINE
• SODIUM is actively reabsorbed in the proximal tubule and 70% of water in the filtrate is reabsorbed with it.
• The remaining 30% of WATER is reabsorbed in the distal tubule and collecting ducts.
• This reabsorbtion is dependent on ANTI DIURETIC HORMONE (ADH) also known as Vasopressin
• Without ADH only dilute, hypo-osmolar urine is produced.
BLADDER; URINE STORAGE AND RELEASE
URINE STORAGE• BLADDER WALL; DETRUSOR MUSCLE; Relaxes during bladder filling and contacts
during bladder emptying (autonomic control)
• BLADDER; NECK INTERNAL SPHINCTER Contracts during bladder filling and relaxes
during bladder emptying (autonomic control)
• EXTERNAL SPHINCTER; PELVIC FLOOR Contracts to maintain bladder and bowel
integrity (voluntary control)
BLADDER TRAINING
Bladder awareness begins in infancy.
Modification of bladder function over time leads to the brain taking control of bladder
function usually by age 3 to 4 years.
BLADDER-BRAIN-KIDNEYS
Working in harmony
For toilet training
DAY TIME CONTINENCE
Successful toilet training requires…
• Recognition of a full bladder or bowel
• Appropriate access to toilet facilities
• Ability to indicate need
• Will to act upon need
• The ability to “hold on”
Generally 2 ½ to 3 ½ yrs
NIGHT TIME CONTINENCE
DRY NIGHTS ARE ACHIEVED
When a bladder doesn’t need to empty when you are asleep.
Or if a bladder does need to empty and you can wake to void.
Generally 5 years and above
Bladder-Brain Relationship
THREE SYSTEMS MODELTHREE SYSTEMS MODEL
Nocturnalpolyuria
(Lack of ADH Release)
Reduced nocturnal functional bladder
capacity
Impaired arousal responseto bladder fullness
from sleep
Nocturnal enuresisNocturnal enuresis
THREE SYSTEMS MODELTHREE SYSTEMS MODEL
Impaired arousal responseto bladder fullness
from sleep
Nocturnal enuresisNocturnal enuresis
AROUSAL and SLEEP
• Pontine Micturition centre; fills bladder to capacity overnight
• Micturition Control centre; recognises bladder is full and defers
• Arousal centre; wakes you up
AROUSAL and SLEEP
• Children with Enuresis have the same number of stages and the same amount of the different depths of sleep as other children
• Wetting can occur during all stages of sleep and not always during “deep” sleep yet many parents have reported their children to be a “deep sleepers”
• Even though sleep may lighten and children may become restless there is not wakening to a full bladder
Therefore AROUSAL is the problem
SLEEP
• Several studies have now shown that patients with enuresis have elevated arousal thresholds
• Elevated sleep threshold is associated with increased bladder activity
• Sleep architecture becomes normal and sleep arousal thresholds return to normal post treatment
THREE SYSTEMS MODELTHREE SYSTEMS MODEL
Nocturnalpolyuria
(Lack of ADH Release)
Nocturnal enuresisNocturnal enuresis
NOCTURNAL POLYURIA
Where nocturnal urine production exceeds Where nocturnal urine production exceeds normal nocturnal bladder capacity.normal nocturnal bladder capacity.
(defined by ICCS as 130% of Expected (defined by ICCS as 130% of Expected Bladder Capacity)Bladder Capacity)
NOCTURNAL POLYURIA
WATER REGULATION/FLUID BALANCE is controlled by
The HYPOTHALAMUS and PITUITARY.
The Hypothalamus monitors changes in extra cellular fluid volume, the sodium concentration and osmotic pressure of plasma. It then signals the post pituitary to release Vasopressin/Anti-Diuretic Hormone into the bloodstream.
NOCTURNAL POLYURIA
• ADH/Vasopressin released when water conservation is required. It acts on the collecting ducts to reduce water loss from kidneys.
• ADH/Vasopressin is suppressed when increased water loss is required from kidneys.
VASOPRESSIN AND URINE
Rittig S et al. Am J Physiol 1989;256:F664–71
0.0
1.0
2.0
3.0
4.0
5.0
0
20
10
30
40
50
60
70
80
pg
/ml
ml/
ho
ur
Vasopressin levels pg/mlNon enuretic childEnuretic child
Urinary excretion rate ml/hrNon enuretic childEnuretic child
Day Night
THREE SYSTEMS MODELTHREE SYSTEMS MODEL
Reduced nocturnal functional bladder
capacityNocturnal enuresisNocturnal enuresis
REDUCED FUNCTIONAL NOCTURNAL BLADDER
CAPACITYGenerally associated with day-time symptoms/
low bladder capacity but not always
Low bladder capacity; ICCS definition; where actual day time voided volumes are less than 70% of Expected Bladder Capacity
(EBC=Age +1x30)
ASSESSMENT OF ENURESIS
HISTORY
• Family Situation• Fluid intake• Voiding habits• Bowel habits• Sleep habit• Co-existing conditions• History of bedwetting inc. family history• Previous experiences• Daytime symptoms
HISTORY; VOIDING HABITS
• Frequency – Increased frequency 8 or more voids a day– Decreased frequency 3 or less voids a day
• Particularly ensure voiding just before falling asleep
• Include nocturia……….Remember access to toilet
HISTORY; STOOL HABIT
Constipation can be difficult as people have differing ideas of normality
Rome iii CriteriaHistory needs to include
• Frequency of stool• Type of stool (Size and consistency)• Associated pain• Faecal incontinence
HISTORY; VOIDING SYMPTOMS
• Urgency; can be normal in younger children
• Refusal to void
• Hesitancy
• Interrupted stream
• Dysuria
• Holding manoeuvres
HISTORY; TRIGGERS TO WETTING
• Urge incontinence -Wetting when rushing to go to the toilet• Giggle incontinence -Wetting when you laugh a lot• Preoccupied wetting -Wetting when you don’t notice• Incontinence immediately post void -Wetting as soon as you have been for a pee• Stress incontinence -Wetting when coughing or sneezing
HISTORY; DAYTIME WETTING
OVERACTIVE BLADDER• Urgency• Increased voiding frequency• Urge incontinence
UNDERACTIVE BLADDER• Low voiding frequency• May need to increase intra abdominal pressure
to void
HISTORY; DAYTIME WETTING
DYSFUNCTIONAL VOIDING
• Habitual contraction of the external sphincter during voiding
• Often unable to empty bladder against the resistance of the sphincter so is associated with residual volume in bladder left after voiding
EXAMINATION
• Good history
• Height and weight
• Ankle reflexes
• Abdomen checking for masses
• Spine; pigmentation, hair etc
• Genitalia only if indicated
INVESTIGATION
IN ALL CASES
• DIPSTIX URINE: MSSU if indicated
• BP
INVESTIGATIONfor selected cases
• Bladder diary
• Detailed renal and bladder ultrasound
• Residual bladder volume
• Flowmetery
• Urodynamics
• Nb Plain x-ray abdomen
FURTHER INVESTIGATIONS RESIDUAL VOLUME
.
What is left after voiding is called POST VOID RESIDUAL VOLUME, it is usually near to zero however a normal residual
volume is up to 10% of Estimated Bladder Capacity (EBC)
Greater than 10% of EBC suggests incomplete bladder emptying
TREATMENT OPTIONS IN ENURESIS
Treating nocturnal enuresis
“Good clinical practice would thus recommend that a 5-year-old child who is
bothered by his or her bedwetting, and motivated to receive treatment, should
indeed receive adequate interventions to help them overcome their wetting”
TREATMENT OF ENURESIS
• SUPPORT• CONSTIPATION• STANDARD MANAGEMENT• FLUID INTAKE• VOIDING• INCENTIVE CHARTS• MEDICATIONS• ALARMS
SUPPORT
• Treatment failures are known to be associated with a greater emotional impact
• Good support will lessen the emotional impact• No treatment is 100% successful for everyone• 1% of adults have nocturnal enuresis• Other co-moribidities exist• We are human we need it!
Severity of PNE versus age (A)Severity of PNE versus age (A)
0
4
8
12
16
20
5
Age (years)
Pre
vale
nc
e (
%)
6 7 8 9 10 11 12 13 14 15 16 17 18 19
<3 wet nights/week
3–6 wet nights/week7 wet nights/week
Yeung et al. BJU Int 2006;97:1069–73
STANDARD TREATMENT
• Lifting and waking
• Nappies
• Adjustments to fluid intake
• Adjustments to voiding habits
LIFTING AND WAKING
• Some concern it may programme the child to void during sleep therefore recommended the child is as awake as possible and that the time is varied
• Can work well in some families but if not successful within a week recommended to stop
NAPPIES
AVOID PUNITIVE
MEASURES
Can save the sanity
of some parents
FLUID INTAKE• Predominately clear fluids• 6-7 drinks or 1 to 1 ½ litres • evenly spread throughout the day
Avoid….• Early morning drought• Caffeine containing or carbonated drinks• Milk late at night• ?Blackcurrant
VOIDING
• Regular relaxed voiding
• Go to the toilet as soon as you first feel the need for it
• Even better, go to the toilet at regular intervals before your bladder tells you to about 6 to 7 times a day.
MEDICATION
• VASOPRESSIN ANALOGUE; DESMOPRESSIN
• ANTI CHOLINERGIC; OXYBUTYNIN
• IMIPRAMINE
DESMOPRESSIN
• Analogue of vasopressin (ADH)
• Potent antidiuretic
• Concentrates urine
• Available in Tablet or Melt formulation
• The spray formulation was withdrawn for Nocturnal enuresis in 2007
Desmopressin
DESMOPRESSIN TREATMENT REGIMEN
DESMOPRESSIN TREATMENT REGIMEN
No
Yes
Desmopressin initial dose: 0.2 mg oral, 120µg melt or for 2 weeks
Dry nights? Increase dose by 0.2 mg, 120 µg to max. 0.4 mg, 240 µg evaluate after 2 weeks
Dry nights?Desmopressinfor 3 months
1-week drug-free period.
Dry without desmopressin? Stop treatment
Continue desmopressin for 3 months
Yes
No
Yes
DESMOPRESSIN
OVERALL SUCCESS 50-70%OVERALL SUCCESS 50-70%
• Desmopressin can be given long term with breaks approximately every three months to ensure treatment is still required
• Full response 20 - 30%
• Partial response 30 - 40%
• There is no increase in adverse affects with long term use
DESMOPRESSIN
MORE LIKELY TO USE IF
• There is a high nocturnal urinary output
• There is Parental intolerance
• A “quick fix” needed
OXYBUTYNIN
• Has both anti-cholinergic and direct smooth muscle relaxant effects on the bladder. Provides local anaesthetic effect on irritable bladder.Urodynamic studies have shown that Oxybutynin increases bladder size, and delays initial desire to void
OXYBUTYNIN
• Anecdotally it works for children with a small bladder capacity
• However in Cochrane review of day time wetting there was little evidence that Oxybutynin on it’s own was any better than placebo. It may need better study!
• It has been found to be useful in combination 70% response compared to 50% (Caione et all 1997)
IMIPRAMINE
• Has anti-cholinergic action• Affects sleep centres in the brain• Antidiuretic effects
• 20% dry on treatment but relapse rate is high• Can still used on a very selected group
NOT RECOMMENDED AS FIRST LINE due to cardio-toxicity
ALARM TREATMENT
• ENURESIS ALARMS have been around in some form since the early part of the last century. They were developed into the Bell and Pad in the 1950’s
• ALARMS are a pad which detects moisture attached to a device to alert the wearer.
• THE PAD can be a bed mat or small enough to wear in underpants
• THE ALERT can be by sound, vibration and/or light
ALARM TREATMENT:
Overall success rates – 30–87%
MORE LIKELY TO WORK• -In small bladder capacity • -if child motivated• -if family supportive• -If wets once per night• -if wakes easily
• Can relapse
ALARM USE
• Only give the alarm if family are ready to use it
• Can be used at an earlier age but generally recommended to be from 8 years upwards
• Best age is probably 9 or 10 years• May take 4 to 6 months to achieve
maximum success
ALARM USE
• ATTACH ALARM just before bedtime and after last micturition.
• ATTACH ALARM under bed sheet or between two pairs of pants.
• WHEN ALARM SOUNDS turn off alarm only after child is awake. The child goes to the toilet to try micturition. When returning to bed re-attach alarm.
ALARM USE
• CONTACT; Works best with good support. This will require regular contact e.g. every 2 weeks in the beginning
• EXPECTATIONS; dry night may take 18 wet nights to appear. Early signs may be quicker waking with a reduction the in amount or frequency of wetting
ALARMS NOCTURNAL VOIDING
PATTERNS
• Study of 60 Children with Enuresis
• Successful treatment resulted in 65% sleeping through the night without wetting
35% developing nocturia
COMPLIMENTARY THERAPIES
• Acupuncture
• Bowen
• Homeopathy
• Chiropractice
• No definite evidence exists for efficacy but studies are ongoing
SUMMARY
HOW TO PICK YOUR THERAPY Available therapies
Good sleep habits
Regular bowel habit
Fluids
Toileting
Desmopressin
Oxybutynin
Alarm
8 MINUTE CONSULTATION
• Ensure Primary Enuresis
• Exclude constipation• Exclude day time symptoms• Check urine• Check BP
• Fluids; clear fluids in early part of the day with no fizzy, caffeine or milk at night.
• Toilet last thingRefer to specialised service
How to decide?
Weigh up
Clinical acumen
Give informed choiceGive informed choice
Further supports
• www.urinecontrol.co.uk
• www.eric.org.uk
• www.promocon.co.uk