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MANAGEMENT AND ASSESSMENT OF WETTING ISSUES IN CHILDREN; ENURESIS Dr Fiona Cameron Community Paediatrician Motherwell

MANAGEMENT AND ASSESSMENT OF WETTING ISSUES IN CHILDREN; ENURESIS Dr Fiona Cameron Community Paediatrician Motherwell

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Page 1: MANAGEMENT AND ASSESSMENT OF WETTING ISSUES IN CHILDREN; ENURESIS Dr Fiona Cameron Community Paediatrician Motherwell

MANAGEMENT AND ASSESSMENT OF WETTING ISSUES IN CHILDREN;

ENURESIS

Dr Fiona CameronCommunity Paediatrician

Motherwell

Page 2: MANAGEMENT AND ASSESSMENT OF WETTING ISSUES IN CHILDREN; ENURESIS Dr Fiona Cameron Community Paediatrician Motherwell

Enuresis

• Definitions

• Aetiology

• Anatomy and physiology

• Impact

• Assessment

• Treatment options

• Summary

Page 3: MANAGEMENT AND ASSESSMENT OF WETTING ISSUES IN CHILDREN; ENURESIS Dr Fiona Cameron Community Paediatrician Motherwell

DEFINITIONS IN ENURESIS

Page 4: MANAGEMENT AND ASSESSMENT OF WETTING ISSUES IN CHILDREN; ENURESIS Dr Fiona Cameron Community Paediatrician Motherwell

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

Page 5: MANAGEMENT AND ASSESSMENT OF WETTING ISSUES IN CHILDREN; ENURESIS Dr Fiona Cameron Community Paediatrician Motherwell

URINARY INCONTINENCE

Continuous incontinence

Intermittent incontinence

Day-time incontinence

Nocturnal incontinence,

Enuresis

Page 6: MANAGEMENT AND ASSESSMENT OF WETTING ISSUES IN CHILDREN; ENURESIS Dr Fiona Cameron Community Paediatrician Motherwell

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

Page 7: MANAGEMENT AND ASSESSMENT OF WETTING ISSUES IN CHILDREN; ENURESIS Dr Fiona Cameron Community Paediatrician Motherwell

• 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

Page 8: MANAGEMENT AND ASSESSMENT OF WETTING ISSUES IN CHILDREN; ENURESIS Dr Fiona Cameron Community Paediatrician Motherwell

• 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,

Page 9: MANAGEMENT AND ASSESSMENT OF WETTING ISSUES IN CHILDREN; ENURESIS Dr Fiona Cameron Community Paediatrician Motherwell

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)

Page 10: MANAGEMENT AND ASSESSMENT OF WETTING ISSUES IN CHILDREN; ENURESIS Dr Fiona Cameron Community Paediatrician Motherwell

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

Page 11: MANAGEMENT AND ASSESSMENT OF WETTING ISSUES IN CHILDREN; ENURESIS Dr Fiona Cameron Community Paediatrician Motherwell

AETIOLOGY

• GENETICS

• EXPERIENCES

• PSYCHOLOGICAL DISTURBANCE

Page 12: MANAGEMENT AND ASSESSMENT OF WETTING ISSUES IN CHILDREN; ENURESIS Dr Fiona Cameron Community Paediatrician Motherwell

AETIOLOGY OF ENURESIS

Page 13: MANAGEMENT AND ASSESSMENT OF WETTING ISSUES IN CHILDREN; ENURESIS Dr Fiona Cameron Community Paediatrician Motherwell

• 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

Page 14: MANAGEMENT AND ASSESSMENT OF WETTING ISSUES IN CHILDREN; ENURESIS Dr Fiona Cameron Community Paediatrician Motherwell

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)

Page 15: MANAGEMENT AND ASSESSMENT OF WETTING ISSUES IN CHILDREN; ENURESIS Dr Fiona Cameron Community Paediatrician Motherwell

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 .

Page 16: MANAGEMENT AND ASSESSMENT OF WETTING ISSUES IN CHILDREN; ENURESIS Dr Fiona Cameron Community Paediatrician Motherwell

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

Page 17: MANAGEMENT AND ASSESSMENT OF WETTING ISSUES IN CHILDREN; ENURESIS Dr Fiona Cameron Community Paediatrician Motherwell

IMPACT OF ENURESIS

Page 18: MANAGEMENT AND ASSESSMENT OF WETTING ISSUES IN CHILDREN; ENURESIS Dr Fiona Cameron Community Paediatrician Motherwell

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….

Page 19: MANAGEMENT AND ASSESSMENT OF WETTING ISSUES IN CHILDREN; ENURESIS Dr Fiona Cameron Community Paediatrician Motherwell

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

Page 20: MANAGEMENT AND ASSESSMENT OF WETTING ISSUES IN CHILDREN; ENURESIS Dr Fiona Cameron Community Paediatrician Motherwell

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.

Page 21: MANAGEMENT AND ASSESSMENT OF WETTING ISSUES IN CHILDREN; ENURESIS Dr Fiona Cameron Community Paediatrician Motherwell

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……

Page 22: MANAGEMENT AND ASSESSMENT OF WETTING ISSUES IN CHILDREN; ENURESIS Dr Fiona Cameron Community Paediatrician Motherwell

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

Page 23: MANAGEMENT AND ASSESSMENT OF WETTING ISSUES IN CHILDREN; ENURESIS Dr Fiona Cameron Community Paediatrician Motherwell

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

Page 24: MANAGEMENT AND ASSESSMENT OF WETTING ISSUES IN CHILDREN; ENURESIS Dr Fiona Cameron Community Paediatrician Motherwell

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)

Page 25: MANAGEMENT AND ASSESSMENT OF WETTING ISSUES IN CHILDREN; ENURESIS Dr Fiona Cameron Community Paediatrician Motherwell

ANATOMY AND PHYSIOLOGY IN ENURESIS

Page 26: MANAGEMENT AND ASSESSMENT OF WETTING ISSUES IN CHILDREN; ENURESIS Dr Fiona Cameron Community Paediatrician Motherwell

URINARY TRACT

Page 27: MANAGEMENT AND ASSESSMENT OF WETTING ISSUES IN CHILDREN; ENURESIS Dr Fiona Cameron Community Paediatrician Motherwell

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

Page 28: MANAGEMENT AND ASSESSMENT OF WETTING ISSUES IN CHILDREN; ENURESIS Dr Fiona Cameron Community Paediatrician Motherwell

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

Page 29: MANAGEMENT AND ASSESSMENT OF WETTING ISSUES IN CHILDREN; ENURESIS Dr Fiona Cameron Community Paediatrician Motherwell

NEPHRON STRUCTURE

Page 30: MANAGEMENT AND ASSESSMENT OF WETTING ISSUES IN CHILDREN; ENURESIS Dr Fiona Cameron Community Paediatrician Motherwell

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.

Page 31: MANAGEMENT AND ASSESSMENT OF WETTING ISSUES IN CHILDREN; ENURESIS Dr Fiona Cameron Community Paediatrician Motherwell

BLADDER; URINE STORAGE AND RELEASE

Page 32: MANAGEMENT AND ASSESSMENT OF WETTING ISSUES IN CHILDREN; ENURESIS Dr Fiona Cameron Community Paediatrician Motherwell

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)

Page 33: MANAGEMENT AND ASSESSMENT OF WETTING ISSUES IN CHILDREN; ENURESIS Dr Fiona Cameron Community Paediatrician Motherwell

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

Page 34: MANAGEMENT AND ASSESSMENT OF WETTING ISSUES IN CHILDREN; ENURESIS Dr Fiona Cameron Community Paediatrician Motherwell

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

Page 35: MANAGEMENT AND ASSESSMENT OF WETTING ISSUES IN CHILDREN; ENURESIS Dr Fiona Cameron Community Paediatrician Motherwell

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

Page 36: MANAGEMENT AND ASSESSMENT OF WETTING ISSUES IN CHILDREN; ENURESIS Dr Fiona Cameron Community Paediatrician Motherwell

Bladder-Brain Relationship

Page 37: MANAGEMENT AND ASSESSMENT OF WETTING ISSUES IN CHILDREN; ENURESIS Dr Fiona Cameron Community Paediatrician Motherwell

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

Page 38: MANAGEMENT AND ASSESSMENT OF WETTING ISSUES IN CHILDREN; ENURESIS Dr Fiona Cameron Community Paediatrician Motherwell

THREE SYSTEMS MODELTHREE SYSTEMS MODEL

Impaired arousal responseto bladder fullness

from sleep

Nocturnal enuresisNocturnal enuresis

Page 39: MANAGEMENT AND ASSESSMENT OF WETTING ISSUES IN CHILDREN; ENURESIS Dr Fiona Cameron Community Paediatrician Motherwell

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

Page 40: MANAGEMENT AND ASSESSMENT OF WETTING ISSUES IN CHILDREN; ENURESIS Dr Fiona Cameron Community Paediatrician Motherwell

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

Page 41: MANAGEMENT AND ASSESSMENT OF WETTING ISSUES IN CHILDREN; ENURESIS Dr Fiona Cameron Community Paediatrician Motherwell

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

Page 42: MANAGEMENT AND ASSESSMENT OF WETTING ISSUES IN CHILDREN; ENURESIS Dr Fiona Cameron Community Paediatrician Motherwell

THREE SYSTEMS MODELTHREE SYSTEMS MODEL

Nocturnalpolyuria

(Lack of ADH Release)

Nocturnal enuresisNocturnal enuresis

Page 43: MANAGEMENT AND ASSESSMENT OF WETTING ISSUES IN CHILDREN; ENURESIS Dr Fiona Cameron Community Paediatrician Motherwell

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)

Page 44: MANAGEMENT AND ASSESSMENT OF WETTING ISSUES IN CHILDREN; ENURESIS Dr Fiona Cameron Community Paediatrician Motherwell

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.

Page 45: MANAGEMENT AND ASSESSMENT OF WETTING ISSUES IN CHILDREN; ENURESIS Dr Fiona Cameron Community Paediatrician Motherwell

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.

Page 46: MANAGEMENT AND ASSESSMENT OF WETTING ISSUES IN CHILDREN; ENURESIS Dr Fiona Cameron Community Paediatrician Motherwell

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

Page 47: MANAGEMENT AND ASSESSMENT OF WETTING ISSUES IN CHILDREN; ENURESIS Dr Fiona Cameron Community Paediatrician Motherwell

THREE SYSTEMS MODELTHREE SYSTEMS MODEL

Reduced nocturnal functional bladder

capacityNocturnal enuresisNocturnal enuresis

Page 48: MANAGEMENT AND ASSESSMENT OF WETTING ISSUES IN CHILDREN; ENURESIS Dr Fiona Cameron Community Paediatrician Motherwell

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)

Page 49: MANAGEMENT AND ASSESSMENT OF WETTING ISSUES IN CHILDREN; ENURESIS Dr Fiona Cameron Community Paediatrician Motherwell

ASSESSMENT OF ENURESIS

Page 50: MANAGEMENT AND ASSESSMENT OF WETTING ISSUES IN CHILDREN; ENURESIS Dr Fiona Cameron Community Paediatrician Motherwell

HISTORY

• Family Situation• Fluid intake• Voiding habits• Bowel habits• Sleep habit• Co-existing conditions• History of bedwetting inc. family history• Previous experiences• Daytime symptoms

Page 51: MANAGEMENT AND ASSESSMENT OF WETTING ISSUES IN CHILDREN; ENURESIS Dr Fiona Cameron Community Paediatrician Motherwell

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

Page 52: MANAGEMENT AND ASSESSMENT OF WETTING ISSUES IN CHILDREN; ENURESIS Dr Fiona Cameron Community Paediatrician Motherwell

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

Page 53: MANAGEMENT AND ASSESSMENT OF WETTING ISSUES IN CHILDREN; ENURESIS Dr Fiona Cameron Community Paediatrician Motherwell

HISTORY; VOIDING SYMPTOMS

• Urgency; can be normal in younger children

• Refusal to void

• Hesitancy

• Interrupted stream

• Dysuria

• Holding manoeuvres

Page 54: MANAGEMENT AND ASSESSMENT OF WETTING ISSUES IN CHILDREN; ENURESIS Dr Fiona Cameron Community Paediatrician Motherwell

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

Page 55: MANAGEMENT AND ASSESSMENT OF WETTING ISSUES IN CHILDREN; ENURESIS Dr Fiona Cameron Community Paediatrician Motherwell

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

Page 56: MANAGEMENT AND ASSESSMENT OF WETTING ISSUES IN CHILDREN; ENURESIS Dr Fiona Cameron Community Paediatrician Motherwell

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

Page 57: MANAGEMENT AND ASSESSMENT OF WETTING ISSUES IN CHILDREN; ENURESIS Dr Fiona Cameron Community Paediatrician Motherwell

EXAMINATION

• Good history

• Height and weight

• Ankle reflexes

• Abdomen checking for masses

• Spine; pigmentation, hair etc

• Genitalia only if indicated

Page 58: MANAGEMENT AND ASSESSMENT OF WETTING ISSUES IN CHILDREN; ENURESIS Dr Fiona Cameron Community Paediatrician Motherwell

INVESTIGATION

IN ALL CASES

• DIPSTIX URINE: MSSU if indicated

• BP

Page 59: MANAGEMENT AND ASSESSMENT OF WETTING ISSUES IN CHILDREN; ENURESIS Dr Fiona Cameron Community Paediatrician Motherwell

INVESTIGATIONfor selected cases

• Bladder diary

• Detailed renal and bladder ultrasound

• Residual bladder volume

• Flowmetery

• Urodynamics

• Nb Plain x-ray abdomen

Page 60: MANAGEMENT AND ASSESSMENT OF WETTING ISSUES IN CHILDREN; ENURESIS Dr Fiona Cameron Community Paediatrician Motherwell

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

Page 61: MANAGEMENT AND ASSESSMENT OF WETTING ISSUES IN CHILDREN; ENURESIS Dr Fiona Cameron Community Paediatrician Motherwell

TREATMENT OPTIONS IN ENURESIS

Page 62: MANAGEMENT AND ASSESSMENT OF WETTING ISSUES IN CHILDREN; ENURESIS Dr Fiona Cameron Community Paediatrician Motherwell

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”

Page 63: MANAGEMENT AND ASSESSMENT OF WETTING ISSUES IN CHILDREN; ENURESIS Dr Fiona Cameron Community Paediatrician Motherwell

TREATMENT OF ENURESIS

• SUPPORT• CONSTIPATION• STANDARD MANAGEMENT• FLUID INTAKE• VOIDING• INCENTIVE CHARTS• MEDICATIONS• ALARMS

Page 64: MANAGEMENT AND ASSESSMENT OF WETTING ISSUES IN CHILDREN; ENURESIS Dr Fiona Cameron Community Paediatrician Motherwell

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!

Page 65: MANAGEMENT AND ASSESSMENT OF WETTING ISSUES IN CHILDREN; ENURESIS Dr Fiona Cameron Community Paediatrician Motherwell

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

Page 66: MANAGEMENT AND ASSESSMENT OF WETTING ISSUES IN CHILDREN; ENURESIS Dr Fiona Cameron Community Paediatrician Motherwell

STANDARD TREATMENT

• Lifting and waking

• Nappies

• Adjustments to fluid intake

• Adjustments to voiding habits

Page 67: MANAGEMENT AND ASSESSMENT OF WETTING ISSUES IN CHILDREN; ENURESIS Dr Fiona Cameron Community Paediatrician Motherwell

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

Page 68: MANAGEMENT AND ASSESSMENT OF WETTING ISSUES IN CHILDREN; ENURESIS Dr Fiona Cameron Community Paediatrician Motherwell

NAPPIES

AVOID PUNITIVE

MEASURES

Can save the sanity

of some parents

Page 69: MANAGEMENT AND ASSESSMENT OF WETTING ISSUES IN CHILDREN; ENURESIS Dr Fiona Cameron Community Paediatrician Motherwell

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

Page 70: MANAGEMENT AND ASSESSMENT OF WETTING ISSUES IN CHILDREN; ENURESIS Dr Fiona Cameron Community Paediatrician Motherwell

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.

Page 71: MANAGEMENT AND ASSESSMENT OF WETTING ISSUES IN CHILDREN; ENURESIS Dr Fiona Cameron Community Paediatrician Motherwell

MEDICATION

• VASOPRESSIN ANALOGUE; DESMOPRESSIN

• ANTI CHOLINERGIC; OXYBUTYNIN

• IMIPRAMINE

Page 72: MANAGEMENT AND ASSESSMENT OF WETTING ISSUES IN CHILDREN; ENURESIS Dr Fiona Cameron Community Paediatrician Motherwell

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

Page 73: MANAGEMENT AND ASSESSMENT OF WETTING ISSUES IN CHILDREN; ENURESIS Dr Fiona Cameron Community Paediatrician Motherwell

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

Page 74: MANAGEMENT AND ASSESSMENT OF WETTING ISSUES IN CHILDREN; ENURESIS Dr Fiona Cameron Community Paediatrician Motherwell

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

Page 75: MANAGEMENT AND ASSESSMENT OF WETTING ISSUES IN CHILDREN; ENURESIS Dr Fiona Cameron Community Paediatrician Motherwell

DESMOPRESSIN

MORE LIKELY TO USE IF

• There is a high nocturnal urinary output

• There is Parental intolerance

• A “quick fix” needed

Page 76: MANAGEMENT AND ASSESSMENT OF WETTING ISSUES IN CHILDREN; ENURESIS Dr Fiona Cameron Community Paediatrician Motherwell

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

Page 77: MANAGEMENT AND ASSESSMENT OF WETTING ISSUES IN CHILDREN; ENURESIS Dr Fiona Cameron Community Paediatrician Motherwell

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)

Page 78: MANAGEMENT AND ASSESSMENT OF WETTING ISSUES IN CHILDREN; ENURESIS Dr Fiona Cameron Community Paediatrician Motherwell

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

Page 79: MANAGEMENT AND ASSESSMENT OF WETTING ISSUES IN CHILDREN; ENURESIS Dr Fiona Cameron Community Paediatrician Motherwell

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

Page 80: MANAGEMENT AND ASSESSMENT OF WETTING ISSUES IN CHILDREN; ENURESIS Dr Fiona Cameron Community Paediatrician Motherwell

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

Page 81: MANAGEMENT AND ASSESSMENT OF WETTING ISSUES IN CHILDREN; ENURESIS Dr Fiona Cameron Community Paediatrician Motherwell

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

Page 82: MANAGEMENT AND ASSESSMENT OF WETTING ISSUES IN CHILDREN; ENURESIS Dr Fiona Cameron Community Paediatrician Motherwell

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.

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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

Page 84: MANAGEMENT AND ASSESSMENT OF WETTING ISSUES IN CHILDREN; ENURESIS Dr Fiona Cameron Community Paediatrician Motherwell

ALARMS NOCTURNAL VOIDING

PATTERNS

• Study of 60 Children with Enuresis

• Successful treatment resulted in 65% sleeping through the night without wetting

35% developing nocturia

Page 85: MANAGEMENT AND ASSESSMENT OF WETTING ISSUES IN CHILDREN; ENURESIS Dr Fiona Cameron Community Paediatrician Motherwell

COMPLIMENTARY THERAPIES

• Acupuncture

• Bowen

• Homeopathy

• Chiropractice

• No definite evidence exists for efficacy but studies are ongoing

Page 86: MANAGEMENT AND ASSESSMENT OF WETTING ISSUES IN CHILDREN; ENURESIS Dr Fiona Cameron Community Paediatrician Motherwell

SUMMARY

Page 87: MANAGEMENT AND ASSESSMENT OF WETTING ISSUES IN CHILDREN; ENURESIS Dr Fiona Cameron Community Paediatrician Motherwell

HOW TO PICK YOUR THERAPY Available therapies

Good sleep habits

Regular bowel habit

Fluids

Toileting

Desmopressin

Oxybutynin

Alarm

Page 88: MANAGEMENT AND ASSESSMENT OF WETTING ISSUES IN CHILDREN; ENURESIS Dr Fiona Cameron Community Paediatrician Motherwell

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

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How to decide?

Weigh up

Clinical acumen

Give informed choiceGive informed choice

Page 90: MANAGEMENT AND ASSESSMENT OF WETTING ISSUES IN CHILDREN; ENURESIS Dr Fiona Cameron Community Paediatrician Motherwell

Further supports

• www.urinecontrol.co.uk

• www.eric.org.uk

• www.promocon.co.uk

[email protected]