Obstructive uropathy presenting as primary

enuresis - A case report

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Case Report

Obstructive uropathy presenting as primaryenuresis e A case report

Kiran Prakash Sathe*

Associate Consultant, Division of Pediatric Nephrology, Sir HN Reliance Foundation Hospital & Research Centre,

Mumbai, India

a r t i c l e i n f o

Article history:

Received 8 October 2014

Accepted 8 November 2014

Available online xxx

Keywords:

Bedwetting

Diurnal symptoms

Urgency

Frequency

Bladder dysfunction

* Block No 8, Bldg C-3, “SUMAN NAGAR”, VE-mail address: kiranpsathe@yahoo.co.in

Please cite this article in press as: SathMedicine (2014), http://dx.doi.org/10.1016

http://dx.doi.org/10.1016/j.apme.2014.11.0040976-0016/Copyright © 2014, Indraprastha M

a b s t r a c t

An adolescent male presented with persistent nocturnal bedwetting. Confounding family

history of nocturnal enuresis lead to delay in seeking medical attention. Careful history

and investigations confirmed underlying obstructive uropathy and bladder dysfunction.

Primary enuresis presenting beyond childhood period should be investigated to look for

underlying organic cause.

Copyright © 2014, Indraprastha Medical Corporation Ltd. All rights reserved.

1. Introduction

Family history of nocturnal enuresis can be a misleading

factor while evaluating caseswith primary enuresis persisting

beyond childhood. Correct history and simple bedside evalu-

ation can help in identifying underlying organic cause.

2. Case report

A 14 year old adolescent male presented with primary

enuresis. He had persistent nocturnal bedwetting with a fre-

quency of once to twice weekly episodes since childhood. He

had a normal development and was well grown for his age.

There were no psychosocial stressors. There was history of

nocturnal enuresis in his father and paternal grandfather

N Purav Marg, Chembu.

e KP, Obstructive uropa/j.apme.2014.11.004

edical Corporation Ltd. A

which subsided by 13 years of age. Presuming the same con-

dition in the patient, the family never sought a medical

opinion and hence never investigated for his symptoms. He

had a normal urine stream. There was no history of recurrent

urinary tract infections (UTI) or constipation. There was no

history of excessive water intake. On direct questioning, there

was history of occasional day time enuresis in addition to the

nocturnal bedwetting. There was history of urge to void

frequently during the daytime. Despite attempts at holding

voiding, he had to rush to the toilet each time. On examina-

tion, he was adequately grown for his age. He was normo-

tensive without pallor or edema. There was phimosis but no

evidence of renal lump or palpable bladder. There was no

obvious evidence of spina bifida. Neurological examination in

the lower limbs was normal with normal anal reflex and

bulbocavernosus reflex.

r, Mumbai 400071, India. Tel.: þ91 9821673216 (mobile).

thy presenting as primary enuresis e A case report, Apollo

ll rights reserved.

a p o l l o m e d i c i n e x x x ( 2 0 1 4 ) 1e22

A 36-hours voiding diary suggested frequent voiding and

suboptimal bladder capacity without polyuria. Urinalysis

suggested pH 6.5, specific gravity 1025 without evidence of

abnormal sediment, glucosuria or proteinuria. Serum creati-

nine was 0.7 mg/dL. Renal ultrasound reported right kidney

9.7 � 3.9 cm; left kidney 9.4 � 4.9 cm with mild left pelvica-

lyceal fullness without dilated ureters. There was evidence of

trabeculated and thickened bladder wall measuring 4.4 mm

with significant post void residue of 45 cc. MRI revealed

normal vertebral bodies, normal spine without evidence of

tethering. Micturating cystourethrogram (MCU) revealed

dilated & elongated posterior urethra without associated

vesicoureteric reflux. An invasive urodynamic study (UDS)

was performed. Filling phase study revealed decreased

compliance of bladder. There was severe degree of detrusor

over activity beyond 80 ml capacity with detrusor pressures

ranging between 104 and 184 cm H20 resulting in severe urge

to void and profuse pericatheter leakage. Maximum bladder

capacity recorded was 211 cc. During the voiding phase, he

could initiate prompt voiding on command with leak point

pressure of 62 cm H20. At the end of the study there was no

significant residual volume. Simultaneous electromyography

revealed normal coordinated and relaxed pelvic floor.

Cystoscopy with circumcision although advised was how-

ever refused by the patient. He was explained about the pos-

sibility of mechanical obstruction in the urinary outflow tract

resulting in bladder dysfunction. Meanwhile the patient was

started on oxybutynin at dose of 2.5 mg twice daily. This was

later increased to 2.5mg thrice daily whichwaswell tolerated.

He was advised restriction of oral fluids after late evening and

double voiding. Within the next two months of starting oxy-

butynin, there was improvement in his symptoms of urgency

and frequency with no further bedwetting.

3. Discussion

Presence of daytime symptoms of enuresis, urgency, fre-

quency and holding tendency in addition to the nocturnal

bedwetting clearly suggested abnormal lower urinary tract

symptoms suggestive of abnormal voiding. The symptoms

were wrongly presumed to be related to familial autosomal

dominant nocturnal enuresis leading to delayed presentation.

Voiding diary was a useful bedside test to arrive at a probable

diagnosis of detrusor over activity and suboptimal bladder

capacity resulting in above symptoms. Both neurogenic

bladder and obstructive uropathy may present with a signifi-

cant post void residue and trabeculated bladder. Normal

neuroimaging ruled out the possibility of neurogenic bladder

and MCU confirmed the bladder outlet obstruction most

probably posterior urethral valves. However the exact nature

and extent of obstruction could not be ascertained as cystos-

copy could not be done. Bladder dysfunction was secondary to

chronic bladder outlet obstruction and manifested with

symptoms of detrusor over activity as described earlier,

incomplete voiding, and reduced bladder compliance. These

functional symptoms including bedwetting resolved after

starting oxybutynin consequent to amelioration of the

detrusor over activity. Absence of VUR and recurrent urinary

Please cite this article in press as: Sathe KP, Obstructive uropaMedicine (2014), http://dx.doi.org/10.1016/j.apme.2014.11.004

tract infections helped to preserve normal renal function.

However, the high pressure detrusor over activity with

bladder outlet obstruction confirmed on UDS puts him at risk

for late deterioration of renal function. Relief of underlying

primary mechanical obstruction would be necessary to avoid

the long term damage.

Conventionally, diagnosis of PUV is made antenatally or in

infancy. Late detection of PUV has been reported in about 10%

cases.1 Bladder dysfunction resulting from high pressure

bladder outlet obstruction can present as nocturnal enuresis

in 60% cases.2 Abnormal voiding pattern, recurrent UTI or

renal failure could be the presentation in occasional cases.1e3

A simple bedside test such as voiding diary can be useful in

arriving at diagnosis and in guiding further investigations.

Diagnosis can be easily missed and such cases may present

late if MCU is not included as a part of work up for enuresis in

older boys.4 Identifying the symptoms of bladder dysfunction

is critical in suspecting such cases.

In conclusion, enuresis persisting into adolescence should

be investigated regardless of family history. Careful history

and voiding diary helps to identify underlying bladder

dysfunction in enuretic children. MCU should be a part of

work up of enuresis persisting beyond childhood period to

identify underlying obstructive uropathy.

Contributors

The author was involved in the concept and design, acquisi-

tion of data, analysis and interpretation of data, drafting the

manuscript, critical revision of the manuscript for important

intellectual content and final approval of the version to be

published.

Conflicts of interest

The author has none to declare.

Acknowledgement

Dr Shirish Yande, Dr Dashmit Singh, Dr Kumud P Mehta.

r e f e r e n c e s

1. Nobrega de Jesus C, Filho J, Goldberg J. Late presentation ofposterior urethral valve: two case reports. Sao Paulo Med J.2008:126e127.

2. Bomalaski MD, Anema JG, Coplen DE, Koo HP, Rozanski T,Bloom DA. Delayed presentation of posterior urethral valves: anot so benign condition. J Urol. 1996;162:2130.

3. Lal R, Bhatnagar V, Mitra DK. Urinary continence followingposterior urethral valves treatment. Indian J Pediatr.1999;66:49e54.

4. Vanwaeyenbergh J, Libert MH, Keuppens FI. Endoscopicresection as treatment of enuresis with posterior urethralvalves. Acta Urol Belg. 1990;58:133e137.

thy presenting as primary enuresis e A case report, Apollo

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