Interesting Case Rounds Nadim Lalani R5 08.21.08.

Interesting Case Rounds

Nadim Lalani R508.21.08

Which of the following are/were “Famous Bedwetters”?

“Fergie Wets Pants!”

“I was late ... I didn’t go to the restroom before I went onstage. It was horrible. But, whatever. It happened ... everyone knows I wet my pants on-stage and had a crystal-meth addiction. That sucks. You have to laugh.”

Objectives

o Management of primary nocturnal enuresis• Case• Background• Treatment

• Alarms• Pharmacotherapy• Behavioural therapy• Other

o NOT discussing DIURNAL or SECONDARY

Case

o 11 yo Boy brought to you by parents because of bedwetting.

o History?• Primary vs Secondary• Nocturnal vs diurnal• Fam hx [enuresis, DM, DI, kidney, neuro, Sickle]• UTI? Sz? Polyuria/Polydypsia? Constipation?encop?• Sleep? [terrors, OSA]• Psychosocial. Developmental. Sexual ab? Parental

response.• Meds [SSRI]

Case

o Physical?• General [growth chart]• Abdo [distended bladder, stool in rectum]• GU [ectopic ureter, labial adhesions, Sexual ab]• Neuro exam[ Sacral dimples or tufts of hair]

o Diagnostics?• Urinalysis. First void SG• Unless secondary or treatment failure [see algorithm]

Case conclusion

o Child had primary NE• Parents working with GP• Tried various methods [albeit suboptimally]

o Child had normal urinalysiso Had ++ hx behavioural

problems/anxiety/depression/hydrophobiao Was on Citalopram o Refered to Community pediatrician

Background:

o Definition:Involuntary discharge of urine at night. Beyond age

of bladder control. > Twice per week for 3 monthsUncomplicated [85%] vs Complicated* [10%]

o Epidemiology:• Boys >> girls [2:1]• 15% of 5yo [8% of 8yo] 1% 15yo• 5% are due to organic pathology

* Have other symptoms [const/encop]

Pathophysiology

o Often no clear etiologyo Causes:

• Maturational delay of voiding coordination• Sleep arousal dysfunction: [kids unable to wake up when

they senses that the bladder is full]• Small functional bladder capacity:• habit polydipsia : [i.e. the child sips drinks all night long]. • Secondary nocturnal enuresis :

• related to stressors at home/school• DM/UTI/Neuro dis/Bladder dysfxn/ Meds [SSRI, diuretix]

Pathophysiology

o Genetics:• Risk: 43% [one parent with NE] 77% [both parents with NE]• 75% of kids with NE have a first-degree relative who had

enuresis• Linkage studies have shown associated genetic loci on

chromosomes 8q, 12q, 13q, and 22q11

General Measures

o Clarify the goal of getting up at night and using the toilet.o Assure the child’s access to the toilet.o Avoid caffeine-containing foods and excessive fluids

before bedtime [<2 oz after 6pm [<75 lb], 3 oz for 75–100 lb, & 4 oz for >100 lb].

o Have the child empty the bladder at bedtime.o Take the child out of diapers.o Include the child in morning cleanup in a nonpunitive

manner.o Preserve the child’s self-esteem.o Best for those < 6yo

Treatment

o Alarms• Invented in 1907.• Many different kinds. “mini alarms” [wear device]• Alarm/light/buzzer goes off when urine present• Least effective <5yo. Most after 7 -8 yo • More effective than drugs• Trial minimum 4 months

• Continue until 14 consecutive dry nights• Overlearn by drinking 2 cups water 7 dry nights• Relapse back to alarm for 14 dry nights

Cochrane review 2005o56 studies. Over 3200 childrenoRCT’s & quasi-RCT’s involving alarms [2400 pts]oExcluded diurnal

Results:oAlarm 60% effective at stopping bedwettingo50% relapse . Less relapse with overlearning and dry bed training.oNo difference in alarm types [but kids prefer wearable ones]oDDAVP faster than alarm but not sustainableoTCA no different, but also not sustainable

Alarms

o Overall cure rate of 50%o Requires buy in from whole family as it’s

disruptiveo Impractical for ‘sleepovers’ and campo No need to go high-end, kids like minio Don’t buy second-hand [don’t work well after

2-3 pts]

Treatment

o Pharmacotherapy : DDAVP• Studied since 1970s• Enuretic kids have decreased nighttime ADH

secretion produce more urine.• Side effects water intoxication• Expensive• IN preparation pulled by FDA/health Canada

• HYponatremia• 5 cases /10 million doses IN vs 1/10 million PO

Cochrane review in 200247 studies >2200 kids used DDAVPResults:oCompared with no treatment :

•1.3 fewer wet nights/week•20% reduction in bedwetting at end of treatment

o DDAVP no different to TCA [TCA more side effects]o DDAVP + alarm better than DDAVP during Rx, but same relapse rate

DDAVP

o Do not use IN preparationo Can use 200-600 mcg tablets before bedtimeo Avoid water after 6pmo CPS:

• Useful only for sleep overs or camp

Pharmacotherapy

o TCA• Imipramine best studied• Mechanism unclear . Anticholnergic?• Side effects [mood/weight/OD/Cardiac/Sz]• CPS Position Statement:

• Short-term• Distressed, Older kids• Reliable parents

Cochrane review 2003o58 studies that used TCA > 3000 kidsResults:oCompared with no treatment:

• 1 free night/week•20% dry during Rx, but relapsed

o Not enough evidence to compare other TCA/dosesoEquivalent to Alarm during therapy, but relapse more than alarm after.oEquivalent to DDAVP during Rx. But relapse moreoBetter than simple behaviour/diet. Worse than complex behav/hypnosis.

Treatmento Simple Behavioural

• Night time Fluid Restriction• Lifting

• Picking up asleep child and taking to BR before they wet bed.

• Scheduled Awakening• Star Charts & reward systems• Retention Control training

• Daytime overload of bladder and attempt to delay micturation.

Cochrane Review 2004o17 studies > 700 kids [380 got behaviour training]Results:• Star charts, Lifting and Waking better than nothing•Might be worth initiating 1st•Drop out associated with frustration and family strife.

Treatment

o Complex behaviouralDry Bed Training:

• Intensive 1st night woken Q1h• If bed wet clean bed [cleanliness] & practice going

to BR• Subsequent nights awoken once/night [getting earlier

and earlier]

Full spectrum Home Training:o Alarm + cleanliness + retention control +

overlearning

Cochrane Review 2004o18 trials >1000 kidsoResults:

oComplex training better than nothingoNo better than alarm alone

Behavioural Therapy

o CPS Position:• Insufficient evidence• Labor intensive and can contribute to frustration

and conflict• Might do more harm than good• Shouldn’t be recommended without careful

consideration

Treatment

o Other modalities Include:• 31 other drugs have been studied• Hypnosis• Psychotherapy• Accupuncture• Chiropractic adjustment.

o Not enough evidence to recommend.

Summary

o Distinguish NE from Diurnal and secondaryo Most important to have supportive

environment & minimise impacto Conditioning using alarm most efficaciouso Special situations can use DDAVPo Difficult circumstances imipramineo Judicious use of behavioural therapyo Should be handled by paediatriciano Persistence urology referral

Feri-Feri

Management of primary nocturnal enuresisCanadian Paediatric Society (CPS)Paediatrics & Child Health 2005;10(10): 611-614

Practice Parameter for the Assessment and Treatment of Children and Adolescents With EnuresisJournal of the American Academy of Child and Adolescent Psychiatry - Volume 43, Issue 12 (December 2004)  

Parent Handout

http://www.caringforkids.cps.ca/growing&learning/Bedwetting.htm