Jul 05, 2015
Dr Natalie Torbolov
August 2013
WITTLE LEAKS
Case Presentation
• 10 year old girl
PSX
• Nocturnal Bedwetting– nightly
– rouseability
– Being toiletted 2 hourly
– No other urinary Sx
– Pull ups
– Dry by day since 3 years old
Case Presentation (cont.)
HPI
• Has only ever had a few dry nights in her life
• Social issues developing
PMHx - Nil, no problems at school
Reg Meds - Nil
Allergies - NKA
No positive family Hx
Examination
• Well looking
• Wt. 37.6 kg Ht. 132.2 cm
• No Sacral pit
• Abdo - NAD
• Normal Neurological examination
• External Genitalia - NAD
Management
• Discussion / explanation to mother of DX: Monosymptomatic Nocturnal Envresis
Trial of Envresis Alarm
• MSU - NAD
• Renal US - NAD
• Abdo - NAD
• Paediatric Consult – Confirmation of DX
- Assistance with Alarm
Childhood Nocturnal Enuresis
• Definition: Involuntary wetting while asleep 2 x week after 5 years of age
• 2nd most common chronic childhood complaint (after allergies)
• 18.9% of children
• 20% of 5 year olds
• 10% of 10 year olds
Childhood Nocturnal Enuresis (Cont.)
• Spontaneous remission 14% per year
• Self esteem & psychosocial function
• Suggestion of impaired cognitive performance which improves with treatment
• Only 34% seek professional help
• 2-3% persistent incontinence into adulthood
Classification
• Primary – never been dry for 6 months• Secondary – Enuresis after 6 months of being
dry– Psychological– Organic DS – eg DM, UTI
• Mono Symptomatic – no day time incontinence
– No urinary tract Sx• Non Monosymptomatic – daytime voiding & Sx
of urgency, frequency
Causes
• Family Hx – 4/10 with affected family member
- Genetic factors – links to Chrom8,12,13, 22 Auto Dom
• Bladder & Brain Connection
– Cortical arousal
– Inability to arouse to a full bladder sensation
–- Detrusor over activity
– Small capacity Bladder
Causes (Cont.)
• Nocturnal Polyuria - anti-direutichormone secretion
• Chronic Constipation – eg soiling
• Other Medical Conditions – OSA, DM, UTI, ADHD
• Sex M:F 2:1
Management of Nocturnal E
• Education & Reassurance – high rate of spontaneous remission
• Motivational Therapy – 1st line for <7 year olds who are not wetting nightly
- enlist co-operation of child eg. Record progress diary
- Rewards – don’t focus on dryness- For agreed upon behaviours
- Penalties – counter productive
Management of Nocturnal E (Cont.)
• Motivational Therapy (Cont.)
- 25% success rate ie. dry for 14 consecutive nights
- 70% - improvement
- No fault emphasis
- Trial 3 – 6 months before moving on
Enuresis Alarms
• 2 Types:
1. Pad & Bell
Enuresis Alarms (Cont.)
• Types (Cont.):
2. Undergarment sensor
Enuresis Alarms (Cont.)
• For motivated families• Frequent enuresis• Most effective
- 66% achieve 14 consecutive nights cf 4% of no Rx controls
• Child in charge of alarm- Testing- Setting- Follow up
Enuresis Alarms (Cont.)
• 12 – 16 weeks to achieve 14 dry consecutive nights
• Range 5 – 24 weeks
• Can be reinstated after relapse
Other Measures
• Monitoring Daily Fluid Intake (80% prior to 5PM)
• Avoid sugar drinks and caffeine, especially after 5 PM
• Treat Constipation• No Pull-ups – instead regular toiletting
schedule• Discourage parental toiletting of child
during night
Medical Treatment - Desmopression
• 200 – 400 mcg dose
• Children > 5 years
• Refractory to alternative methods
• Alternative for rapid or short term improvement
• When failed / refused alarm
Medical Treatment – Desmopression(Cont.)
• Indications
- Nocturnal Polyuria & normal functional bladder capacity
• Efficacy
- 30% - total dryness
- 40% - in wetting
- High relapse rate after cessation 60 -70%
Medical Treatment – Desmopression(Cont.)
• Administration & SFx
- 1 hour before bed
- Dose titrated to best effect
- Dilutional Hyponatrema – limit fluids 240ml 1 hour prior to bed
- Cease if NVD
Medical Treatment – Desmopression(Cont.)
• Administration & SFx (Cont.)
- Lack of response – due to nocturnal bladder capacity
- Taper rather than stop abruptly
- Can be used in combination with alarm
Medical Treatment – Tricyclic Antidepressants
- time in REM sleep
- Stimulate Vasopressin secretion
- Relax Detrusor mm
- 3rd Line
- SFx – Cardiac conduction disturbance
- Similar efficacy to Desmopressin
- Imipramine 10mg – 25mg 1 hour before bed
Medical Treatment – Anticholinergic Drugs
• Not effective in nocturnal enuress
• Better for day time wetting or if both persist
• Used with Desmopressin to increase bladder capacity
When to Refer
• Suspicion of neurological or urological anomalies
• Persistent Uti’s
• No response after 8-12 weeks
• Presence of significant daytime incontinence
Useful Resources
• Continence Foundation of Australia–www.continence.org.au
–Helpline – 1800 330 066
– Information on alarm purchase / hire
• The International Children’s Continence Society–www.i-c-c-s.org
Useful Resources (Cont.)
• Children’s Hospital Westmead– The nocturnal enuresis clinic (bedwetting
clinic)– http://www.chw.edu.au/site/directory/entrie
s/bedwetting.htm– Enuresis Clinic Wed & Thurs PM
Dr Patricia CauldwellPh 9845 1462Fax 9845 1491Referrals from GP or paediatricians by fax
References
• Bottomley G. Treating Nocturnal Enuresis in Children Practitioner June 2011 255 (1741) 23-6, 2-3
• Hjalmas K. Nocturnal Enuresis in Children Nord Med 1998 Jan 113(1) 13-5; 15
• Tan ND, Baskin LS, Management of Nocturnal Enuresis in Children Up to Date – Lit R/V to June 2013
• Caldwell P, Claudia NG, Management of Childhood Enuresis Medicine Today, August 2008, Vol9, Number 8, 16-22
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