Enuresis

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Enuresis

  1. 1. Enuresis CSN Vittal
  2. 2. Enuresis Definition : Involuntary voiding of urine at least two nights per month beyond the age of 5 years by which bladder control is normally obtained and without any congenital or acquired defects of the urinary tract.
  3. 3. Enuresis Achievement of bladder control  85% by 5 yrs  Remaining 15% at a rate of 15% per year  Only 0.5 to 1% - no control at adolescence
  4. 4. Types of Enuresis Primary Child who never gained nocturnal urinary control Accounts of 85% of cases Secondary At least a 6 – month period of dryness has preceeded the onset of wetting
  5. 5. Enuresis Presentation  Type I : Monosymptomatic  Type II : Diurnal enuresis without daytime frequency  Type III : Nocturnal enuresis with daytime frequency  Type IV : Nocturnal enuresis with daytime frequency and voiding dysfunction
  6. 6. Types of Enuresis Uncomplicated Complicated OnsetOnset Primary Secondary DaytimeDaytime symptomssymptoms Absent Present StreamStream Normal Abnormal Physical Exam.Physical Exam. Normal Abnormal UrinalysisUrinalysis Normal Abnormal
  7. 7. Therapeutic Responses Initial success: 14 consecutive dry nights have been achieved with treatment Lack of success: Failure to meet the above criteria Relapse: When 2 or more wet nights within two weeks of initial success and the interval between the initial success and relapse measured Continued success: There is no relapse after 6 months of initial success Complete success: There has been no relapse in 2 years after an initial success
  8. 8. Development of Urinary Control 1. Nocturnal bowel control 2. Day time bowel control 3. Day time voiding control 4. Night time voiding control
  9. 9. Genetics 1. Familial pattern 2. Risk of enuresis 7.5 when father was enuretic than when mother was. 3. 75% if both parents were enuretic 4. 45% in families with one parent enuretic 5. 15% when neither parent was enuretic 6. Primary – aut. Dominant with penetrance above 90% with disease locus in chr 13q
  10. 10. Evaluation 1. Complete history • Primary or sec. • Nocturnal or diurnal • Does encopresis associated • Associated urinary tract symptoms like dysuria, polyuria, pollakiuria, hematuria, pyuria, etc. 2. Developmental history • Birth history • Achievement of milestones • Neurological deficits • CNS disorders 3. Family history • H/o. enuresis in parents • Traumatic incidents • Parental harmony
  11. 11. Physical Examination 1. Visualization of urinary system 2. Abdomen exam – for renal / bladder mass 3. Genitals – hypospadiasis 4. Neurological 1. Peripherl reflexes 2. Perianal sensations 3. Tone 4. Gait 5. Lower back 1. Tuft of hair 2. Vertebral anomaly
  12. 12. Types of Nocturnal Enuresis Polysymptomatic Daytime enuresis, encopresis, urgency, dribbling PE, neurological abnormalities + +ve urinalysis, c/s, USG Need contrast studies, urodynamic assessment Monosymptomatic Solely nocturnal Normal physical exam. & urethrogram No further investigations
  13. 13. General Tratement 1. Avoid excessive fluids 2. Empty bladder at bed time 3. Told to wake up at night and use toilet to remain dry 4. Improve access to toilet 5. Include the child in morning cleaning up of urine-soiled cloths
  14. 14. Behavioural Intervention Active participation & commitment of • parents • the child & • the pediatrician
  15. 15. Motivation Therapy (for > 7 yrs. Old) 1. Convince parents that the child wants to be dry 2. Child is encouraged to assume responsibility for his enuresis and actively participate in treatment 3. Move from blame for wet nights to praise for dry nights. 4. A dry morning should receive positive recognition and should receive lavish words of praise from everyone in family. 5. A major breakthrough may warrant material reward.
  16. 16. Alarm Therapy 1. Alarm triggered when the diaper gets wet to awaken the child from sleep and stop micturition. 2. By repetitive inhibition of micturition a conditioning process occurs ultimately. 3. With 3 mo. of treatment – 92% cured 4. Relapse rate is 30% 5. Response to retreatment is good 6. Adjuvant pharmacotherapy helps
  17. 17. Wet Alarm Therapy
  18. 18. Multidimentional behavioural Therapy 1. Full spectrum home training 2. Scharf’s Comprehensive Treatment Program
  19. 19. Bladder Stretching 1. Increased oral fluids, lengthening of period between daytime voiding 2. Holding back urination until the point of incontinences – can help increase anatomical and functional bladder capacity
  20. 20. Pharmacotherapy 1. DDAVP (1-deamino-8 Arginine Vasopressin) for > 4 yrs old. • Reduces nocturnal urine output to a volume lower than functional bladder capacity • Useful in those who do not manifest diurnal rhythm of vasopressin • Dose: 20 micrograms (one spray) in each nostril • Max. up to 80 micrograms Adverse Effects Hyponatremia, disorientationm seizures, coma
  21. 21. Pharmacotherapy 2. Anticholinergics • Oxybutenin chloride Acts by increasing bladder capacity and reducing frequency of detrusor contractions. Adverse Effects: Dryness of mouth, blurred vision, facial flushing. Dose: For > 7 yrs : 5 mg 2-3 times a day
  22. 22. Pharmacotherapy 3. Tricyclic antidepressants • Imipramine Alteration of sleep mechanisms and rousal pattern Cholinergic properties Adverse Effects: Anxiety, insomnia, dry mouth, nausea, personality changes. Cardiac arrhythmias, hypotension, respiratory complications, convulsions Dose: 25 mg for 6-8 yrs old 50-75 mg for older children Administered at 6 pm. Treatment for 3 – 6 months, then tapered off Antidote: Physostigmine
  23. 23. Surgical Therapy Cystoplasty In select cases
  24. 24. Conclusion Enuresis is basically a symptom and not a disease state Intervention is justified for psychological benefit of child and family Problem of enuresis should be solved with 5 “P” regimen • Praise • Patience • Perseverance • Passion • Positive attitude

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