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Practical guidlines for assessing and treating enuresis
- 1. Enuresis practical Enuresis practical guidlines guidlines Heba mohammedHeba mohammed bahbahbahbah
- 3. Micturation reflexMicturation reflex The micturition reflex is overridden by voluntary control. Descending pathways from the cerebral cortex can inhibit parasympathetic neurons and stimulate motor neurons that excite the external urethral sphincter and thus inhibit the micturition reflex.
- 5. DefinitionsDefinitions IcontinenceIcontinence:-:- Uncontrollable leakage of urineUncontrollable leakage of urine Continuous intermittentContinuous intermittent •Urine leakage inUrine leakage in discrete amountsdiscrete amounts • Applicable toApplicable to children more thanchildren more than 5 years5 years Constant urine leakageConstant urine leakage Applicable to all agesApplicable to all ages Associated withAssociated with congenitalcongenital malformationsmalformations Night -time Enuresis Day- time
- 6. Enuresis: DefinitionEnuresis: Definition An involuntary wetting during sleep, at leastAn involuntary wetting during sleep, at least twice a week, in children older than 5 yearstwice a week, in children older than 5 years of age with no congenital or acquiredof age with no congenital or acquired defects of the centraldefects of the central nervousnervous systemsystem
- 7. Enuresis: ClassificationEnuresis: Classification Primary:Primary: The child has never achieved sustainedThe child has never achieved sustained continence at night for a period of at least 6 monthscontinence at night for a period of at least 6 months Mono-symptomatic Without daytime symptoms Non-mono-symptomatic With daytime symptoms SecondarySecondary: Bedwetting occurs after the child has been dry at night for more than 6 months
- 9. PathogenesisPathogenesis High arousal threshold Nocturnal polyuria due to nocturnal lack of ADH Bladder dysfunction: A small bladder capacity or nocturnal detrusor overactivity
- 10. geneticsgenetics
- 11. Evaluation at the first visitEvaluation at the first visit Primary with day- time symptoms Primary without day-time symptoms Secondary bed wetting Duration Daytimesymptoms
- 12. Day time symptoms Holding manouver hesitancy urgency frquancy Urological proplems
- 13. Evaluation at the first visitEvaluation at the first visit Primary with day- time symptoms Primary without day-time symptoms Secondary bed wetting
- 14. Assessment of PrimaryAssessment of Primary EnuresisEnuresis The pattern of bedwettingThe pattern of bedwetting Assessment of fluid intakeAssessment of fluid intake Bladder diaryBladder diary Bowel habitsBowel habits Psychological assessmentPsychological assessment comorbidities
- 15. The pattern of bedwettingThe pattern of bedwetting How many nights a week does bedwetting occur? How many times a night does bedwetting occur? Does there seem to be a large amount of urine? At what times of night does the bedwetting occur? Does the child wake up after bedwetting Functional bladder disorder Wets the bed most nights Ever wets more than once a night Wets small volumes Nocturnal polyuria Wets one or two nights Wet Large volumes
- 16. Assessment of fluid intakeAssessment of fluid intake Age (years) Volume (mL/day) Boys Girls 4-8 1000-1400 1000-1400 9-13 1400-2300 1200-2100 14-18 1400-2500 2100-3200
- 17. Bladder diaryBladder diary Bladder capacity= 30+(30 × age )mL Low voided volumes [maximum voided volume <70% of the expected bladder capacity] Nocturnal urine production > 130% of the expected bladder capacity
- 18. Bowel habitsBowel habits • Bowel movement frequency, stool consistencyBowel movement frequency, stool consistency • Faecal incontinenceFaecal incontinence
- 19. Psychological assessmentPsychological assessment Child Behavioral problems How does the child view his/her enuresis Parents Difficulty to cope with the burden of bedwetting Anger, negativity, or blame towards the child
- 20. Psychological assessmentPsychological assessment Child Behavioral problems How does the child view his/her enuresis Parents Difficulty to cope with the burden of bedwetting Anger, negativity, or blame towards the child
- 21. Assessment of PrimaryAssessment of Primary EnuresisEnuresis • Good historyGood history • Physical examinationPhysical examination (bad general ,external(bad general ,external genitalial neurological(occult spina bifidagenitalial neurological(occult spina bifida))
- 22. Assessment of PrimaryAssessment of Primary EnuresisEnuresis • Urine analysisUrine analysis • Urine osmolalityUrine osmolality • Lumbo-sacral x-rayLumbo-sacral x-ray • Abdominal ultrasonographyAbdominal ultrasonography • VCUGVCUG • Urodynamic studyUrodynamic study
- 23. • Urine analysisUrine analysis (when):?(when):? if secondary , bad health, UTI??if secondary , bad health, UTI?? • No radiologyNo radiology • No urodynamic studyNo urodynamic study
- 24. Should a 5-year-old child be activelyShould a 5-year-old child be actively treated for enuresis?treated for enuresis? If primary nocturnal enuresis is not distressing to the child, treatment is unnecessary, although parents should be reassured about their child’s physical and emotional health and counseled about eliminating guilt, shame, and punishment. (Grade B)
- 25. Response:14 consecutive dry nights or a 90% ↓in no of wet nights/ week Partial response:Symptoms improved but 14 consecutive dry nights or a 90%↓in no of wet nights/ week has not been achieved
- 26. Children under 5 years Children more than 5 years Treatment of PrimaryEnuresisTreatment of PrimaryEnuresis
- 27. Treatment of PrimaryTreatment of Primary EnuresisEnuresis Advice First line Second line Third
- 29. General DietFluid intake Toilet pattern Lifting and walking Reward advice •Not the child's fault •No punishment •Reassurance (dry after a given time) •Children change their bedding Healthy diet with no restriction Avoid caffeine- based drinks before going to bed urinate at regular interval during the day and befor sleep •Safe the bed only positive rewards for agreed behaviour rather than dry nights( fluid-toilet –management)
- 30. First line treatment Alarm Desmopressin an alarm is considered inappropriate, particularly if: ◆ bedwetting is very infrequent (that is, less than 1–2 wet beds per week) ◆ the parents or carers are having emotional difficulty coping with the burden of bedwetting rapid-onset and/or short-term improvement in bedwetting is the priority of treatment or − an alarm is inappropriate or undesirable (see recommendation Alarm is the first line for families who are well motivated and well informed Do not exclude alarm treatment as an option for children and young people with: ● daytime symptoms as well as bedwetting ● secondary onset bedwetting
- 32. Start desmopressin treatment Is complete dryness achieved after 1–2 weeks? Assess response at 4 weeks Continue treatment for 3 months Stop desmopressin for 1 week to check whether dryness has been achieved(grdual) Consider increasing dose (240 –400) assessment of factors associated with poor response (adhernce,30%sleep apnea ,constipation , underlying disease (urological proplems) or social and emotional factors yes No Respons e Partial Increase the dose Give the drug 1–2 hours before bedtime restrict fluid Continue treatment for another 6 months No
- 33. Management ofManagement of RecurrencesRecurrences • Another course of desmopressin (repeated courses may beAnother course of desmopressin (repeated courses may be used)used) • Regular withdrawal of desmopressin (for 1 week everyRegular withdrawal of desmopressin (for 1 week every 3 months)3 months) • Gradual withdrawal of desmopressin rather than stopping itGradual withdrawal of desmopressin rather than stopping it suddenly (increase of 'no-medication days' over an 8-weeksuddenly (increase of 'no-medication days' over an 8-week period)period) • Using an enuresis alarmUsing an enuresis alarm
- 34. Treatments NotTreatments Not RecommendedRecommended • strategies that interrupt normal passing of urine or encourage infrequent urination during the day • dry-bed training with or without an alarm.
- 35. Second-Line TherapySecond-Line Therapy Desmopressin or alarm + Anticholinergic drugs
- 36. Anticholinergic Drugs bedwetting that has partially responded to desmopressin alone bedwetting that has not responded to desmopressin alone bedwetting that has not responded to an alarm combined with desmopressin Do not use an anticholinergic: ● alone for children and young people with bedwetting without daytime symptoms ● combined with imipramine
- 37. Oxybutynin: 5mg assess 1–2 month? Continue treatment for 3 months with Gradual tapering Respons e Partial Continue treatment for another 6 months Have the greatest chance of success in the child with signs of detrusor overactivity, i.e. low daytime voided volumes. Repeated courses can be used Doses can be doubled in over 12 years children The main side effects are dry mouth, headaches, constipation, retention of urine and very occasionally unusual behaviour or night terrors
- 38. Third-line Therapy Desmopressin or alarm + Tricyclic anti-depressants
- 39. TricyclicTricyclic AntidepressantsAntidepressants • Significant anticholinergic effects and additional central effects
- 40. ImipramineImipramine How Is It Given?How Is It Given? • Start as a low dose (25 mg for children > 6 years, 50 to 75 mg for children > 11 years) and increase fortnightly to the maximum dose allowed for the age of the child (50 mg in children 7 to 12 years of age and up to 75 mg in older children) • The single daily dose should be given around 3 hours before sleep • A course of treatment should last for 3 months maximum before reducing the dose slowly and stopping it for a week or so to assess progress
- 42. Take Home MessegeTake Home Messege • The initial evaluation of the enuretic child should focus on good history and with no radiology or invasive procedures • The first step in assessment is to exclude underlying disorders, such as diabetes, kidney disease or urogenital malformations • The main goals of treatment are to increase the number of dry night and to alleviate the emotional impact of enuresis
- 43. Take Home MessegeTake Home Messege • Positive reward systems have a better impact on the enuretic child (Grade B) • Bladder training, retention control training, and dry bed training are no longer recommended
- 44. Take Home MessegeTake Home Messege • Therapy is a stepwise process. Partial response is better than no response • The first-line treatment is the enuresis alarm or desmopressin • In therapy resistant cases occult constipation needs to be ruled out • The second line of therapy is anticholinergic treatment combined with desmopressin
- 45. Take Home MessegeTake Home Messege • In situations when all other treatments have failed, imipramine treatment is warranted, provided the cardiac risks are taken into account