Primary mono-symptomatic NE is a multi-axial problem in need of holistic view during its management

4. - von Gontard & Neveus, 2006.
Enuresis is derived from the Greek
word (Enourein) which means “to
void urine”.
It refers to emptying the bladder in
inappropriate locations that relative
to the individual's age and
maturational level (e.g., bed;
clothing).

5. Enuresis
Urology
Pediatric
Psychiatry
Endocrinology
Neurology

6. Management Consensus
Up till now there is no
consensus, protocol or
guidelines for the
management of NE and all
treatments are individual
diligent based on experience.

8. History of Enuresis
- Glicklich, 1951.
The earliest record of enuresis
in literature is in the Papyrus
Ebers, of Ancient Egyptian
Pharaons dated 1550 BC.
They used a mixture of juniper
berries, cypress leaves and beer.

9. History of Enuresis
- Glicklich, 1951.
Pre-1970s: frogs were tied to Nigerian child’s penis nocturnally
1904: The first “bell & pad” alarm was created by the German physician, Dr.
Meinhard Pfaundler.
1989: Desmopressin acetate (DDAVP), was introduced and approved by FDA
1999: Japanese urologist introduced electronic alarm that monitor sleeping
brainwaves and bladder contraction that gives alarm when the child is about to
urinate during sleep.
1709: The bedwetting child was forced to drink urine.
Pre-1970s: frogs were tied to Nigerian child’s penis nocturnally.
1904: The first “bell & pad” alarm was created by the German
physician, Dr. Meinhard Pfaundler.
1989: Desmopressin acetate (DDAVP) was FDA approved.
1999: Japanese electronic alarm monitoring sleeping brainwaves and
bladder contraction that gives alarm when the child is about to
urinate while asleep.
1709: Enuretic children were forced to drink urine in the next day.

11. Nocturnal Enuresis
- Pereira , et al. 2016.
NE is defined as a complete or
nearly complete micturition in
bed during sleep more than 2
times a week for at least 3
consecutive months in a healthy
child above the age of 5 years.

12. Incidence
- Butler , et al. 2008.
Following allergy, NE is the
second most common chronic
pediatric problem affecting 10 –
15% of children by the age of 5
years.
Spontaneous remission is usual
and affected children reduces year
by year to reach 1% at adulthood.

13. Impact of NE
- Joinson, et al. 2007.
Bedwetting has a deep impact
on social, scholastic and
emotional wellbeing of children
during an important period of
psychosocial development.

14. Organic NE
- Michael, et al. 2001.
Constitutes about 5% of all cases of
NE.
Occurs due to organic
neurological or urological diseases,
DM, diabetes insipidus and
epilepsy.

15. Secondary NE
- Michael, et al. 2001.
Secondary NE means recurrence of
nocturnal bed wetting after more than
6 months of dryness.
It may be precipitated by upper airway
obstruction, urinary tract infection,
chronic constipation, ADHD, conduct
disorder, specific phobia, generalized
anxiety or depression.

16. Primary NE
- Michael, et al. 2001.
Primary NE refers to no prior
period of sustained dryness.
It may be either:
(1) Monsymptomatic.
(2) Non-monosumptomatic.

17. Monosymptomatic NE
- Telli ,et al. 2015.
MNE children have normal daytime voiding.
Possible etiologies include:
(1) Nocturnal polyuria with decreased arousal
of full bladder during sleep due to brainstem
enuresis inhibiting reflexes maturational
delay.
(2) Genetic factors (Polygenetic, mainly in
chromosomes 12 & 13).
(3) Psychological components.

18. Non-Monosymptomatic NE
- Raheem, et al. 2013.
Non-MNE is caused by overactive
bladder presented by daytime
symptoms including frequency,
urgency, hesitancy and interrupted
stream, repeated lower urinary or
genital pain
Children always show variable sized
nocturnal wet patches and awakening
after wetting.

19. Nocturnal Enuresis
Functional Organic
Secondary Primary
Monosymptomatic Non-monosymptomatic

21. Aim of the Work

23. Inclusion Criteria
The study was conducted on 40
primary MNE children, aged 6 – 18
years and 20 healthy control
subjects matching the patient's age
and sex.

24. Exclusion Criteria
Children with non MNE, secondary
NE, mental disorders, psychiatric
problems and organic neurological
or urological disorders.

26. Clinical Assessment
History taking: was done to all subjects with special stress on
frequency of NE, family history of NE and previous treatment
trials. Upper airway obstruction, urinary tract infection and
constipation were treated before joining the study.
Neurological and urological examinations, urine analysis and
abdominal ultrasound were done to exclude organic causes.

27. Polysomnogram
Patients and control were subjected to one night PSG

28. Vasopressin Level
Vasopressin level by ELISA:
(1) Diurnal (at 9 – 11 am)
(2) Nocturnal (at 9 – 11 pm).
Normal level is 2 – 400 picogram
/ml.

29. Psychological Assessment
An Arabic-translated and validated version of Child Behavior
Checklist (CBCL) was completed by a parent and scored using
a computerized scoring software system (Assessment Data
Manager-version 9.1).
CBCL yields four global T-scores: competence, internalizing
behavior problems, externalizing behavior problems, and total
problem behaviors.

32. Mean Age

33. Sex Distribution
60%
40%

34. Family History

35. 0
20
40
60
80
100
FH SBO
Spina Bifida Occulta
20%23%
Enuretics Control

36. Previous Desmopressin Response
No previous ttt
Complete response
Partial response
22.5%
12.5%
55%10%
No response

38. 0
90
180
270
360
450
E C
Sum of Diurnal – Nocturnal Vasopressin
Enuretics Control
p=0.031

39. Vasopressin

40. -17
-12
-7
-2
3
8
13
18
23
28
33
E C
Nocturnal–Diurnal Vasopressin Difference
Enuretics Control
p<0.0001

41. Child Behavior Checklist

42. 0
10
20
30
40
50
60
E C
CBCL Anxious Depressed Symptoms
Enuretics Control
p=0.004

43. 0
10
20
30
40
50
60
E C
CBCL Social Problems
Enuretics Control
p=0.0011

44. 0
10
20
30
40
50
60
E C
CBCL Attention Problems
Enuretics Control
p=0.0011

45. 0
10
20
30
40
50
60
E C
CBCL Internalizing Problems
Enuretics Control
p=0.0009

47. 0
1
2
3
4
5
6
7
E C
Total Sleep Time (Hours)
Enuretics Control
p=0.816

48. 0
10
20
30
40
50
60
70
80
90
E C
Sleep Efficiency (%)
Enuretics Control
p=0.503

49. 0
0.3
0.6
0.9
1.2
1.5
E C
Apnea Hypopnea Index
Enuretics Control
p=0.88

50. 0
4
8
12
16
E C
Stage 1 Latency (Minutes)
Enuretics Control
p=0.86

51. 0
4
8
12
16
E C
Stage 2 Latency (Minutes)
Enuretics Control
p=0.9

52. 0
15
30
45
60
75
90
E C
REM Latency (Minutes)
Enuretics Control
p=0.73

53. 0
4
8
12
16
20
24
28
E C
Deep Sleep Latency (Minutes)
Enuretics Control
p<0.0001

54. 0
1
2
3
4
5
6
E C
N1 % TST
Enuretics Control
p =0.027

55. 0
10
20
30
40
50
E C
N2 % TST
Enuretics Control
p<0.0001

56. 0
5
10
15
20
E C
REM % TST
Enuretics Control
p<0.0001

57. 0
10
20
30
40
50
E C
Deep Sleep (N3) % TST
Enuretics Control
p<0.0001

58. 0
5
10
15
20
E C
Sleep Stages Transition Index
Enuretics Control
p<0.0001

59. 0
1
2
3
4
5
6
7
E C
Periodic Limb Movement Index
Enuretics Control
p =0.002

60. 0
4
8
12
16
E C
Snore Index
Enuretics Control
p =0.018

63. NE Frequency Age
2.5
3.5
4.5
5.5
6.5
7.5
6 8 10 12 14 16 18
Age
Frequency

64. -100
-80
-60
-40
-20
0
20
40
60
2.5 3.5 4.5 5.5 6.5 7.5
NE Frequency ADH Difference
Frequency
ADHdifference

65. NE Frequency REM % TST
0
5
10
15
20
25
2.5 3.5 4.5 5.5 6.5 7.5
Frequency
REM%TST

66. NE Frequency N1 % TST
1.5
2.5
3.5
4.5
5.5
6.5
7.5
2.5 3.5 4.5 5.5 6.5 7.5
Frequency
N1%TST

67. NE Frequency N2 % TST
10
20
30
40
50
2.5 3.5 4.5 5.5 6.5 7.5
Frequency
N2%TST

68. NE Frequency SSTI
5
10
15
20
25
30
35
2.5 3.5 4.5 5.5 6.5 7.5
Frequency
SSTI

69. NE Frequency N3 % TST
20
30
40
50
60
70
80
90
2.5 3.5 4.5 5.5 6.5 7.5
Frequency
N3%TST

70. -10
0
10
20
30
40
50
60
2.5 3.5 4.5 5.5 6.5 7.5
NE Frequency Snore Index
Frequency
SnoreIndex

73. Sleep Stages % of Total in Bedtime
◘ EEG monitoring was done for 1
hour 3 times daily, started within
the first 48 hours after admission
until the 20th day or the
appearance of vasospasm signs.
PSG in 2 studied enuretic children showing marked prolongation of N3
NREM (3) and shortening of each of REM (R) and N2 NREM (2).

74. NE case Hypnogram
◘ EEG monitoring was done for 1
hour 3 times daily, started within
the first 48 hours after admission
until the 20th day or the
appearance of vasospasm signs.
Hypnogram of a case of NE showing decreased REM % of TST and
increased each of deep sleep and sleep stage transition index.

76. MNE Etiological Heterogeneity

77. Factors Increase The Frequency
(1) Strong family history of NE.
(2) Inverted vasopressin rhythm.
(3) Higher sleep architecture changes.
(4) Increased psychological abnormalities.
(5) Presence of spina bifida occulta.
(6) Comorbidity.

78. Nocturnal Enuresis

79. Do Not Forget

80. Recommendations

81. Recommendations

82. Recommendations

84. Study Limitations
Most parents refused water cyctometry which resulted in its
elimination from the study protocol and exclusion of non-
monosymptomatic NE.

86. I am very grateful to all children
and parents who accepted to
participate in the study

89. Wafik S. Bahnasy1, Yasser A. El-Heneedy1, Ehab A. El-Seidy1, Ibrahim S. Ibrahim2, Mohammad A. Seleem3, Amira Y. Ahmed4
Departments of Neurology1, Chest2, Psychiatry3, Clinical Pathology4, Tanta University, Egypt