chilhood enuresis

1. CHILDHOOD ENURESIS
Presented by :- Dr. Kumar Keshav Chandra

2. HEADINGS
• Anatomy of bladder
• Physiology of micturition
• Bladder innervation
• Micturition reflex
• Voiding and its control
• Disorder of micturition
• Nocturnal enuresis

3. URINARY BLADDER ANATOMY
• Urinary bladder functions as a storage organ that can
empty to completion at appropriate time and place.
• The bladder is the most anterior element of the pelvic
viscera.
• Situated in the pelvic cavity when empty, but expands
superiorly into the abdominal cavity when full.
• The urinary bladder is abdominal at birth, positioned at
the extraperitoneal area of the lower abdominal wall.
• Around the 5th or 6th year of age the bladder gradually
descends into the area of the true pelvis.

4. URINARY BLADDER
ANATOMY
It has 4 parts
1. Apex
2.Base
3.Superior surface
4.Inferolateral surfaces

5. URINARY BLADDER ANATOMY

6. PHYSIOLOGICAL ANATOMY OF
URINARY BLADDER
• Urinary bladder is a hollow organ, having parts
namely:
• BODY – formed by detrusor muscle
• NECK - has trigone in its posterior aspect
• Emptying of bladder is mainly guarded by Internal
And External Sphincter
• Internal Sphincter – completely involuntary. ( smooth
muscle)
• External Sphincter- voluntary. ( skeletal muscle)

8. INNERVATION OF URINARY BLADDER
• Urinary bladder and Internal sphincter are supplied by
sympathetic and parasympathetic nerve fibers.
• Sympathetic supply : L1, L2 ( Hypogastric nerve)
• Parasympathetic supply : S2,S3,S4 ( Nervi erigentes / pelvic
nerve)
• External sphincter is supplied by somatic nerve fibres.
(through onuf’s nucleus S2,3,4. Pudendal nerve) , having
voluntary control of urination.
• Pelvic nerve ( nervi erigentes) also has sensory fibers, which
carry impulse from the stretch receptors present on the wall
of urinary bladder and urethra.

9. • Stretch receptor on bladder—sensation carried
to spinal cord by sensory fibers of pelvic
nerve—sense of distension carried in post
column and sense of pain through lateral
spinothalamic tract—reaches to brain stem
(pontine centre) and suprapontine centre(para
central lobule, basal ganglia, thalamus)
• Output from supra pontine centre to pontine
centre is inhibitory most of the time.
• This supra pontine output becomes facilitatory
only when it is socially acceptable to void.

10. INNERVATION OF URINARY BLADDER

11. Sympathetic supply
stimulation of hypogastric
nerve causes,relaxation of
detrusor muscle and
constriction of internal
sphincter
results in filling of bladder
(Nerve of filling)
• Parasympathetic supply
stimulation of pelvic nerve
causes contraction of
detrusor muscle and
relaxation of internal
sphincter
it results in emptying of
bladder.
(nerve of micturition).

12. TYPES OF NERVES NERVE FIBRES ACTION COMMENTS
SYMPATHETIC HYPOGASTRIC
NERVES(L1,L2,L3)
INFERIOR
MESNTERIC
GANGLION
motor to internal
urethral sphincter,
inhibitory to
detrusor
Help in filling of bladder and
prevent reflux of semen into
the bladder during ejaculation
PARASYMPATHETIC PELVIC NERVES
(S2,S3,S4)
motor to detrusor
inhibitory to
internal urethral
sphincter
•Muscarinic receptors
•emptying of urinary
bladder
SOMATIC PUDENDAL NERVES
(S2,S3,S4)
Voluntary control of
External urethral
sphincter
This maintains the tonic
contractions of the skeletal
muscle fibers of the external
sphincter, so that this
sphincter is contracted
always. During micturition this
nerve is inhibited, causing
relaxation of the external
sphincter and voiding of
urine.
SENSORY HYPOGASTRIC,
PELVIC AND
PUDENDAL NERVES
Cortical sensation

13. MICTURITION REFLEX

14. • FILLING
• The walls of the ureters contain smooth muscle having regular
peristaltic contractions occurring one to five times per
minute move the urine from the renal pelvis to the bladder,
where it enters in spurts synchronous with each peristaltic
wave.
When the volume of urine in bladder reaches threshold level to
initiate Micturition reflex (this threshold level is adjusted by
higher centers of micturition )
Bladder wall stretches Stretch receptors on the bladder wall
are activated…Sensory signal is given to spinal centers
through sensory fibres of parasympathetic (pelvic nerve)
Reflex arc is produced in spinal cord…

15. continued
Motor signal is given to urinary bladder through motor fibres of
parasympathetic nerve ( pelvic nerve)
DETRUSOR muscle contracts and INTERNAL SPHINCTER relaxes
and urine passes down into proximal urethra..
Again afferent impulse from urethra is given to spinal cord…
Afferent impulse reaches the higher centers in brain
If the signal from higher center is TO MICTURATE impulse
created from spinal center BLOCK PUDENDAL NERVE and
sympathetic efferents to external sphinctor are inhibited…So,
External sphincter relaxes and micturition occurs…

16. continued
• If the signal from higher center is NOT TO MICTURATE,
sympathetic efferents are stimulated
• As a result, DETRUSOR EXPANDS and INTERNAL SPHINCTER
constricts… External sphincter remain constricted…
So, Urine continues to accumulate in bladder..

17. CENTERS FOR MICTURITION
SPINAL CENTRES :
• Located in sacral and lumbar segments in form of sympathetic
and parasympathetic control.
• Controlled by higher center of brain.
• HIGHER CENTERS :
• Facilitatory center : Pontine micturition centre(barrington nucleus),
acting as a coordination center. Posterior hypothalamus.
• Inhibitory center : cortical center(paracentral lobule). These are
inhibitory to pontine center.
• Controls pontine center till a suitable socially acceptable situation
for micturition is available.

18. NORMAL VOIDING AND BLADDER CONTROL
Fetal voiding occurs by reflex bladder contraction in concert with
simultaneous contraction of the bladder and relaxation of the
sphincter.
The infant has coordinated reflex voiding as often as 15-20
times/day.
. Bladder vol. of new born 20-30 ml.
• Over time, bladder capacity increases
• In children up to the age of 14 yr, the mean bladder capacity in
milliliters = [AGE (in yr) +2] × 30.
• = AGE (in yr) × 30 + 30.
• At 2-4 yr, the child is developmentally ready to begin toilet training.
• Females typically acquire bladder control before males, and bowel
control typically is achieved before bladder control

19. To achieve conscious bladder control, several conditions must
be present:
 Awareness of bladder filling
 cortical inhibition (suprapontine modulation) of reflex bladder
contractions
 ability to consciously tighten the external sphincter to
prevent incontinence
 normal bladder growth
 and motivation by the child to stay dry.
 The transitional phase of voiding refers to the period when
children are acquiring bladder control.

20. MATURATION OF BLADDER CONTROL
FETUS/
AT BIRTH
Spinal cord reflex Spontaneous / reflex
micturition
1-2
YEARS
bladder capacity +
Neural maturation of
frontal and parietal lobe
Sensation of bladder filling
present but voiding is reflex
3-4
YEARS
Voluntary control of EUS
when awake(day time
continence)
Can delay micturition
5 YEARS Cortical inhibitory control
achieved
Dry by night
>6 yrs Ability to initiate voiding
even when bladder has not
given a “full” signal
Voiding under socially
acceptable circumstances

21. • So fully mature bladder control have:-
Generous bladder capacity
Voluntary control of EUS
Ability of cerebral cortex to initiate and inhibit a
detrusor contraction for any bladder capacity, which
enables voiding under socially acceptable conditions.

22. The sequence of maturational events for fecal and
urinary continence
Night-time fecal continence
Daytime fecal continence
Daytime urine continence
Night-time urine continence.
Majority of children are dry by day by the age of 2½ years and at night by 3-
4 years.

23. DISORDERS OF MICTURITION
The International Children’s Continence Society (ICCS) has recommended
the use of standard nomenclature when describing lower urinary tract
malfunctions in children above 5-year-old which are as follows:-
• Decreased daytime voiding frequency: 3 or fewer voidings/d
• Increased daytime voiding frequency: 8 or more voidings /d
• Polyuria: 24-hour urine output of more than 2 l/m2 BSA.
• Incontinence: Uncontrollable leakage of urine
 Continuous: Continuous leakage of urine, not in discrete portions,
which indicates malformation or iatrogenic damage
 Intermittent: Leakage of urine in discrete portions during the day
and/or night.
 Nocturnal incontinence is synonymous with enuresis
 Urge incontinence: Incontinence in patients experiencing urgency,
e.g. incontinence in children with overactive bladder
 Voiding postponement: Incontinence in the presence of habitual
holding maneuvers

24. .
Enuresis: Intermittent incontinence of urine while sleeping
(nocturnal incontinence)
• Monosymptomatic: Enuresis without any (other) lower urinary tract
symptoms.
 Non-monosymptomatic: Enuresis with lower urinary tract
symptoms , such as daytime incontinence, urgency and holding
maneuvers.
• Primary: Enuresis in a child, who has never been dry
• Secondary: Enuresis in a child who has previously been dry for at
least 6 months . Factor associated includes Nocturnal polyuria,
detrusor instability, and an abnormally deep sleep pattern
Overactive bladder: The condition in patients experiencing urgency
symptoms
Underactive bladder: The condition in patients with low voiding
frequency; need to increase intra-abdominal pressure to void
(replaces the term underactive bladder or lazy bladder)

25. Dysfunctional voiding: The habitual contraction of the urethral sphincter
during voiding, as observed by uroflow measurements.
Maximum voided volume: The largest voided volume, as documented in
a bladder diary(diary maintained for 3 day)It replaces the term
functional bladder capacity
Expected bladder capacity: Age related expected maximum voided
volume, as determined by the formula, [30 + (age in years × 30)] in ml.

26. Cystometric definitions
• Detrusor overactivity: The observation during cystometry of
involuntary detrusor contractions during the filling phase.
• Detrusor-sphincter dyssynergia: The cystometric observation of a
detrusor voiding contraction concurrent with an involuntary
contraction of the urethra.
• Detrusor underactivity: The cystometric observation of a contraction
of decreased strength and/or duration, resulting in prolonged bladder
emptying and/or a failure to achieve complete bladder emptying
• Residual urine: Urine left in the bladder after voiding.
Residual urine in excess of 5 to 20 ml indicates incomplete bladder
emptying.
A postvoid residual of more than 5 ml in the neonate and greater than 10% of
the expected capacity in the older child is considered abnormal.

27. Nocturnal Enuresis
• It is defined as normal, nearly complete, involuntary evacuation of
the bladder at a wrong place and time at least twice a month( for
more than 3 consecutive month )after the 5th year of life.
• Overall, 75% of children with enuresis are wet only at night, and
25% are incontinent day and night.
• Bladder control is usually attained between the ages of one and five
years.
 More than 85 percent children will have complete diurnal and
nocturnal control by five years of age. The remaining 15 percent of
children gain continence at a rate of approximately 15 percent per
year and by adolescence 0.5-1 percent children continue to have
enuresis.
 Up to the eleventh year, enuresis is twice as common in boys as it
is in girls; thereafter the incidence is similar or slightly higher in
girls.

28. Etiology
Most of the children with primary nocturnal enuresis are functional.
Only 2-3% 0f nocturnal enuresis have true organic cause.
There is no single definite underlying cause for enuresis, and the
condition may be multifactorial:
1. Maturational Delay- This is the most likely cause of nocturnal
enuresis, since spontaneous cure rates increase with age and the
sequence to dryness mimics the pattern seen in normal children.
• Delayed maturation of the cortical mechanisms that allow voluntary
control of the micturition reflex.
• Boys take longer to reach specific milestones and have a greater
incidence of enuresis.
• 2. Genetics:- controlling gene have been localized to chromosomes
12 and 13(ENUR1). If one parent was enuretic, each child has a 44%
risk of enuresis; if both parents were enuretic, each child has a 77%
likelihood of enuresis. Mode of inheritance is AD with reduced
penetrance .

29. • 3. Antidiuretic hormone:- ADH has a circadian rhythm, with
increased secretion occurring during the night and peak secretion
between 4 and 8 am. A lack of this circadian rhythm or impaired
response of the kidneys to ADH may be a possible etiology for
nocturnal enuresis. Reduced ADH production at night, resulting in
an increased urine output (nocturnal polyuria).
• 4. Defective sleep arousal:- All children are most difficult to
arouse in the first third of the night and easiest to awaken in the
last third, but enuretic children are more difficult to arouse than
those with normal bladder control
• 5. Bladder Capacity:-The balance between bladder capacity and
nocturnal urine production may be the ultimate determinant of
whether or not an enuretic episode will occur.
• The functional capacity, i.e. the volume of urine that the bladder
can hold when awake or asleep, may be reduced in children with
enuresis.
• This is determined as the largest volume voided after measuring
each void for 3 consecutive days and is compared to the estimated
bladder capacity calculated using the age based formula.

30. 6. Organic factors, such as urinary tract infection, obstructive
uropathy may lead to incomplete bladder emptying.
7. Obstructive sleep apnea may be an additional risk factor in obese
children with primary monosymptomatic nocturnal enuresis.
8. Co morbid conditions:- Constipation and neuropsychiatric
disorders such as attention deficit hyperactivity disorder are
common in children with enuresis.

31. Clinical Manifestation and Diagnosis
• A careful history should be obtained, especially with respect
to fluid intake at night and the pattern of nocturnal enuresis.
• Children with diabetes insipidus ,diabetes mellitus , and
chronic renal disease can have a high obligatory urinary
output and a compensatory polydipsia.
• The family should be asked whether the child snores loudly at
night.
• Many children with enuresis have sleepwalk or talk in their
sleep.
• A complete physical examination should include palpation of
the abdomen and possibly a rectal examination after voiding
to assess the possibility of a chronically distended bladder and
constipation.

32. • The child with nocturnal enuresis should be examined
carefully for neurologic and spinal abnormalities.
• There is an increased incidence of bacteriuria in enuretic
females, and, if found, it should be investigated and treated.
• A urinalysis to rule out infection, proteinuria and glucosuria is
warranted in all children.
• A renal USG is reasonable in an older child with enuresis or in
children who do not respond appropriately to therapy.
• If there are no daytime symptoms, the physical examination
and urinalysis are normal, and the urine culture is negative,
further evaluation for urinary tract pathology generally is not
warranted

33. TREATMENT
 No single therapeutic plan is ideal for all patients.
 Assessing the level of motivation of the patient and his
parents prior to offering the choice of treatment is important.
 The best approach to treatment is to reassure the child and
parents that the condition is self-limited and to avoid punitive
measures that can affect the child's psychological
development adversely.
 The decision about when to start treatment should be guided
by the degree of concern and motivation on the part of the
child rather than the parents.
 Active treatment should be avoided in children younger than
6 yr of age.

34. 1. General measures:-
There is little objective evidence that withholding fluids in
the evening, random awakening of the child to void or
punitive measures result in significant cessation of enuresis.
• Fluid intake should be restricted to 60 ml after 6 or 7 PM.
Adequate fluid intake during the day as 40 percent in the
morning, 40 percent in the afternoon and 20 percent in the
evening is recommended.
• Caffeinated drinks like tea, coffee and sodas should be
avoided in the evening
• The parents should be certain that the child voids at bedtime.

35. 2. Motivational therapy
:-The success of any form of therapy depends largely on
the child being motivated to work towards sleeping
dry.
• Every attempt is made to remove any feeling of guilt.
• The child should be encouraged for total involvement
in the therapy with maintenance of a dry night diary.
• Dry nights merit praise and encouraging words from
the parents.
• 25 % of children may be cured with appropriate
motivational therapy alone.
.

36. 3.Conditioning therapy(Alarm)
• Involves use of a loud auditory or vibratory alarm attached to a
moisture sensor in the underwear or a mat under bedsheet. The
alarm activates when voiding occurs and is intended to awaken
children and alert them to void and conditioned response to
awakening to the sensation of full bladder.
• The child should awaken to the alarm, void in the toilet and
reattach the alarm .
• The alarm should be used consistently every night.
• In case of response, alarm therapy is continued until at least 14
consecutive dry nights are achieved.
• This form of therapy has a reported success of 30–60%, although
the relapse rate is significant.
• The alarm is best used after 7 yrs of age and its use continued for
six months for better long-term success.

38. 4. Pharmacotherapy:-
• Pharmacologic therapy is intended to treat the symptom of
enuresis and thus is regarded as second line and is not curative.
Direct comparison with alarm therapy favor the alarm because of
lower relapse rates, although initial response rates are equivalent.
 DESMOPRESSIN:-
synthetic analog of VASOPRESSIN that reduces urine production
overnight.
• FDA-approved in children and is available as a tablet, with a dosage
of 0.2-0.6 mg 2 hr before bedtime.
• In the past a nasal spray was used, but some children experienced
hyponatremia and convulsions with this formulation, and the nasal
spray is no longer recommended for nocturnal enuresis.

39. • Hyponatremia has not been reported in children using the oral
tablets.
• Fluid restriction at night is important, and the drug should not be
used if the child has a systemic illness with vomiting or diarrhea or
if the child has polydipsia.
• Desmopressin acetate is effective in as many as 40% of children
and is most effective in those approaching puberty.
• If effective, it should be used for 3-6 month, and then an attempt
should be made to taper the dosage.
• TAB MINIRIN/ TAB D-VOID (0.1 mg/0.2mg)

40. Anticholinergic drug
For therapy-resistant enuresis or children with symptoms of
an overactive bladder, anticholinergic therapy is indicated.
Oxybutynin 5 mg or tolterodine 2 mg at bedtime often is
prescribed. If the medication is ineffective, the dose may be
doubled. The clinician should monitor for constipation as a
potential side effect.
TAB CYSTRAN/ NOCTURINE/OXYSPAS (5mg/10 mg)- oxybutynin
TAB TEROL/ DETRUSITOL (1/2mg)– tolteradine.

41. Tricyclic antidepressants
• A third-line treatment is imipramine, which is a TCA.
• This medication has mild anticholinergic and α-adrenergic effects,
reduces the urine output slightly, and also might alter the sleep
pattern.
• The dosage of imipramine is 25 mg in children age 6-8 yr,
50 mg in children age 9-12 yr, and
75 mg inteenagers.
• Reported success rates are 30–60%.
• Side effects include anxiety, insomnia, and dry mouth, and heart
rhythm may be affected.
• If there is any history of palpitations or syncope in the child, or
sudden cardiac death or unstable arrhythmia in the family, long QT
syndrome in the patient needs to be excluded
• Tab ANTIDEP/IMIPRAMINE(25/50mg).

42. SUMMARY OF TRAETMENT
• DDAVP has better short-term results but the alarm device has
better long-term outcome.
• If long-term efficacy, cost and safety are considered, enuresis
alarms are superior.
• In unsuccessful cases, combining therapies often is effective.
• Alarm therapy plus desmopressin is more successful than either
alone.
• The combination of oxybutynin chloride and desmopressin is more
successful than either alone.
• Desmopressin and imipramine also may be combined.

43. The three system model, i.e.
 Desmopressin for low vasopressin release,
 Oxybutynin along with bladder training for instability and the
 Alarm to enhance arousability from sleep, is usually
satisfactory.
• A combination of one of these with motivational therapy is
ideal. Reassurance of the child for direct involvement in the
therapy improves the outcome.
• Children who fail both the first line therapies further
evaluation to rule out non-monosymptomatic enuresis,
ensuring correct technique of administration of therapies
prescribed, and exclusion of constipation and psychiatric
disorders.