This document provides an overview of childhood enuresis (bedwetting), including definitions, epidemiology, etiology, clinical manifestations and diagnosis, and treatment options. It defines primary and secondary enuresis and notes that psychological problems are usually a result rather than a cause. Treatment options discussed include supportive management, alarm therapy, desmopressin, anticholinergic medications like oxybutynin, and imipramine. Alarm therapy and desmopressin are identified as the most effective evidenced-based treatments.

1. CHILDHOOD ENURESIS
Dr. Majd Azez
Resident at Urologist surgery of faculty of medicine of Damascus
university
11-9-2014

2. BACKGROUND & DEFINITION
 The word enuresis is derived from a Greek word
(enourein) that means “to void urine.”
 Enuresis may be
1. Primary (75%)
Nocturnal urinary control never achieved
2. Secondary (25%)
The child was dry at night for at least a few
months and then enuresis occurs
 In PE, psychological problems are almost always the
result of the condition and only rarely the cause. In
SE, however, psychological problems are a possible
cause, albeit not a common one.
 The comorbidity of behavioral problems is 2-4 times
higher in children with enuresis.

3.  Enuresis can be further divided into the following
3 subtypes on the basis of the time of occurrence :
 Nocturnal (ie, during sleep)
 Diurnal (ie, during waking hours)
 Nocturnal and diurnal (also known as
nonmonosymptomatic enuresis)
 The International Children’s Continence Society
[ICCS] restricts the term to wetting that occurs at
night
 75% of children with enuresis are wet only at night
25% are wet day and night
 By 5 yr of age, 90-95% are nearly completely continent
during the day and 80-85% are continent at night

4. DEVELOPMENT OF CONTINENCE
 In infants , void 20 times a day
 Over the next 2 years, 11 times .
 Around this time that children also begin to recognize
symptoms of bladder fullness .
 3 years of age, children have some conscious control and
most have daytime control with occasional accidents
 Most children are dry by day and night by the age of 4
years .
 Maturation of communication between :
 pontine micturition centre
 pontine storage centre,
 cerebellum, which receives sensory input from the bladder and
pelvic floor
 the basal ganglia
 frontal lobes

5. EPIDEMIOLOGY
 Approximately 60% of children with nocturnal enuresis
are boys.
 Family history is also important and is positive in 50% of
cases.
 Although primary nocturnal enuresis may be
polygenetic, candidate genes have been localized to
chromosomes 12 and 13.
 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.
 Nocturnal enuresis without overt daytime voiding
symptoms affects up to 20% of children at the
age of 5 yr
 It ceases spontaneously in approximately 15% of
involved children every year thereafter.
 Its frequency among adults is less than 1%.

6. ETIOLOGY
 Idiopathic
 Disorder of sleep arousal
 Nocturnal polyuria
 Small nocturnal bladder capacity
 Overactive bladder or dysfunctional voiding
 Cystitis
 Psychological causes
 Sleep-disordered breathing
 Urethral obstruction
 Seizure disorder
 Ectopic ureter : 3-4 times more common in girls than in
boys and causes incontinence only in females.
 Diabetes mellitus
 Diabetes insipidus

8. CLINICAL MANIFESTATIONS AND DIAGNOSIS
 Careful History should be obtained, especially with
respect to fluid intake at night and pattern of
nocturnal enuresis.
 Children with diabetes insipidus, diabetes mellitus,
and chronic renal disease may have a high
obligatory urinary output and a compensatory
polydipsia.

9. CLINICAL MANIFESTATIONS AND DIAGNOSIS
 The family should be asked whether the child
snores loudly at night.
 A complete physical examination should include
palpation of the abdomen and rectal examination
after voiding to assess the possibility of a
chronically distended bladder.
 The child with nocturnal enuresis should be
examined carefully for neurologic and spinal
abnormalities.
 There is an increased incidence of bacteriuria in
enuretic girls, and, if found, it should be
investigated and treated .

10. CLINICAL MANIFESTATIONS AND DIAGNOSIS
 Laboratory Studies :
 Urinalysis is the most important screening test in a child with
enuresis .
 cystitis usually have white blood cells (WBCs) or
bacteria evident in the microscopic urinalysis.
 If the urinalysis findings suggest cystitis , a clean-catch
urine specimen should be sent for culture and sensitivity.
 Urethral obstruction may be associated with red blood
cells (RBCs) in the urine.
 The presence of glucose suggests diabetes mellitus.
 A random or first-morning specific gravity greater than
1.020 excludes diabetes insipidus.
 Blood tests usually are not needed.

11. CLINICAL MANIFESTATIONS AND DIAGNOSIS
 Ultrasonography :
 Diagnostic imaging studies are not routinely indicated;
however, patients with coincidental daytime voiding
symptoms should undergo ultrasonography of the
bladder and kidneys.
 In patients with significant daytime symptoms whose
ultrasonograms are normal, more invasive investigations
should be deferred for 3 months, during which period
the voiding routine and emptying are improved, cystitis
is treated or prevented, and bowel health is improved.
 The residual volume of urine is normally less than 5 mL.

12. CLINICAL MANIFESTATIONS AND DIAGNOSIS
 Voiding Cystourethrography Plain Radiography :
 If the bladder wall is thickened or trabeculated or a significant
postvoid residual volume of urine is noted, voiding
cystourethrography (VCUG) should be considered.
 VCUG is warranted for patients in whom a neurogenic bladder is
suspected. The lumbosacral spine should be visualized during
the procedure to look for sacral agenesis or spinal dysraphism.
VCUG is also warranted when urethral obstruction is suspected
on the basis of an abnormal urinary stream or abnormal
ultrasonography findings.
 If obstructive sleep apnea (OSA) is suspected, consider lateral
radiography of the neck or referral to a pediatric otolaryngologist
for direct visualization of the nasopharynx should be considered.

13. CLINICAL MANIFESTATIONS AND DIAGNOSIS
 MRI :
MRI of the spine is indicated in any patient with any of
The following :
 An abnormal neurologic examination finding of the lower
extremities
 A visible defect in the lumbosacral spine
 The triad of encopresis, gait abnormality, and daytime
symptoms
 MRI should be considered in patients with
significant daytime voiding dysfunction that does
not improve with treatment, even if neurologic and
orthopedic examination findings are normal.

14. CLINICAL MANIFESTATIONS AND DIAGNOSIS
 Urodynamic Studies and Cystoscopy :
 Urodynamic studies help clarify the diagnosis of neurogenic
bladder.
 A video urodynamic study measures both filling-phase
parameters (eg, bladder capacity, presence or absence of
unstable detrusor contractions, bladder compliance, and the
state of the bladder neck) and voiding-phase parameters
(eg, voiding pressures, bladder emptying, and the state of the
external urethral sphincter).
 Urodynamic studies and cystoscopy should be reserved for
patients with urethral obstruction and neurogenic bladder and
for patients with dysfunctional voiding who do not improve
after 3 months of therapy.

15. CLINICAL MANIFESTATIONS AND DIAGNOSIS
 Uroflowmetry
 Uroflowmetry is a simple, noninvasive
measurement of urine flow that is helpful in
screening patients for neurogenic bladder and
urethral obstruction .
 Patients with dysfunctional voiding, urethral
obstruction, or neurogenic bladder have prolonged
curves or an interrupted series of curves and low
peak and average urine flow rates.

16. TREATMENT

17.  The best approach to treatment is to reassure parents that the
condition is self-limited and to avoid punitive measures that
may affect the child's psychologic development adversely.
 Specific treatment is generally discouraged before the age of
7 years
 The only therapies that have been shown to be effective in
randomized trials are alarm therapy and treatment with
desmopressin acetate or imipramine.
 Nonmonosymptomatic enuresis may be more difficult and
time-consuming to treat
 Bladder training exercises are not recommended
 Enuresis is not a surgically treated condition. However,
ectopic ureter and obstructive sleep apnea (OSA) respond to
specific surgical interventions.

18. o Supportive management :
 Supportive therapy as an initial management
carries a high grade of recommendation.
 Explaining the condition to the child and his parents
 Eating and drinking habits should be reviewed,
stressing normal fluid intake during day and reducing
fluid intake in the hours before sleep
 Certain measures are sensible in all patients with
nocturnal enuresis: void just before getting into bed,
avoid huge fluid loads during the evening hours, and
avoid caffeine after 3:00 pm
 Keeping a chart depicting wet and dry nights has been
shown to be successful.

19.  Alarm Therapy :
 It is reported to improve bedwetting by encreasing nocturnal
bladder capacity or by enhanced arousal; it does not reduce
nocturnal urine output.
 Although most children with enuresis do not awaken to the alarm,
they often stop emptying the bladder.
 Some improve within the first 2 weeks of treatment, and others
improve only after several months. A Cochrane review of 56
randomized trials involving 3257 children concluded that alarm
therapy is beneficial. About two thirds of children on alarm
therapy were dry, but about half relapsed, so that only about a
third remained dry at 6-month follow-up.
 In successfully treated children, alarm therapy should be
continued for at least 3 months and for 1 month after
sustained dryness.
 Relapses are common, developing in 29-66% of children, and
sometimes respond to further alarm therapy. If the child is still wet
after a minimum of 3 months of consecutive use, alarm therapy
can be discontinued and considered unsuccessful.

20. PHARMACOLOGIC THERAPY
 Desmopressin acetate :
 Antidiuretic , analog of ADH , increases renal reabsorption of
water, reducing urine output in patients with a decreased
nocturnal peak in ADH .
 success rates of 70% , relapse rates are high
 It is currently given orally
 1 hour before bedtime
 The recommended starting dose for the tablet is 0.2 mg, a
maximum dose of 0.6 mg.
 The equivalent starting dose for the orally disintegrating
tablet is 120 μg, and the maximum dose is 360 μg.
 A nasal spray is no longer recommended due to an increased
risk of overdosing and severe hyponatremia
 Combination of alarm therapy with desmopressin therapy has
been reported to result in dryness not achievable with either
therapy alone.

21.  Anticholinergic agents “ Oxybutynin ” :
 helpful in some patients, especially those with overactive bladder, dysfunctional voiding, or
neurogenic bladder.
 reduce uninhibited detrusor contractions, increase the threshold volume at which an uninhibited
detrusor contraction occurs, and enlarge the functional bladder capacity.
 Anticholinergic adverse effects include dry mouth, blurred vision, facial flushing, constipation,
poor bladder emptying, and mood changes. Constipation as an adverse event is especially
problematic in that it might increase the risk for wetting.
 Anticholinergic medications should not be administered during a fever, because an
anticholinergic effect is a decrease in sweating
 Oxybutynin is given in a dose of 2.5-5 mg administered at bedtime. A long-acting preparation is
available but has not been approved for use in children.
 Tolterodine is not approved for use in children younger than 12 years.
 Flavoxate, a urinary spasmolytic, might be helpful in some patients with overactive bladder and
dysfunctional voiding but is approved only for children older than 12 years.
 The combination of desmopressin acetate and oxybutynin chloride
might be efficacious in children with overactive bladder or
dysfunctional voiding who respond to anticholinergic therapy with
improved daytime symptoms but who continue to wet at night.

22.  Imipramine “TCA” :
 A Cochrane review of 58 randomized trials concluded that
imipramine is effective in reducing bedwetting; children
treated with imipramine had 1 fewer wet night per week .
 The relapse rate is high when the medication is discontinued.
 The usual dose, taken 1-2 hours before bedtime, is 25 mg for
patients aged 6-8 years and 50-75 mg for older children and
adolescents.
 Adverse effects include constipation, difficulty initiating
voiding, irritability, drowsiness, reduced appetite, and
personality changes .
 Because of the unfavorable adverse effect profile and the
significant risk of death with overdose, the World Health
Organization (WHO) does not recommend imipramine for the
treatment of enuresis.

23. THANKS