Nocturnal Enuresis

Nocturnal
Enuresis
11 March 2019
1
rabiezahran@Gmail.com
Dr . Rabie Fahmy Zahran.
Tropical M . Consultant.
Damietta Fever Hospital.
Egypt.

11 March 2019rabiezahran@Gmail.com
2
‫الذاريات‬(21)

3
Physiological
Anatomy
Of
Urinary Bladder

4
Physiological Anatomy of Urinary Bladder…
Urinary bladder is a hollow organ, having :
BODY – formed by detrusor muscle responsible for
emptying of bladder.
NECK - has trigone in its posterior aspect.
Emptying of bladder is mainly guarded by sphincters :
INTERNAL SPHINCTER – completely involuntary. ( smooth
muscle) supplied by sympathetic & parasympathetic nerve
fibres.
Sympathetic supply : L1, L2 ( Hypogastric nerve)
Parasympathetic supply : S2,S3,S4 ( pelvic nerve)
EXTERNAL SPHINCTER- voluntary. ( skeletal muscle)
supplied by somatic nerve fibres. ( Pudendal nerve).
Pelvic nerve has sensory fibers, which carry impulse from the
stretch receptors present on the wall of urinary bladder.

5
MERCIER'S BAR

6

7
Maturation reflexes

11 March 2019
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Objectives
1)Recognize the psychological effect of
NE on the child and family.
2)Know the difference between 1ry &
2dry NE.
3)Understand how to use a good
history to guide ttt. For NE.
4)Know the different lines of ttt. and
what is the first-line therapy.
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The word enuresis is
derived from a Greek
word (enourein) that
means “to void urine.”
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10

Loss of
self-esteem
shame
Anxiet
y
Low school
performanc
e
Punishment
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11
Why tears on
your eyes ?

Nocturnal Enuresis
Primary
NE
Secondary
NE
A child who has been continent for
at lest 6 months before the onset
of bedwetting is considered to have
2dry NE.
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DSM- 5 criteria for enuresis :
The behavior occurs in a
child who is at least 5
years old ( or has reached
the equivalent
developmental level )
>
=
5
y
The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition
(DSM-5)
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The behavior either :
A ) Occurs at least twice a week for at least
3 consecutive months or
B ) Results in clinically significant distress or
social, functional, or academic impairment
Frequen
cy
Significanc
e
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Nocturnal ( ie, during sleep )
Diurnal ( ie, during waking hours )
Nocturnal and diurnal ( also known
as non-mono-symptomatic enuresis )
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Enuresis
Twice a
week
3 consecutive
months>
=
5
y
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Normal Variations
Dry by
Night,%
Dry by Day.
%
Age, years
10252
48852.5
78953
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Diagnosis
Thorough history
Complete physical examination.
+
Urine analysis
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Cause
s
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Constipatio
n
Cystitis
Obstructive sleep apnea.
DM & DI
Overactive bladder or
dysfunctional voiding
(prolonged withholding of urine
)
Neurogen
ic bladder
Female Ectopic ureter
Male posterior
uretheral valve
Idiopathic
Genetic
Psychological distress
(divorce , birth of new
sibling )
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Disorder of sleep arousal
Nocturnal polyuria .
low bladder capacity

Idiopathic
Genetic
Enuresis is usually transmitted in an autosomal dominant
fashion.
Chromosome 22 was identified as the site of enuresis.
N
E
N
E
N
E
N
E
N
E
N
E
N
E
N
E
50%
77%
Age of resolution in parents can guide expectation of
resolution in child.
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Obstructive sleep apnea.
Nocturnal
Anti-diuretic Hormone (ADH )
Atrial natriuretic peptide (ANP )
Nocturnal polyuria
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ANP = hormone secreted from cardiac atria causing reduction in expanded extracellular fluid
volium by increasing renal sodium excretion.

Constipation
Restrict bladder capacity
&
colonic movement at night.
Triger
detrusor
muscle
contraction
UTI
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Cystitis
History
Urinalysis
Urine culture
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Ectopic Ureter
<
Wet day & night
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Diabetes Mellitus
Urinalysis
Glucosuria
Enuresis is
not a
presenting
symptom of
new onset
DM.
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Diabetes Insipidus
Urinalysis
(Morning sample )
Low specific
gravity
SG > 1.015
NB :
Diabetes
Insipidus is a
very rare cause
of enuresis
S. Na level.
S osmlaraty
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Nocturnal
Polyuria
Urine production greater than 130%
of the child expected bladder
capacity (EBC )
EBC = 30 ml + ( age in years ×30 ml )
Excess nocturnal
sleep fluid intake ,
Disordered
breathing.
 Heart
abnormalities.
Metabolic
conditions
Low secretion of nocturnal ADH.
Increase nocturnal solute
excretion
Causes means
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Disorder of sleep
arousal
Children with
enuresis do not
wake up
normally in
response to an
audary signals
‫خ‬
‫خ‬
‫خ‬
‫خ‬
‫خ‬
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Small nocturnal bladder
capacity
Nocturnal
Enuresis
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The activity of the external urethral sphincter
might fall below a critical level during sleep &
thereby trigger a detrusor contraction.

Overactive bladder or dysfunctional
voiding
<
Urinary frequency,
urgency ,
squatting behavior,
daytime wetting
enuresis.
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Urodynamic studies reveal unstable detrusor contractions
early in the filling phase.
Symptom
s

Neurogenic bladder
Myelomeningocele , tethered cord,& spinal cord
trauma
Enuresis
Examine the back
Anal wink
Stand in the
toes.
(integrety of the
S2-4 spinal reflex
arc)
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34
Tethered Cord
(TC) is a disorder in
which the spinal
cord is "stuck" to a
structure within the
spine such as dura,
scar tissue from a
previous operation,
a bony spicule or
even a tumor.
Tethered Cord syndrome

Screening
Questions in
busy practice
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Type of Nocturnal Enuresis ?
At what age
was your child
consistently dry
at night ?
Never dry
suggest
primary NE
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Night only or day and night ?
Does the child have a
history of urine control
problems during the
day, including :
Daytime incontinence,
significant urgency or
frequency ?
UTI
Overactive
bladder
Ectopic
ureter
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Constipation ?
How often does a child have
bowel movements ?
Are the bowel movements
associated with pain or
bleeding ?
Does the child have stools
of large enough caliber to
clog the toilet ?
Does the child have
unintentional fecal voiding
+ve
answers
suggest
constipatio
n or
encopresis
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39
Encopresis :
It is the involuntary
discharge of feces
(ie, fecal
incontinence). In
most cases, it is the
consequence of
chronic constipation
and resulting
overflow
incontinence,

Sleep Apnea ?
Does the child have sleep
apnea,:
snoring ,gasping for air,
mouth breathing, cyanosis,
daytime somnolence,
irritability, ADHD like
symptoms, pulmonary
hypertension,
poor academic performance
?
+ve
answers
suggest
Obstructi
ve sleep
apnea
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ADHD = Attention Deficit Hyperactivity Disorder = Is is the most commonly
diagnosed mental disorder of children.

Does your child have to
run to the bathroom ?
Does your child hold
urine until the last
minute ?
Dose your child ever wet
more than once a night ?
 How many times a day
does your child void ?( >
7 times )
+ve
answers
suggest
functional
bladder
disorder
Functional bladder
disorder ?
11 March 2019
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Is it Functional bladder disorder Or Nocturnal
polyuria ?
How many nights a week
does your child wet the bed
?
1-2
nights
Large
volume
=
Nocturn
al
polyuria
Most nights
Small volume
=
Functional
bladder
disorder
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Does your child seem to wet
Large or small volumes ?

Have you try any treatment ?
Alert for responses suggesting that
the child has been punished or
shamed.
Ask about :Stressors :
Birth of new siblings
Death of relatives.
Trouble in school.
Abuse.
Divorce.
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Interest and motivation
Is the child bothered by
the problem ?
Behavioral
modification is
unlikely to be
successful if the
child is not
interested to
participate.
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Complete physical Examination
Large tonsils May suggest OSA
Abdominal masses May suggest
Constipation or
Encorpresis
Large kidney May suggest
Hydronephrosis .
Large bladder Neurogenic
bladder.
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Identify :
The anus,
Vaginal opening,
Urethral opening.
If not seen.
Labial
adhesionFemale
with
Unexplain
ed
recurrent
UTI
Skin changes from
chronic wetness or
irritation.
Ectopic Ureter
Oxyuris
infestation
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Sacral dimplies.
Taft of hair over the
midline.
Abnormal or
asymmetric gluteal
clifts.
Tethered
cord
Cord
lipoma
Persistant
dural sinus
Examine the child back and search
for :
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Investigations
Urinalysis is the only
mandatory
investigationLeukocyte esterase
Nitrites
WBCs
RBCs
Protein
Glucose
Specific gravity
Urine culture
UTI
Proteinuria
Hematuria
DM
DI
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Treatment
Should be avoided before
the age of six (6 years old )
Unless surgery is needed.
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Behavioral Modification
 Reward for dry
nights.
 Positive
reinforcement may
enhance treatment
results.
 Punishment has
no role to play in
care.
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Behavioral Modification
Recommendations :
 Frequent voiding during the day and
always before bed.
 Child should be relax, use optimal
posture, and take time to empty the
bladder completely.
 At school , void regularly, at least 2
or 3 times daily.
 Drink liberal amounts during the
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The beast treatment is :
The Bedwetting Alarm
Of all the treatments for
NE, the alarm is one of
the most effective and
has the beast long-term
cure rate and less
relapses.
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 Parents should awaken the
child when the alarm sounds.
 The child should void in the
bathroom and then assist their
parents in changing their
bedding before returning to
bed.
After alarm sounds:
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Recommendations:
The alarm should be tried for at
least 2-3 months.
 Use of the alarm until at least 14
consecutive dry nights are
achieved.
 If relapse occurs, then a second
trial of alarm therapy can be
successfully used.
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Drug therapy
for NE.
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Desmopressin
 1st line ttt.
 It is a vasopressin analogue
that reduses the amount of urine
produced at night.
 Age : 6 years or older
 Dose : 0.2 – 0.4 mg at bed
time.
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Instructions before use:
Limit fluid intake starting 1 hour
before the medication is given & until
the child wakes the next morning.
 Fluid intake after desmopressin
Fluid retention Hyponatremia
seizures .
 Hold the ttt if acute illness with fluid &
electrolyte imbalance occure.
Withdrawal of the medication every 3
months
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Oxybutynin ,tolterodine
 Anti-cholinergic drugs are not recommended as a
1st line ttt in any child with NE.
 They are recommended if alarm or desmopressin
therapy has been failed.
 Can be used as an adjunctive therapy in :
Small bladder capacity.
Overactive bladder.
 Not recommended if the child is constipated.
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Oxybutynin ,tolterodine
Recommended starting dose
:
5 mg of oxybutynin. At bed
time.
2 mg of tolterodine at bed time.
 Children must be instructed
in proper voiding techniques &
frequency to limit post–void
residual volume.
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Imipramine
 Relapse rate is high.
 It is not considered the 1st line agent
based more on their risk on their benefit.
 Cause prolongation of QT interval.
 Significant risk of death with
overdose.
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Home Message
1) NE is considered in a child aged 5
years or more with twice a week
bedwetting for 3 consecutive
months .
2) Please: Do take the problem
lightly.
3) Please take full history.
4) Complete examination is
mandatory.

63
6) Punishment has no role to play
in ttt but may worsen the results.
7) Drug therapy is not the 1st line in
ttt.
8) Bedwetting alarm is the 1st line
ttt.
9) Desmopressin is the 1st drug to

64
References
1)Video of professor Osama Naga.
2)Medscape.
3)Google gallery.

rabiezahran@Gmail.com 11 March 2019
65

Nocturnal Enuresis

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