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1. Dr. Mohammed Qazzaz

2. Normal Development of Elimination
Development of control of urination
and defecation needs
physical and cognitive maturation and
affected by
cultural norms, socioeconomic status,
and cultural practices

3. Important points
• The invention of disposable diapers facilitated later
toilet training.
• Social changes, including increased maternal work
outside of the home and group child care, also have
influenced the trend to later initiation of toilet training.
• Toilet training now usually begins after the second
birthday and is achieved at about 3 years of age in
middle-class white U.S. populations.

4. • Prerequisites for achieving elimination in the toilet
include the child's ability to recognize the urge for
urination and defecation.
• The entire process of toilet training can take 6
months and need not be hurried.
• Successful parent–child interaction is very
important to achieve the best results.

5. Enuresis
Definition, classification
Definition of Enuresis
It is urinary incontinence in a child who is adequately
mature to have achieved continence.
Enuresis is classified as diurnal (daytime) or nocturnal
(nighttime).
• Nocturnal Enuresis (synonymous with intermittent
nocturnal incontinence) refers to discrete episodes of
urinary incontinence during sleep in children ≥5 years
of age.

6. classification of enuresis
Monosymptomatic (isolated) enuresis:
without any other lower urinary tract symptoms .
without a history of bladder dysfunction.
Non-monosymptomatic enuresis: Enuresis in
children with other lower urinary tract symptoms
(eg, increased frequency, daytime incontinence,
urgency, genital or lower urinary tract pain).

7. Classification:
Primary 80% (incontinence in a
child who has never achieved
dryness for at least continuous 6
months).
Secondary (incontinence in a child
who has been dry for at least
continuous 6 months).

8. Etiology
• Enuresis is a symptom with multiple possible etiologic
factors, including:
developmental difference,
organic illness, or
psychological distress.
Genetic factors
Nocturnal polyuria and antidiuretic hormone
isufeciency
Detrusor overactivity.
Small bladder capacity.

9. •Genetic factors :
• An autosomal dominant form of primary
nocturnal enuresis with a penetrance
greater than 90 percent .
• Chromosome affected :
13q13-q14.3
12q13-q21
22q11 .

10. • Nocturnal polyuria and antidiuretic hormone –
Mechanisms
for increased nighttime urine output may include:
increased fluid intake before bedtime .
reduced response to antidiuretic hormone
(ADH).
and/or decreased secretion of ADH .
The relationship between ADH secretion and
nighttime urinary flow rates is debated.

11. Detrusor overactivity :
•Although detrusor abnormalities are
more frequently associated with daytime
urinary incontinence, detrusor
overactivity should be considered in
children with refractory
monosymptomatic nocturnal enuresis .

12. • Small bladder capacity –
• At birth, bladder volume is approximately 60 mL (2
ounces); bladder volume increases with age at a
relatively steady rate of approximately 30 mL (1 ounce)
per year until 10 years of age.
• Children with nocturnal enuresis, even those who do not
have daytime symptoms, have been noted to have a
smaller bladder capacity than age-matched children who
do not have nocturnal enuresis .

13. Clinical findings
• urinary frequency and associated constipation or
cystitis
are suggestive of reduced bladder capacity .
• The reduced bladder capacity appears to be functional
rather than anatomic.

14. Primary enuresis
• often is associated with a family history .
• A genetic etiology has been hypothesized, as autosomal
dominant inheritance .
• Most children with enuresis do not have a psychiatric
disorder, but stressful life events can trigger loss of bladder
control.
• Sleep physiology may play a role in the etiology of nocturnal
enuresis, with a high arousal threshold commonly noted.

15. Primary enuresis
• Nocturnal polyuria relates to a lack of a nocturnal
vasopressin peak in a subgroup of enuretic children, .
• Malfunction of the detrusor muscle with a tendency for
involuntary contractions even when the bladder contains
small amounts of urine is another possible etiology
• Reduced bladder capacity can be associated with enuresis
and is commonly seen in children who have chronic
constipation with a large dilated distal colon, which
impinges on the bladder.

16. Epidemiology
• Enuresis is the most common urologic condition in children.
Prevalence:
• 15% in 5-year-olds,
• 7% in 8-year-olds, and
• 1% in 15-year-olds.
• The spontaneous remission rate is reported to be 15% per
year.
• Nocturnal enuresis in boys compared with girls is 1.4:1.
• Daytime enuresis is lower than nocturnal enuresis but has a
female predominance, 1.5:1 at 7 years of age.

17. PATHOGENESIS
• Nocturnal enuresis occurs when the child does not wake to
void .
• In any given child, this may result from one or a combination
of several related factors, including:
maturational delay,
genetic factors,
nocturnal polyuria,
disturbed sleep,
small bladder capacity, and
detrusor overactivity .
• Psychologic and behavioral abnormalities appear to be a
result, rather than a cause, of enuresis .

18. EVALUATION
• The evaluation of the child with monosymptomatic
nocturnal enuresis includes:
history,
physical examination, and
urinalysis.
Goal : To determine whether the child has:
 bowel and bladder dysfunction
or
 enuresis as a manifestation of an underlying medical
problem (eg, posterior urethral valves or other anatomic
abnormality, spinal dysraphism, diabetes) .

19. Clinical Manifestations
The history
• Pattern of voiding including frequency, timing
(diurnal/nocturnal), associated conditions or stressful
events (e.g., bad dreams, consumption of caffeinated
beverages, or exhausting days),

21. • A review of systems should
include a developmental history
and detailed information about
the neurologic, urinary, and
gastrointestinal systems
(including patterns of
defecation).

22. • Sleep patterns is important, including snoring,
parasomnias, and timing of nighttime urination.

23. • A family history often reveals that one or both parents
had enuresis as children.
• child abuse, physical and sexual abuse history should be
included as part of the psychosocial history.
• interventions before seeking a physician's help.
Identifying these interventions and how they were
carried out aids the understanding of the child's
condition and its role within the family.

24. Physical examination
 The physical examination begins with observation of the
child and the parent for clues about child developmental
and parent-child interaction patterns.
 Special attention is paid to the abdominal, neurologic, and
genital examination.
 A rectal examination is recommended if the child has
constipation.
 Observation of voiding is recommended if a history of
voiding problems, such as hesitancy or dribbling, is elicited.
 The lumbosacral spine should be examined for signs of
spinal dysraphism or a tethered cord.

25.  spinal dysraphism or a tethered cord.

26.  spinal dysraphism or a tethered cord.

27.  spinal dysraphism or a tethered cord.

28. Laboratory tests
Urinalysis :
• Specific gravity or osmolality to exclude polyuria
due to diabetes insipidus.
• To exclude glycosuria due to diabetes mellitus .
Urine culture: particularly if there are UTI
symptoms
• To role out UTI .
Serum , urea and creatinine to role out chronic
kidney disease.

29. Imaging
Renal and pelvic sonogram with/without Voiding
cystourethrogram:
• If there is severe voiding dysfunction, or a neurologic
finding.
• If vesicoureteral reflux, hydronephrosis, or posterior
urethral valves are found, the child is referred to a
urologist for further evaluation and treatment.

30. Voiding cystourethrogram showing unilateral reflux

31. Differential Diagnosis
 There is no commonly identified cause of enuresis and, in
most cases, enuresis resolves by adolescence without
treatment.
 Children with primary nocturnal enuresis are most likely to
have a family history and are least likely to have an
identified etiology.

32. Children with secondary diurnal and
nocturnal enuresis are more likely to have an
organic etiology, such as:
UTI,
diabetes mellitus, or
diabetes insipidus.

33.  Children with primary diurnal and nocturnal enuresis may have:
 neurodevelopmental condition or
bladder dysfunction.
 Children with secondary nocturnal enuresis may have:
 psychosocial stressor or
a sleep disturbance as a predisposing condition for enuresis.

34. Treatment
considerations
• Treatment of underlying organic causes of enuresis.
• Elimination of underlying chronic constipation is often
curative.
• For a child whose enuresis is not associated with an
identifiable disorder:
all therapies must be considered in terms of cost in:
time,
money,
disruption to the family .

35. Treatment
options
most commonly used treatment options are:
• Motivational therapy :
• Biofeedback therapy (bladder training exercises).
• Conditioning therapy and
• Pharmacotherapy .
anticholinergic and other drugs,
They can be used considerably separate , or in
combinations.

36. 1- Motivational therapy
Families can minimize the impact on the child's self-esteem by:
• Avoiding punitive approaches.
• A nonhumiliating approaches.
• Allay the anxiety of the child and parents.
• Ensuring that the child is competent to handle issues of their
own
comfort, hygiene, and aesthetics, depending on age,
development,
and family culture.
• Stars chart for follow-up evaluation .
• Prizes for prolonged dryness.

38. 2- Biofeedback therapy
• Biofeedback therapy is a non-drug treatment in which
patients learn to control bodily processes that are normally
involuntary, such as muscle tension.
• Biofeedback therapy is a safe, simple, and minimally invasive
treatment modality in children with MsE particularly who is
resistant to pharmacological treatment.
• This treatment, may :
increase total bladder capacity , by (gradual increment of
voluntary bladder retention) .
Strengthening the urine stream by (intermittent
urination),to decrease the amount of the bladder postvoid
amount).

39. 3- Conditioning therapy
Enuresis alarms(EAs)
• The most widely used conditioning
therapy for nocturnal enuresis is the
Enuresis alarm .
• Initial success rate of 30-60% with a
significant relapse rate.
• EA is worn on the wrist or clipped onto
the pajama and has a probe that is
placed in the underpants or pajamas in
front of the urethra.
• The alarm sounds when the first drop
of urine contacts the probe.
• The child is instructed to get up and
finish voiding in the bathroom when
the alarm sounds.

40. 4- Pharmacotherapy
Desmopressin
• Decreases urine production and has proved to be safe in
the treatment of enuresis.
• The oral medication is started at 0.2 mg per dose (one dose
at bedtime) and on subsequent nights is increased to 0.4 mg
and then to 0.6 mg if needed.
• This treatment must be considered symptomatic, not
curative, and
• has a relapse rate of 90% when the medication is
discontinued.

41. Imipramine (Tricyclic antidepressants),
• Now rarely used for enuresis, reduces the frequency of nighttime
wetting, and the initial success rate is 50%.
• Imipramine is effective during treatment only,
• with a relapse rate of 90% on discontinuation of the medication.
• The most important contraindication is the risk of
overdose,(associated with fatal cardiac arrhythmia).

42. Anticholinergic drugs:
• Monotherapy with anticholinergic drugs, such
as oxybutynin(novotropan), is not effective in treating
monosymptomatic nocturnal enuresis .
• However, anticholinergic agents may be useful in children
with nocturnal enuresis and daytime incontinence , and
overactive blabber .

43. SUMMARY AND RECOMMENDATIONS
• Enuresis refers to discrete episodes of urinary incontinence during
sleep in children who are ≥5 years of age.
• Monosymptomatic enuresis refers to enuresis in children without any
other lower urinary tract symptoms and without a history of bladder
dysfunction.
• Monosymptomatic nocturnal enuresis has a high rate of spontan-
eous resolution: 15 % yearly .
• Monosymptomatic nocturnal enuresis may result from one or a
combination of several related factors in a given child (eg,
maturational delay, genetic factors, nocturnal polyuria, disturbed
sleep, small bladder capacity, detrusor overactivity).
• The evaluation of children with nocturnal enuresis should include a
complete history , voiding diary , physical examination , and urinalysis.
• Children who have clinical or radiographic findings suggestive
of renal/urologic abnormality or bladder overactivity should be
referred to a pediatric nephrologist/urologist for further evaluation.
• Referral to a pediatric neurosurgeon may be warranted for children
with clinical or radiographic findings suggestive of spinal dysraphism.