ppt about Nocturnal Enuresis for adult and children

1. NOCTURNAL
ENURESIS
BY
ESLAM EMAD M.FAWZY

2. DEFINITION
Nocturnal = at nighttime
Enuresis= Involuntary discharge of urine

3. EPIDEMIOLOGY
Normal Physiologically in all infants till age of 4
15% normal children have nocturnal enuresis at age of 5
99% are dry by age of 15
Nocturnal enuresis is more common in boys 2:1
Nocturnal enuresis may be happened to Adults due to
primary or secondary causes

4. DEVELOPMENT OF URINARY CONTROL
Physiology of micturition
• spontaneous micturation as a spinal cord reflex
• distention simulates a detrusor contraction
Then with development
• Bladder Capacity increase
• Sphincter voluntary integrated into the reflex
• constricts to prevent incontinence
• relaxation during micturition
• Complete by age 4

5. ETIOLOGY
• Nocturnal enuresis In children
Classified according to period of being dry into
Primary
Secondary

6. PRIMARY CAUSES IN CHILDREN
Delayed development
Small bladder capacity & instability
little antidiuretic hormone (ADH):
delayed development of the ADH circadian rhythm
Genetic
• 1 parent 44% of children
• 2 parents 77% of children

7. SECONDARY CAUSES IN CHILDREN
• occurs after a period of staying dry, is more likely to be
related to a medical condition as:
• Urinary tract infection “Cystitis”
• Birth Defect : Spina bifida
• Psychological and social factors. Stress, Fear

8. NOCTURNAL ENURESIS IN ADULTS
Primary Causes
Urodynamic abnormalities : Not due to anatomic
abnormality
•Functional bladder capacity (FBC) is a smaller volume.
The FBC is the amount of urine the bladder holds before sending a
signal to the brain to indicate the need to void
•‘Overactive’ or ‘unstable’ bladder (OAB)
Detrusor overactivity has been found in up to 70 – 80% of primary
nocturnal enuresis patients.
 Persistent primary enuresis - rare

9. • Secondary causes
Neurogenic bladder (Automatic bladder)
 Chronic complication of BPH Enuresis “Nocturnal”
Chronic retention
 Urinary tract infection can sometimes cause bed wetting.
 obstructive sleep apnea
Occurs with increased atrial natriuretic peptide and
activation of renin-angiotensin system
Stress or anxiety can also cause the problem
Alcohol consumption urine ADH & Awareness
NB| Requires anatomic investigation, neurologic and
urodynamic evaluation

10. EVALUATION FOR CHILDEREN
• Families with a history of enuresis await spontaneous
cure - more tolerant
• Families without such a history perform tests and
produce a cure
• Urologic tests are rarely indicated for
monosymptomatic bedwetters
• Rarely find an organic lesion

11. EVALUATION
• Screening Evaluation for 2ry causes of N.Enuresis
• Nocturnal enuresis Monosymptomatic
• Nerologic Examination & EEG
• No daytime wetting, urgency, polyuria
• No UTI by urine analysis & Culture
• U/S & Radiological Evaluation “ baldder & ureteric wall
thickness , Prostate and other anatomical abnormalities”
• If There is 2ry cause Treat the cause

12. TREATMENT - BEHAVIOR MODIFICATION
• 1st line therapy in children
• Bladder Training
• goal is to increase the time interval between voiding
• enlarges functional capacity of bladder
• Child is encouraged to retain urine after 1st urge
• When combined with conditioning therapy, very
successful
• Reinforcement by assumes & Motivation for dry
time

13. TREATMENT - BEHAVIOR MODIFICATION
• Conditioning Therapy
• Use of a urinary alarm is the most
effective for nocturnal enuresis - 80%
cure
• Child wakes up and voids in toilet
• Followed by sensation of a full bladder
and production of the same inhibition as
the alarm
• Failure is often due to lack of parental
understanding and cooperation
• May take months
• May be combined with pharmacotherapy

14. TREATMENT - DRUGTHERAPY
• Anticholinergics
• Only 5 - 40% effective (equal to placebo) in
nocturnal enuretics
• useful to eliminate bladder instability
• urgency, frequency, day and night incontinence (87%)
• more effective in urodynamically proven instability
(90%)

15. • DDAVP “Desmopressin”- intranasal or oral
Significantly reduces number of wet nights
Temporary treatment - only 33% cured
May lead to hyponatremic seizures - limit fluids
before administering dose
Not first-line treatment
TREATMENT - DRUGTHERAPY

16. • Imipramine “Drug of choice” 25 mg age 5-8 & 50 mg for older
Cure > 50% Improvement - 80%
Discontinuation - 60% relapse
Peripheral action
• weak anticholinergic >> bladder capacity & stability
• weak smooth muscle antispasmotic
Central action
• decreases REM early sleep - less enuresis early in the night
and more common in the last third of sleep
TREATMENT - DRUGTHERAPY

17. SUMMARY
• Reassurance- harmless, perhaps genetic, high rate of
spontaneous resolution
• Exclude- infection, neuropathy, obstruction & other 2ry
causes of N.E
• Begin with conditioning therapy and behavior modification
• Add the use of medications as necessary

18. REFERENCES
• Stephen Confer, MD ,Ben O. Donovan, MD ,Brad Kropp, MD ,
Dominic Frimberger, MD University of Oklahoma Research
• Johnson, Mary. "Nocturnal Enuresis“
• "Nocturnal enuresis in the adolescent: a neglected problem". British
Journal of Urology. Retrieved 2008-02-02.
• Robson WL. Clinical practice. Evaluation and management of
enuresis. N Engl J Med. 2009
• emedicine.medscape.com
• bladderandbowelfoundation.org