This document presents a case of a 10-year-old girl with monosymptomatic nocturnal enuresis, or nighttime bedwetting without other urinary symptoms. Her examination and tests were normal. The document discusses the diagnosis, causes, and management options for childhood nocturnal enuresis, which commonly includes motivational therapy and enuresis alarms. Medical treatments like desmopressin may also be used but have higher relapse rates after stopping. Referral is recommended if enuresis does not improve after 8-12 weeks of treatment or if other issues are suspected.

2. Dr Natalie Torbolov
August 2013
WITTLE LEAKS

3. Case Presentation
• 10 year old girl
PSX
• Nocturnal Bedwetting
– nightly
–  rouseability
– Being toiletted 2 hourly
– No other urinary Sx
– Pull ups
– Dry by day since 3 years old

4. Case Presentation (cont.)
HPI
• Has only ever had a few dry nights in her life
• Social issues developing
PMHx - Nil, no problems at school
Reg Meds - Nil
Allergies - NKA
No positive family Hx

5. Examination
• Well looking
• Wt. 37.6 kg Ht. 132.2 cm
• No Sacral pit
• Abdo - NAD
• Normal Neurological examination
• External Genitalia - NAD

6. Management
• Discussion / explanation to mother of DX:
 Monosymptomatic Nocturnal Envresis
 Trial of Envresis Alarm
• MSU - NAD
• Renal US - NAD
• Abdo - NAD
• Paediatric Consult – Confirmation of DX
- Assistance with Alarm

7. Childhood Nocturnal Enuresis
• Definition: Involuntary wetting while
asleep 2 x week after 5 years of age
• 2nd most common chronic childhood
complaint (after allergies)
• 18.9% of children
• 20% of 5 year olds
• 10% of 10 year olds

8. Childhood Nocturnal Enuresis (Cont.)
• Spontaneous remission 14% per year
• Self esteem & psychosocial function
• Suggestion of impaired cognitive
performance which improves with
treatment
• Only 34% seek professional help
• 2-3% persistent incontinence into
adulthood

9. Classification
• Primary – never been dry for 6 months
• Secondary – Enuresis after 6 months of being
dry
– Psychological
– Organic DS – eg DM, UTI
• Mono Symptomatic – no day time
incontinence
– No urinary tract Sx
• Non Monosymptomatic – daytime voiding & Sx
of urgency, frequency

10. Causes
• Family Hx – 4/10 with affected family member
- Genetic factors – links to Chrom
8,12,13, 22 Auto Dom
• Bladder & Brain Connection
–  Cortical arousal
– Inability to arouse to a full bladder
sensation
–- Detrusor over activity
– Small capacity Bladder

11. Causes (Cont.)
• Nocturnal Polyuria -  anti-direutic
hormone secretion
• Chronic Constipation – eg soiling
• Other Medical Conditions – OSA, DM,
UTI, ADHD
• Sex M:F 2:1

13. Management of Nocturnal E
• Education & Reassurance – high rate of
spontaneous remission
• Motivational Therapy – 1st line for <7 year
olds who are not wetting nightly
- enlist co-operation of child eg. Record
progress diary
- Rewards – don’t focus on dryness
- For agreed upon behaviours
- Penalties – counter productive

14. Management of Nocturnal E (Cont.)
• Motivational Therapy (Cont.)
- 25% success rate ie. dry for 14 consecutive
nights
- 70% - improvement
- No fault emphasis
- Trial 3 – 6 months before moving on

15. Enuresis Alarms
• 2 Types:
1. Pad & Bell

16. Enuresis Alarms (Cont.)
• Types (Cont.):
2. Undergarment sensor

17. Enuresis Alarms (Cont.)
• For motivated families
• Frequent enuresis
• Most effective
- 66% achieve 14 consecutive nights cf 4%
of no Rx controls
• Child in charge of alarm
- Testing
- Setting
- Follow up

18. Enuresis Alarms (Cont.)
• 12 – 16 weeks to achieve 14 dry
consecutive nights
• Range 5 – 24 weeks
• Can be reinstated after relapse

19. Other Measures
• Monitoring Daily Fluid Intake (80% prior to
5PM)
• Avoid sugar drinks and caffeine, especially
after 5 PM
• Treat Constipation
• No Pull-ups – instead regular toiletting
schedule
• Discourage parental toiletting of child
during night

20. Medical Treatment - Desmopression
• 200 – 400 mcg dose
• Children > 5 years
• Refractory to alternative methods
• Alternative for rapid or short term
improvement
• When failed / refused alarm

21. Medical Treatment – Desmopression
(Cont.)
• Indications
- Nocturnal Polyuria & normal functional
bladder capacity
• Efficacy
- 30% - total dryness
- 40% -  in wetting
- High relapse rate after cessation 60 -70%

22. Medical Treatment – Desmopression
(Cont.)
• Administration & SFx
- 1 hour before bed
- Dose titrated to best effect
- Dilutional Hyponatrema – limit fluids
240ml 1 hour prior to bed
- Cease if NVD

23. Medical Treatment – Desmopression
(Cont.)
• Administration & SFx (Cont.)
- Lack of response – due to  nocturnal
bladder capacity
- Taper rather than stop abruptly
- Can be used in combination with alarm

24. Medical Treatment – Tricyclic
Antidepressants
-  time in REM sleep
- Stimulate Vasopressin secretion
- Relax Detrusor mm
- 3rd Line
- SFx – Cardiac conduction disturbance
- Similar efficacy to Desmopressin
- Imipramine 10mg – 25mg 1 hour before bed

25. Medical Treatment – Anticholinergic
Drugs
• Not effective in nocturnal enuress
• Better for day time wetting or if both
persist
• Used with Desmopressin to increase
bladder capacity

26. When to Refer
• Suspicion of neurological or urological
anomalies
• Persistent Uti’s
• No response after 8-12 weeks
• Presence of significant daytime
incontinence

27. Useful Resources
• Continence Foundation of Australia
–www.continence.org.au
–Helpline – 1800 330 066
– Information on alarm purchase / hire
• The International Children’s Continence
Society
–www.i-c-c-s.org

28. Useful Resources (Cont.)
• Children’s Hospital Westmead
– The nocturnal enuresis clinic (bedwetting
clinic)
– http://www.chw.edu.au/site/directory/entrie
s/bedwetting.htm
– Enuresis Clinic Wed & Thurs PM
Dr Patricia Cauldwell
Ph 9845 1462
Fax 9845 1491
Referrals from GP or paediatricians by fax

29. References
• Bottomley G. Treating Nocturnal Enuresis in
Children Practitioner June 2011 255 (1741) 23-
6, 2-3
• Hjalmas K. Nocturnal Enuresis in Children Nord
Med 1998 Jan 113(1) 13-5; 15
• Tan ND, Baskin LS, Management of Nocturnal
Enuresis in Children Up to Date – Lit R/V to June
2013
• Caldwell P, Claudia NG, Management of Childhood
Enuresis Medicine Today, August 2008, Vol
9, Number 8, 16-22

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