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Defination
Primary enuresis
Secondary enuresis
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Incidence
20% of children at age 5
Spontaneously resolve in 15% of the involved children per yr. <1% not grow out
Males 3:1 females |
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Causes of primary enuresis
The reason why enuretic child fails to awaken when the bladder is full is unknown, but appear to be involved in:
Genetic: Often with family history. Risk is 44%- one parent were enuretic and 77%- two parent were enuretic.
Delayed maturation of the cortical (brain) control
Failure of sleep arousal -impaired activation of brain receptors by bladder distention - High arousal threshold- deep, uninterrupted sleep
Irregular bowel movements (Constipation)
Small bladder capacity
Nocturnal vasopressin deficiency- High urine production (polyuria) during sleep
- Up to age 12, normal bladder capacity equal to oz/per year of age +2
- Polyuria may be define as nocturnal volume > 35% of total 24 hour urine production, including the first morning void
- Low hormone secretion-vasopressin, aldosterone/ATII
- Low renal tubular reabsorb sodium
Uninhibited bladder destrusor- Bladder destrusor hyperactivity- incontinence or urgency, usually also have daytime wetting.
Birth defect |
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Causes of Secondary Enuresis
- Urinary tract infection
- Vulvovaginitis
- Psychological, life change events, stress, sibling rivalry
- Obstructive sleep apnea
- Diabetes & diabetes insipidus
- Neurogenic:spinal bifida, cerebral palsy, central neuro-system tumor
- Posterior urethral values, vesicoureteral reflux, ectopic ureter
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| Management |
Knowing the causes
Treatment for the underlying reasons for 2 nd enuresis
Wait to see the improvement for the child with delayed maturation
Holding Back Practice for 4-6 weeks to increase bladder capacity by increasing urine volume: |
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Let child drink about 250ml of liquid, then holds on as long as without wetting self.
Reward for every 3-5 extra minutes the child can hold.
Voiding & measuring urine volume
Training ends when the child is able to postpone urination for 45 minutes |
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Conditional & Behavioral adjustment arousal disturbance & other primary enuresis
- Do not play too hard during daytime (which can cause sleeping deeply)
- Quiet evening time
- Do not drink too much after dinner
- No drink right before night time sleep
- Set alarm and wake up the child 1 to 3 times for urination during the night
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| Waking schedule with enuresis alarm: overall better response (70%) than medications, relapse rate 30%, drop-out rate up to 57% |
| 1 st night |
- Hook up the alarm on the child
- Explain the proceedings to the child
- Wake child every hour, to inquire the need
- Use the toilet or walk the child to toilet
- Praise the child with voiding in the toilet and maintaining a dry bed
- If the alarm sound/wet: Walk the child to toilet & change of the sheets & clothes
- Most the children will stay dry
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| Subsequent nights |
Dry: move awakening time up 15-30 min & give sticker / reward
Wet: hold awakening time steadily walk the child to toilet & no consequence
Review every morning / reward immediately |
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Medications
DDAVP-desmopressin >= 6years Oral Desmopression
Nasal Desmopression
Synthetic analogue of ADH- increase noctural (night) urine concentration and decrease noctural urine volume
Effective 24.5% overall, 79% in monosymptomatic patients
Oxybutynin chloride (Ditropan) - >=5yr Oxybutynin
Anticholinergic, smooth muscle relaxant. 9% response, 19% unchanged, 72% shifted to other presentation.
Imipramine: >=6yr Imipramine
Action unknown, 36% response rate |
