Enuresis

Question 1

When do most children achieve day and night urinary continence?

Answer 1

3-4 years of age

Question 2

Define enuresis.

Answer 2

The ‘involuntary discharge of urine by day or night or both, in a child aged 5 years or older, in the absence of congenital or acquired defects of the nervous system or urinary tract’

Question 3

How is nocturnal enuresis broadly classified?

Answer 3

• Primary (the child has never achieved continence)
  
  • Without daytime symptoms
  • With daytime symptoms e.g. frequency, urgency, daytime wetting , difficulty with poor stream,
• Secondary (the child has been dry for at least 6 months before)

Question 4

How common is enuresis?

Answer 4

8-20% of 5 year olds

1. 5-10% of 10 year olds
2. 5-2% of adults

Boys:girls 2:1

Question 5

What are the risk factors for nocturnal enuresis?

Answer 5

• Males
• Daytime incontinence, faecal incontinence and constipation
• FH - two thirds of children have affected first degree family member
• Sleep apnoea
• Obesity (present in 40% of obese children)
• Neurological problems e.g. spina bifida, cerebral palsy.
• Stress - separation from mother, bullying, can cause relapse after period of dryness.

Question 6

What is the management of enuresis? (NICE 2010)

Answer 6

Identify and treat underlying cause/triggers e.g. cosntipation, DM, UTI

Educate - fluid intake, diet, toileting behaviour

1. Reward systems - should be given for agreed behaviour rather than dry nights i.e. using the toilet to pass urine before sleep
2. Enuresis alarm - consider for usse depending on age, maturity and abilities; also depends on frequency of bedwetting and motivation and needs of the family
   
   1. Frist line in children <7 years old
3. Desmopressin
   
   1. First line in children > 7 years OR if enuresis alarm has not been effective/is not acceptable to the family

Question 7

What are the causes of nocturnal enuresis?

Answer 7

• Excessive nocturnal urine production
• Poor sleep arousal by full bladder
• Reduced bladder capacity

Question 8

How do you diagnose enuresis?

Answer 8

Thorough history but no investigations necessary unless there are daytime symptoms or symptoms suggestive of possible infection/diabetes/constipation.

Severe daytime symptoms also warrant referral.

Question 9

What are some organic causes of enuresis?

Answer 9

These are uncommon but include:

• UTI
• Faecal retention severe enough to reduce bladder volume ad cause bladder neck dysfunction
• Polyuria from osmotic diuresis e.g. diabetes mellitus, renal concentrating disorders like CKD.

Other: developmental, attention or learning difficulties.

Question 10

What is the prognosis of enuresis?

Answer 10

Management needs to be painstaking to succeed.

Only resolves spontaneously in 5% of children affected each year.

Question 11

How do you educate parents about enuresis?

Answer 11

• Explain to parents and child:
• Problem is beyong conscious control
• Stop punitive procedures as they are counterproductive
• Excessive or insufficient fluid intake and abnormal toileting patterns should be addressed
• Waking or lifting during the night does not promote long-term dryness
• Best to award the child for agreed behaviour e.g. stars for going to the toilet before bed or helping change the sheets rather than dry nights

Question 12

What is an enuresis alarm?

Answer 12

• Sensory placed in the childs pants or under the child which sounds an alarm when it becomes wet.
• For it to be effective the alarm must wake the child and child must be motivated to follow the procedure
• It doesn’t have to be reset that night

Question 13

What is desmopressin? How is it administered?

Answer 13

• Synthetic of ADH may be used in children over 7 years
• Can be in tablet form or sublingually
• May need to restrict fluid intake after use
• May need to continue for 3-6 months