Bedtime and daytime wetting

Question 1

Nocturnal enuresis in normal children

Answer 1

Can be due to delayed development of normal sphincter control

Question 2

Primary vs secondary enuresis

Answer 2

Primary is when has never developed dryness, secondary is wetting in a child who was dry

Question 3

How common is primary enuresis, gender discrepancy

Answer 3

10% 6 year old and 3% of 12 year olds

Question 4

Causes of primary enuresis (6)

Answer 4

Delayed maturation (familial)
Reduced ADH
Reduced bladder awareness
Emotional stress
UTI
Polyuria due to diabetes or renal disease

Question 5

Causes of secondary enuresis (4)

Answer 5

Emotional upset
UTI
Diabetes
Threadworm infection

Question 6

Causes of diurnal enuresis (7)

Answer 6

UTI
Neurogenic
Congenital abnormalities->ectopic ureter
Severe constipation
Psychogenic due to stress
Sexual abuse
Physiological (urgency)

Question 7

Important history

Answer 7

Has the child ever been dry
If so at what age
Was there a trigger that led to wetting again (birth of a sibling)
Anything to suggest stress as a cause
Possibility of sexual abuse
Any symptoms of UTI
Constipation
Polyuria, polydipsia, weight loss
History of diabetes, renal disease
How have the parents dealt with the bed wetting, criticise, punish
What have the parents tried- fluid restriction, sitting on toilet at night, star charts
What is the pattern of wetting- nocturnal, day and night, urgency, dribbling incontinence
Features suggesting neuropathic bladder.

Question 8

Important examination

Answer 8

Any evidence of neurological or congenital abnormality? Check leg reflexes and perineal sensation
Check for evidence of spina bifida occulta- lipoma/hairy patch over sacral area.
Is there a palpable fecal mass
Evidence of renal disease
Check for hypertension

Question 9

Investigations and outcomes

Answer 9

Urine MCS
Urine dipstick- glucose
Renaln USS and isotope if ectopic ureter ++suspected

Question 10

Management of primary nocturnal enuresis

Answer 10

Generally wait until age 7- when child can take more responsibility, reward/star charts at night
Enuresis alarm->wakes child when begins urinating->wake up and go. Works within a couple of weeks.
Try to avoid nappies and pull-ups, can delay time to dry. Cannot use alarm with nappies/pull ups
Bladder training->unrestricted fluids during the day to teach children to deal with a full bladder. If dry for 7 nights, give extra fluid at night for “overlearning”
Avoid caffeinated drinks and fruit juice
Lifting is avoided as teaches child to go to toilet while half asleep
ADH- tablets at night->when alarm fails. Use for 3 months then taper.

Question 11

Parent information on causes of bed wetting

Answer 11

Some of the possible factors are:

Genetic tendency. Bedwetting does tend to run in families. If one or both parents wet the bed when they were children, then it is quite likely to occur in their children.
Smallish bladder capacity.
Deep sleeper.
Kidneys continue to produce a lot of urine at night (most people make less urine when they are asleep).

Question 12

Parent information about when to see a doctor

Answer 12

At least 6 yo
Troubled/frustrated
Punish or feel you may punish child for bedwetting
Childs wets/bowel movements in pants during the day

Question 13

Causes of daytime wetting without NE

Answer 13

Urge incontinence->overactive bladder. Use oxybutynin (anticholinergic)
Dysfunctional voiding->poor coordination between detrusor and bladder neck activity with poor relaxation of external sphincter during voiding
Neurological and urological pathology

Question 14

Dysfunctional voiding

Answer 14

Poor detrusor and sphincter coordination
\+Intravesical pressure
\+residual urine
Upper tract dilitation
Teach->pelvic floor relaxation, ensuring optimal voiding techniques

Question 15

Acquisition of bladder and bowel control

Answer 15

Most children are unable to obtain bowel and bladder control until 24 to 30 months. The average age of toilet-training is 27 months.

Question 16

Indicators child may be ready for toilet training

Answer 16

Your child should be able to:
Walk well in order to get to the potty chair.
Tell you when there is a need to go to the potty.
Control the muscles used for going to the potty.

Question 17

Signs child may be wanting to toilet train

Answer 17

Signs that your child may be ready for toilet-training include the following:

1) Asks to have the diaper changed or tells you a bowel movement or urine is coming
2) Shows discomfort when the diaper is wet or dirty
3) Enjoys copying what parents or older children do
4) Follows you into the bathroom and see how the toilet is used
5) Wants to do things (like going to the potty) to make parents happy or to get praise
6) Has dry diapers for at least two hours during the day or is dry after naps or overnight