Enuresis

Question 1

Define

Answer 1

Potty training started around 2.5y, but every child is different…

o Dry by day = by 4yo

o Dry by day and night = by 5yo (most by 3-4 years old)

Normal micturition occurring at an inappropriate or socially unacceptable time or place
* occurring after a developmental age when bladder control should be established (~5 years)

Bed wetting = nocturnal enuresis

Inability to control bladder function during the day = diurnal enuresis

Types
**Primary nocturnal enuresis **

• nocturnal enuresis in which the child has never had a period of dryness longer than 6 months
• Most common cause is a variation on normal development

**Secondary nocturnal enuresis **

nocturnal enuresis recurring after a period of more than 6 months of the child being dry at night

Causes:

1. Emotional upset most commonly - e.g., bullying or recent parental separation
2. UTI
3. Diabetes
4. Constipation

Question 2

Causes of Primary - daytime enuresis

Answer 2

Defined as a lack of bladder control during the day in a child that is old enough to be continent (over 3-5 years)

Causes:
1. Lack of attention to bladder sensation (manifestation of developmental or psychogenic problem)
2. Detrusor instability (sudden, urgent urge to void induced by sudden bladder contractions)
3. Bladder neck weakness
4. Neuropathic bladder (bladder is enlarged and fails to empty properly, irregular thick wall, associated with spina bifida and other neurological conditions
5. Psychogenic or developmental
6. UTI
7. Constipation
8. Ectopic ureter (causes constant dribbling and child is always damp)

Question 3

Investigations of Primary - daytime enuresis

Answer 3

Possible examination findings:

Neuropathic bladder:

• Distended bladder
• Abnormal perineal sensation and anal tone
• Abnormal leg reflexes and gait
• Sensory loss in distribution of S2, S3 and S4 dermatomes
• Spinal lesion may be present
• Girls who are DRY at NIGHT but wet on getting up are likely to have pooling of urine from an ectopic ureter opening into the vagina
• Urine dip and should be sent for MC&S
• USS may reveal abnormalities - consider if not responding to treatment
• 2 week bladder diary
• MCUG
• Urodynamic studies may be required
• MRI may be used to exclude a spinal defect

Question 4

Management of Primary - daytime enuresis

Answer 4

Children in whom a neurological cause has been EXCLUDED, may benefit from:

• Star charts
• Bladder training
• Pelvic floor exercises

Anticholinergic drugs e.g. oxybutynin, which reduces bladder contractions, may be useful

Question 5

Causes of secondary enuresis

Answer 5

The loss of previously achieved urinary continence may be due to:

• Emotional upset (MOST COMMON)
• UTI
• Constipation associated
• Urgency, frequency, haematuria and dysuria
• Generalised abdo pain -> can cause vomiting
• Polyuria from an osmotic diuresis e.g. diabetes mellitus, diabetes insipidus, CKD
• Imp to check for AI conditions - by giving examples like T1DM, rheumatoid, etc.
• If worried about Wilm’s tumour - ask about mass

INVESTIGATIONS
* Urine dipstick to check for infection, glycosuria and proteinuria
* Assessment of urine concentrating ability by measuring osmolality of an early morning urine sample (rarely, a water deprivation test may be needed)
* USS of the renal tract

Management:
The following underlying causes can be managed in primary care:

• UTI
• Constipation

The following underlying causes are likely to need specialist referral:

• Diabetes
• Recurrent UTI
• Psychological problems
• Family problems
• Developmental, attention or learning difficulties
• Known or suspected or neurological problems

Question 6

Management of primary bedwetting (without daytime symptoms)

Answer 6

Children <5 years management:

Reassure parents – often resolves by 5yo
Educate – easy access to toilet at night, bladder emptying before bed, positive reward system

Children >5 years management:

Infrequent (<2/week) -> offer watch-and-see approach

Frequent:

• 1st line: enuresis alarm, positive reward system (i.e. encourage child to help change sheets)
• 2nd line: desmopressin
• 1st line if >7yo
• 1st line for short-term control (i.e. sleepovers, school trips, etc.)
• 3rd line: combination
• Referral to enuresis clinic, community paediatrician if bedwetting not responded to 2 courses tx

Question 7

Management of primary bedwetting (with daytime symptoms)

Answer 7

Primary Bedwetting (with daytime symptoms)

o Referral to enuresis clinic, community paediatrician

· Investigations (if indicated):

o Renal USS Urine diary Dipsticks

o MCUG Urine MC&S

Question 8

Advice/ Meded

Answer 8

Bedwetting not the child/parent’s fault / take a neutral attitude to bedwetting so not to embarrass

Reason is excess volume that does not wake the child to go to the toilet

Reassure that pretty much all children become dry with time as their bladder capacity increases and they learn to wake at the sensation of a full bladder

• Child should go to the toilet regularly and particularly before bed
• Avoid caffeine before bed, healthy diet encouraged
• Easy access to toilet
• Waterproof mattress or bed pads can be used
• Lifting or waking during the night does not promote long-term dryness
• Positive reward systems can be used (e.g. rewards for going to the toilet before bed, drinking the recommended amount of fluid during the day)
• SUPPORT: ERIC (Education and Resources for Improving Childhood Continence)

Question 9

Summary

Answer 9

SUMMARY

Look for possible causes (e.g. constipation, diabetes)

Advise on fluid intake, diet and toileting behaviour

Reward systems (e.g. star charts)

1st line, <7 years = enuresis alarm

Desmopressin: may be used 1st line if >7 years or if short-term control is needed (e.g. holiday)

Question 10

PACES

Answer 10

Name of Diagnosis:

Having examined Varun’s tummy and performed a test with his urine, I could not find any concerning reasons why he has been wetting the bed.

Briefly explain what it is:

But what I can say is bed wetting is no one’s fault

It occurs when the urine produced over night exceeds the capacity of the bladder (which stores the urine) to hold it in, and the sensation of the full bladder doesn’t wake the child up

I’d like to reassure you that this is a common problem and all children tend to grow out of it with time as their bladder capacity increases.
How is it managed:

Firstly, we can help support Varun through a number of lifestyle changes:

Avoid all food and drink 1 hour before Varun goes to bed

Encourage Varun to wee regularly throughout the day and wee before bed.

During the night, it would also be good to make sure that Varun has easy access to the toilet.

It is something that can be quite distressing and embarrassing for a child, so it is important that you respond to Varun with love, patience and reassurance.

To help motivate Varun stick by all this, I would recommend using a positive reward system like a star chart if that would appeal to him:

Where he gets a sticker for things like going to the toilet before bed and regularly throughout the day.

Seeing that you have tried a number of things already, I am also going to prescribe a bed-wetting alarm.

Essentially it is a device that sounds at the first sign of bed wetting, waking the child and stopping them from peeing,

The idea is that by doing this over weeks, eventually the child will be able to wake at the sensation of a full bladder and go to the toilet without the alarm sounding.

However, it is something that requires patience and persistence so don’t be disheartened if you don’t see results straight away!

Risks and safety net

If after 3m Varun does not seem to be responding, then pls don’t hesitate to come back and we can see if we can try something else to help