Enuresis

Question 1

Enuresis - background (3)

Answer 1

1. Def = involuntary emptying of bladder (>5y in girls, >6y in boys)
2. If occurs during the day (while awake) = diurnal enuresis. Nocturnal enuresis is more common. May be primary or secondary
3. 6% of 5yo and 3% of 10yo are not dry at night. Boys outnumber girls by 2:1

Question 2

Night-time enuresis - causes

Answer 2

May be primary, with children not having established an appropriate period of bladder control in early childhood, or secondary occurring after a period of established bladder control

Primary

1. Strong family history
2. Boys more common than girls
3. Majority of cases have no underlying organic cause. Thought to be due to delayed maturation of bladder control systems

Secondary

1. Renal tract: UTI
2. Endocrine (2): DM, diabetes insipidus
3. (3) Behavioural problems/emotional upset (commonest cause)/abuse

Question 3

Night-time enuresis - ix

Answer 3

Primary enuresis

1. Urine culture
2. Urinalysis - infection, glycosuria and proteinuria

Secondary enuresis

• Same as above, plus:
  3. U/S of renal tract - ax pre- and post-micturition bladder urine residual volume, and ax underlying anatomical abnormalities
  4. Ax of urinary concentrating ability by measuring osmolality of early morning urine sample
  5. Possible BGL if DM suspected, serum sodium if DI suspected

Question 4

Night-time enuresis - mx

Answer 4

Primary

1. Explanation of condition + basics. Parents should stop punitive procedures. Encourage regular drinks (water) but restrict in last hour before bed
2. Star chart - child earns praise and a star each morning if the bed is dry; wet beds are treated in a matter of fact way and the child is not blamed for them
3. Enuresis alarm - if child does not respond to a star chart. Sensor placed under the child’s pants or under the child sounds an alarm when it becomes wet. Child gets out of bed, goes to pass urine, returns and helps to remake a wet bed before going to sleep. Takes several weeks to achieve dryness but usually effective. 1/3 relapse after several months - repeat tx usually produces lasting dryness
4. Desmopressin = short-term relief from bedwetting, e.g. for holidays/sleepovers. Taken orally or sublingually
5. Self-help groups - provide advice and assistance to parents

Secondary
- Tx underlying cause

Question 5

Daytime enuresis - causes

Answer 5

1. Developmental/psychogenic causes (lack of attention to bladder sensation)
2. Bladder instability or neuropathy
   - Detrusor instability = sudden, urgent urge to void induced by sudden bladder contractions
   - Neuropathic bladder = bladder enlarged and fails to empty properly; associated with spina bifida and other neurological conditions
3. UTI
4. Constipation
5. Ectopic ureter (causes constant dribbling and child is always damp)
   - 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

Note - nocturnal enuresis is also usually present

Question 6

Daytime enuresis - ex (3)

Answer 6

1. May show evidence of neuropathic bladder (3)
   a. Bladder may be distended
   b. May be abnormal perineal sensation + anal tone
   c. May have abnormal leg reflexes and gait
2. Look for sensory loss in distribution of S2, S3 and S4 dermatomes
3. Spinal lesion may be present

Question 7

Daytime enuresis - ix

Answer 7

1. Urine sample - MCS

Perform other ix if indicated

2. U/S may show bladder pathology, with incomplete bladder emptying or thickening of bladder wall
3. Urodynamic studies may be required
4. X-ray of spine may reveal vertebral anomaly
5. MRI may be required to confirm/exclude a non-bony spinal defect (e.g. tethering of cord)

Question 8

Daytime enuresis - mx

Answer 8

1. Exclude and tx neurological causes
2. If no neurological cause, child may benefit from (3): star charts, bladder training and pelvic floor exercises
3. Tx constipation
4. Enuresis alarm
5. Anticholinergic drugs (e.g. oxybutynin) to damp down bladder contractions - may be helpful if other measures fail