Enuresis and Haematuria

Question 1

When do children normally achieve day and night time continence?

Answer 1

The majority of children achieve day and night time continence by 3 or 4 years of age.

Question 2

What is the definition of enuresis?

Answer 2

Enuresis may be defined as the involuntary discharge of urine by night, in a child aged 5 for girls and 6 in boys, in the absence of congenital or acquired defects of the nervous system or urinary tract. Enuresis by day is incontinence.

Nocturnal enuresis can be defined as either primary (the child has never achieved continence) or secondary (the child has been dry for at least 6 months before).

Question 3

What are the risk factors for enuresis?

Answer 3

Genetic
Disordered sleep
Constipation
ADHD

Question 4

What should you ask about in a history of someone with enuresis?

Answer 4

Take detailed history of when bed wetting occurs, how often per night, daytime symptoms, constipation, recurrent UTI etc. If previously dry then starts bed wetting explore potential emotional problems or even abuse.
Look for possible underlying causes/triggers (e.g. Constipation, diabetes mellitus, UTI if recent onset, caffeine)

Question 5

How should you investigate a child with enuresis?

Answer 5

Urine Dip

Consider bladder USS rarely

Question 6

When should treatment be started in enuresis?

Answer 6

Treatment should be started after 6yrs for boys and 5 yrs for girls

Question 7

What general management advice should be given for enuresis?

Answer 7

Advise on fluid intake, diet and toileting behaviour and reassure child (and parent) that they are not infantile or dirty

Question 8

What are the management steps for enuresis?

Answer 8

1. Reward systems (e.g. Star charts). NICE recommend these should be given for agreed behaviour rather than dry nights e.g. Using the toilet to pass urine before sleep
2. Consider whether an alarm or drug treatment is appropriate, depending on the age, maturity and abilities of the child or young person, the frequency of bedwetting and the motivation and needs of the family’.
3. Desmopressin may be used in those over 7yrs particularly if short-term control is needed or an enuresis alarm has been ineffective/is not acceptable
4. Combination

Question 9

What are the common causes of haematuria in children?

Answer 9

Structural – congenital kidney malformations, stones, cancer (Wilm’s)
Inherited – PCKD, Alport’s syndrome, inherited nephritis and sickle cell disease
Glomerulonephritis
Idiopathic haematuria – cause unknown

Question 10

How should a child with haematuria be investigated?

Answer 10

Microscopic haematuria only needs further investigation if persistent 
Urine dip and microscopy  
BP measurement very important 
US of kidneys ureters and bladder 
Us and Es and kidney function 
Kidney biopsy

Question 11

What red flags should be looked out for in combination with haeamturia?

Answer 11

Abnormal renal function 
Proteinuria +2 
Hypertension 
Fluid overload 
Persistent macroscopic haematuria