Enuresis (Bedwetting)

Question 1

What is enuresis?

Answer 1

‘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 2

When do most children achieve active continence?

Answer 2

3-4yo

Question 3

Differentiate primary vs secondary enuresis.

Answer 3

1. Primary
   
   • = continuous enuresis for at least 6 months
2. Secondary
   
   • = Relapse of enuresis after at least 6 months of dryness
   • Secondary NE usually does not have an organic cause, but nonetheless consider:UTI, sexual abuse, DM/DI, epilepsy, OSA - hypoventilation, neurogenic bladder

Question 4

Differentiate monosymptomatic vs non-monosymptomatic enuresis.

Answer 4

1. Monosymptomatic
   
   • Night wetting without daytime urinary symptoms
2. Non-monosymptomatic
   
   • Night wetting with daytime urinary symptomse.g.:
     
     • Increased voiding frequency
     • Urgency
     • Jiggling
     • Daytime incontinence
     • Others: hesitancy, straining, weak stream, intermittency, infrequent voiding, holding manoeuvres, a feeling of incomplete emptying, post-micturition dribble and genital or LUT pain

Question 5

What are some contributing factors to enuresis?

Answer 5

• Maturational delay
• Uncompleted toilet training
• Smaller bladder capacity
• Increased night time urine volume(most people produce less)
• Difficulties in arousal from sleep(deep sleeper)
• Family history (if one parent had nocturnal enuresis, there is a 30% chance offspring will have it, increasing to 70% if both parents were affected)

Question 6

When do we start to treat enuresis?

Answer 6

• > 10 years old require urgent attention
• Avoid treating under 6 (they aren’t worried about it and they may grow out of it)
• Most places start treating at 7 years (social impact is greater)

Question 7

What are some general measures to take when managing enuresis? What should we avoid?

Answer 7

• Reassurance

- Reassure that it is not their fault
- Discuss prevalence in a way that makes sense to children - e.g. in terms of in child's class at school
- Discuss prevalence

• Motivation: get child involved - make a chart!
• Avoid
- Nappies/pull-ups - unlikely to improve with these
- Fluid restriction
- Admonishing

Question 8

What is the mainstay management of enuresis? Detail:

• Length of use
• Types
• How it works

Answer 8

Bed wetting alarms:
- Use 8-12 weeks
- Types
1. Mattress alarm
□ Placed further than arm’s reach for child
□ Child’s responsibility to wake up and turn off the alarm
2. Body-worn alarm

• Mechanism of action
  
  • Classical conditioning
  • Increases circadian rhythm for ADH release
  • Increases bladder capacity

Question 9

What medication can we use for enuresis? Detail:

• What it is
• How to use
• How long its used

Answer 9

Desmopressin:

• Synthetic analogue of ADH
• One hour before bed, sublingual melts
• No drinking before they take it and until the next morning (risk of hyponatraemia and seizures)
• Use 3 months and taper dose - not curative