Enuresis (DSM + CPS Position Paper) Flashcards
how many criteria are there for enuresis
4
criterion A for enuresis
repeating voiding of urine into bed or clothes, whether involuntary or intentional
criterion B for enuresis
the behaviour is clinically significant as manifested by either a frequency of at least TWICE A WEEK for at least THREE consecutive months or the presence of clinically significant distress or impairment in social, academic or other areas of functioning
criterion C for enuresis
chronological age is at least 5 years (or equivalent developmental level)
criterion D for enuresis
behaviour is not attributable to physiological effects of a substance (i.e diuretic, antipsychotic medication), other another medical condition (i.e diabetes, spina bifida, seizure disorder)
list the three possible specifiers for enuresis
- nocturnal only –> passage of urine only during nighttime sleep
- diurnal only –> passage of urine during waking hours
- nocturnal and diurnal –> combination of above two subtypes
what is another name for the nocturnal-only subtype of enuresis
monosymptomatic enuresis
which is the most common subtype of enuresis
nocturnal only
when does nocturnal enuresis typically occur in the night
typically first third of the night
what is another name for the diurnal subtype of enuresis
urinary incontinence
what are the two general groups of those with diurnal enuresis / urinary incontinence
- those with urge incontinence–> sudden urge symptoms and detrusor instability
- voiding postponement–> consciously defer micturition urges until incontinence results
is the urinary voiding most commonly involuntary or intentional in enuresis
most commonly involuntary
what is the prevalence of enuresis among 5, 10 and 15+ year olds
5 year olds–> 5-10%
10 year olds–> 3-5%
15+ year olds–> 1%
what are the two types of course of enuresis
primary vs secondary
define primary enuresis
individual has never established urinary continence
define secondary enuresis
individual develops the disturbance after a period of established urinary continence
are there differences in prevalence of comorbid mental disorders between primary and secondary enuresis
no
when does primary enuresis begin
by definition, at 5 years old (i.e if they have not yet achieved urinary continence by 5 years, they are considered to have primary enuresis)
when does secondary enuresis typically have its onest
between 5-8 years –> may occur at any time however
what is the rate of spontaneous remission of enuresis after age 5 years
5-10% per year
*most children with the disorder become continent by adolescence
in what % of cases does enuresis persist into adulthood
1% of cases
diurnal enuresis is uncommon after what age
9 years
list environmental risk factors for enuresis
psychosocial stress
delayed or lax toilet training
list genetic and physiological risk factors for enuresis
- is assoc. with delays in the development of normal circadian rhythms of urine production –> resulting nocturnal polyuria or abnormalities of central vasopressin receptor sensitivity and reduced bladder functional capacities with bladder hyperreactivity (unstable bladder syndrome)
- nocturnal enuresis is a genetically heterogenous disorder –> there is heritability (see next card)
what is the increased risk of nocturnal enuresis for offspring of enuretic mothers? enuretic fathers?
risk is 3.6x higher in offspring of enuretic mothers
10.1x higher in offspring of enuretic fathers
in nocturnal enuresis more common in males or females
males
is diurnal enuresis more common in males or females
females
ddx enuresis
neurogenic bladder or another medical condition
medication side effects
is the dx of enuresis made in the presence of neurogenic bladder
no
do most children with enuresis have a comorbid mental disorder?
no
–> though the prevalence of comorbid behavioural symptoms is higher in those with enuresis vs those that dont have enuresis
what other symptoms can come along with enuresis
developmental delays–> i.e speech, language, motor, learning
encopresis
sleepwalking
sleep terror disorder
what medical condition is more common in kids with enuresis
UTIs–> especially those with the diurnal type
is there a genetic link for primary nocturnal enuresis
yes–> chromosome 13
in what situations should primary nocturnal enuresis be treated with pharmacotherapy and/or alarms
in cases where it poses a significant problem for the child
strength of recommendation = B, level of evidence = III
list specific strategies for parents to help their child achieve continence
- alarm devices in the management of nocturnal enuresis
- pharmacological therapy
- behavioural therapy
what should be avoided before bed in the setting on enuresis
caffeine containing foods + excessive fluids
what is the purpose of nighttime alarms in the treatment of primary nocturnal enuresis
to teach the child to respond to a full bladder while asleep –> the alarm goes off when the child starts to void
it may teach the child to wake up to the alarm and then, by approximation, transfer the waking to the sensation of the bladder
how do the alarms work for primary nocturnal enuresis
they are portable and worn on the body
run on batteries
sensitive to a few drops of urine and give prompt alarm response
no buzzer burns or shocks
the success of alarms for primary nocturnal enuresis depends on what?
on if the child is motivated and on the willingness of both the child and the parents to be awakened
are most effective in children older than 7-8 years
how long should you trial an alarm for primary nocturnal enuresis
3-4 months–> may take 1-2 months to see an improvement
use until there have been 14 consecutive dry nights
what does the data show about efficacy about alarm systems for primary nocturnal enuresis
actual cure rate is just under 50% (but basically no one without an alarm achieved cure)
*CPS recommends use of alarm devices for older, motivated children from motivated families for whom more simple measures are unsuccessful
what pharmacotherapy can be considered for primary nocturnal enuresis
- desmopressin acetate –> synthetic analogue of ADH
(basically used as hormone replacement as some kids seem to have variations in their ADH secretion leading to overflow incontinence at night)
- there are other considerations but outside scope of this exam most likely
2. imipramine
3. anticholinergics (ie oxybutinin)
in which situations might desmopressin acetate be the most helpful
short term treatment ie camp or sleepovers
how does imipramine work in primary nocturnal enuresis
not sure
the antienuretic response is often immediate
response rate similar to desmopressin
if a child is not distressed about primary nocturnal enuresis should they be treated
no
what should be the focus of treating primary nocturnal enuresis
minimizing the emotional impact on the child
treatments for psychogenically induced enuresis
individual psychotherapy
crisis intervention
family therapy
