Enuresis (DSM + CPS Position Paper)

Question 1

how many criteria are there for enuresis

Answer 1

4

Question 2

criterion A for enuresis

Answer 2

repeating voiding of urine into bed or clothes, whether involuntary or intentional

Question 3

criterion B for enuresis

Answer 3

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

Question 4

criterion C for enuresis

Answer 4

chronological age is at least 5 years (or equivalent developmental level)

Question 5

criterion D for enuresis

Answer 5

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)

Question 6

list the three possible specifiers for enuresis

Answer 6

1. nocturnal only –> passage of urine only during nighttime sleep
2. diurnal only –> passage of urine during waking hours
3. nocturnal and diurnal –> combination of above two subtypes

Question 7

what is another name for the nocturnal-only subtype of enuresis

Answer 7

monosymptomatic enuresis

Question 8

which is the most common subtype of enuresis

Answer 8

nocturnal only

Question 9

when does nocturnal enuresis typically occur in the night

Answer 9

typically first third of the night

Question 10

what is another name for the diurnal subtype of enuresis

Answer 10

urinary incontinence

Question 11

what are the two general groups of those with diurnal enuresis / urinary incontinence

Answer 11

1. those with urge incontinence–> sudden urge symptoms and detrusor instability
2. voiding postponement–> consciously defer micturition urges until incontinence results

Question 12

is the urinary voiding most commonly involuntary or intentional in enuresis

Answer 12

most commonly involuntary

Question 13

what is the prevalence of enuresis among 5, 10 and 15+ year olds

Answer 13

5 year olds–> 5-10%

10 year olds–> 3-5%

15+ year olds–> 1%

Question 14

what are the two types of course of enuresis

Answer 14

primary vs secondary

Question 15

define primary enuresis

Answer 15

individual has never established urinary continence

Question 16

define secondary enuresis

Answer 16

individual develops the disturbance after a period of established urinary continence

Question 17

are there differences in prevalence of comorbid mental disorders between primary and secondary enuresis

Answer 17

no

Question 18

when does primary enuresis begin

Answer 18

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)

Question 19

when does secondary enuresis typically have its onest

Answer 19

between 5-8 years –> may occur at any time however

Question 20

what is the rate of spontaneous remission of enuresis after age 5 years

Answer 20

5-10% per year

*most children with the disorder become continent by adolescence

Question 21

in what % of cases does enuresis persist into adulthood

Answer 21

1% of cases

Question 22

diurnal enuresis is uncommon after what age

Answer 22

9 years

Question 23

list environmental risk factors for enuresis

Answer 23

psychosocial stress

delayed or lax toilet training

Question 24

list genetic and physiological risk factors for enuresis

Answer 24

1. 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)
2. nocturnal enuresis is a genetically heterogenous disorder –> there is heritability (see next card)

Question 25

what is the increased risk of nocturnal enuresis for offspring of enuretic mothers? enuretic fathers?

Answer 25

risk is 3.6x higher in offspring of enuretic mothers

10.1x higher in offspring of enuretic fathers

Question 26

in nocturnal enuresis more common in males or females

Answer 26

males

Question 27

is diurnal enuresis more common in males or females

Answer 27

females

Question 28

ddx enuresis

Answer 28

neurogenic bladder or another medical condition

medication side effects

Question 29

is the dx of enuresis made in the presence of neurogenic bladder

Answer 29

no

Question 30

do most children with enuresis have a comorbid mental disorder?

Answer 30

no

–> though the prevalence of comorbid behavioural symptoms is higher in those with enuresis vs those that dont have enuresis

Question 31

what other symptoms can come along with enuresis

Answer 31

developmental delays–> i.e speech, language, motor, learning

encopresis

sleepwalking

sleep terror disorder

Question 32

what medical condition is more common in kids with enuresis

Answer 32

UTIs–> especially those with the diurnal type

Question 33

is there a genetic link for primary nocturnal enuresis

Answer 33

yes–> chromosome 13

Question 34

in what situations should primary nocturnal enuresis be treated with pharmacotherapy and/or alarms

Answer 34

in cases where it poses a significant problem for the child

strength of recommendation = B, level of evidence = III

Question 35

list specific strategies for parents to help their child achieve continence

Answer 35

1. alarm devices in the management of nocturnal enuresis
2. pharmacological therapy
3. behavioural therapy

Question 36

what should be avoided before bed in the setting on enuresis

Answer 36

caffeine containing foods + excessive fluids

Question 37

what is the purpose of nighttime alarms in the treatment of primary nocturnal enuresis

Answer 37

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

Question 38

how do the alarms work for primary nocturnal enuresis

Answer 38

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

Question 39

the success of alarms for primary nocturnal enuresis depends on what?

Answer 39

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

Question 40

how long should you trial an alarm for primary nocturnal enuresis

Answer 40

3-4 months–> may take 1-2 months to see an improvement

use until there have been 14 consecutive dry nights

Question 41

what does the data show about efficacy about alarm systems for primary nocturnal enuresis

Answer 41

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

Question 42

what pharmacotherapy can be considered for primary nocturnal enuresis

Answer 42

1. 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)

Question 43

in which situations might desmopressin acetate be the most helpful

Answer 43

short term treatment ie camp or sleepovers

Question 44

how does imipramine work in primary nocturnal enuresis

Answer 44

not sure

the antienuretic response is often immediate

response rate similar to desmopressin

Question 45

if a child is not distressed about primary nocturnal enuresis should they be treated

Answer 45

no

Question 46

what should be the focus of treating primary nocturnal enuresis

Answer 46

minimizing the emotional impact on the child

Question 47

treatments for psychogenically induced enuresis

Answer 47

individual psychotherapy

crisis intervention

family therapy