Enuresis & wetting

Question 1

What is enuresis?

Answer 1

Involuntary discharge of urine by day, night or both in a child aged >5years in the absence of congenital or acquired defects of the nervous system or urinary tract.

Children achieve day and night time continence by age 3-4.

Question 1

Who does enuresis affect?

Answer 1

Boys > girls

*children are most often fit with no underlying psychological / physical trigger.

=> assoc. with family hx in 2/3 cases

=> secondary enuresis is very common in children who experience psychological distress

Question 2

There are two types of enuresis: primary and secondary. Define these.

Answer 2

1. Primary enuresis: children who have never achieved urinary continence overnight
2. Secondary enuresis: children who have previously achieved urinary continence overnight (for at least 6 months)
   => concerns about illness / abuse (safeguarding issue?)

Question 3

What are the physical causes of enuresis?

Answer 3

1. Diabetes mellitus
2. Urinary tract infections
3. Constipation
   * test for these if any doubts

Question 4

What is the investigation for enuresis?

Answer 4

1. Full history + exam
2. Urine dip always
   * Secondary enuresis requires more in depth investigations to ensure no underlying physical cause

=> urine dip

=> urine osmolarity

=> renal ultrasound

Question 5

How is enuresis managed?

Answer 5

Depends on underlying cause.

1. Generally, children + parents counselled that bed-wetting is very common and child should not be blamed.
   => advise on fluid intake and diet
   => day time toilet used regularly (4-7 times)
2. Star charts - initial conservative method
   => reward system - given for agreed behaviour e.g. toilet before bed, drinking recommended levels of fluid, etc rather than dry nights
3. Nocturesis alarm - first line in children <7years
   => devise that detects water in underwear and activates alarm prompting child to wake up & go to the bathroom - usually effective in training children
   => 56% dry at 1yr
4. Trial synthetic ADH (sublingual desmopressin) in children >7years if alarm has failed or rapid control (short term i.e. sleepovers, school trips) needed
   => drug increases water reabsorption and reduced urine production overnight
   => relapse common

Question 6

Infrequent bed wetting (<2nights/week) occurs in:
=> 15% at 5 years,
=> 5% at 10 years,
=> 1-2% at >15 years

Usually due to delayed maturation of bladder control (family hx +ve)

Answer 6

INFO CARD

Question 7

History:

1. Nights/week child wets the bed
2. More than once per night?
   (Severe bed wetting less likely to resolve spontaneously)
3. Any day time symptoms?
   (diurnal wetting may respond to oxybutynin)
4. Frequency / urgency may suggest an overactive bladder
5. Fluid intake during day?

Answer 7

6. Any constipation / soiling?
7. Hx of recurrent UTI
   (underlying urological abnormality?)
8. If the child was dry and recently started bed wetting, consider systemic illness or possible child abuse