GU- Enuresis Flashcards
vol or invol urination into clothes at the age when toilet training should be complete
“enuresis” per text
incontinence durine sleep
nocturnal enuresis
enuresis during waking hours
diurnal emuresis
night time wetting with no daytime concerns
monosymptomatic nocturnal emuresis
nocturnal enuresis plus some type of bowel or bladder dysfunction
non-monosymptomatic enuresis (NMNE)
enuresis in child who has never had urinary control
primary enuresis
enuresis in a child has previously been dry 6-12 months then begins wetting
secondary enuresis
DSM-V diagnostic criteria
minimum age 5 years old
at least one episode per month for at least 3 months
ICCS infrequent enuresis
4 or less times per month
ICCS frequent enuresis
four of more times per week
causes of enuresis
has definitive cause, not due to bad behavior or attention seeking
familial disposition- many found to be due to constipation
developmental comorbidities- strong collelation with adhd
always consider trauma or abuse
constipation, neuro dev delay, small bladder. sleep disorders, stress/family disruption, polyurina, inappropriate toilet training
palpate abd for signs of fecal impaction
hard mass in LLQ
indication of full bladder
abd tenderness over suprapubic area midline
testing UA and diff dx
UA- should be normal, looking for organic causes enuresis such as UTI- most common cause
DM, sickle cell-increased intake = increase output
CRF- inablilty to concentrate urine
hypercalciurea, neurogenic bladder, obstr uropathy, vaginitis, sleep apnea
differential dx pollakiuria
self limiting and benign
“daytime extraordinary urinary frequency”
8-12 times day, often as Q15-30 min
doesnt respond to meds, typically lasts 6 months but can last years
treatment should focus on daytime issue first if present then focus on night time
Treatment - urotherapy
non pharmocologic therapy
not as effective as alarm therapy and meds- good starting point
urotherapy education
Education-how bladder works, minimize embarassment/scolding, reinforce positives and childs wanting to be dry
urotherapy - bladder training
bladder training-void Q2hrs during day, awakning and prior to bed, proper sitting and emptying
urotherapy diet and fluids
adequate water between bfast and lunch to avoid evening thirst- eliminate carb beverages, citus juices and caff
no dairy 4 hours before bedtime
no fluids 2 hours before bedtime
NEVER takes prescidence over adequate hyrdration
urotherapy - monitor progress and manage constipation
keep voiding diary
manage constipation issues
How long should we try urotherapy before medication and enuresis alarm?
3 months
use of alarms and desmopressin are also first line treatment, choice of urotherapy vs alarm/meds is up to family
how do alarms reduce nocturnal enuresis?
increasing nocturnal bladder capacity or by enhanced arousal
does not reduce nocturnal output
how is alarm worn and when to follow up and d/c
worn with undrpants, parents should awaken child if he/she doesnt awake
nightly for2-4 (3) months and until after patient is dry for at least 1 month (14 days min)
follow up is biweekly or monthly
Drug therapy for monosymptomatic nocturnal enuresis -first, second and third
desmopressin acetate (DDAVP)-first line
imipramine (tofranil) - only thrid line therpy at tertiary care facilities- third line
desmopressin dose
0.2-0.4mg daily at bedtime
120mcg melt daily at bedtime up to 240 as equivalent dosage
desmopressin info- reduces nighttime urine production
effective in kids with nocturnal polyuria and normal bladder volume
take on empty stomach, no caff/choc/nutrasweet/carb bev
30 min before bed then wake to void within 10hrs
kids at least 6 years old
do not use with nasal spray
caution in HTN, CF (hyponatremia) any lyte imbalances
use least amount effective
can use daily or intermittantly
d/c in 6 months to check for relapse, 80-100% will relapse with d/c
oxybutynin dose
anticholenergic - second line
5 mg once daily at bedtime,
increase by 5mg
MAX DOSE 20MG/DAY
oxybutynin notes
relaxes smooth mosclus of bladder to increase capacity, has antispasmotic and analgesic properties
effective for daytime enuresis
kids at least 5 years old
concerns for referral
weak or interrupted stream
need to use abd pressure to urinate
daytime incont and nocturnal enuresis combined
ectopic ureter results in
costant leakage
no response
less than 50% reduction in enuresis
partial response
50-99% reduction
complete response
100% reduction
relapse
more than one symptom relapse per month
continued success
no sympt at 6 months
complete success
no symptoms for 2 years
what age can treatment start?
6 years old
What do we do for 3-5 year olds?
benign neglect in the face of accidents
for older children, more aggressive treatments are warranted, rarely indicates disease
Drug therapy for monosymptomatic nocturnal enuresis -second line
Anticholenergics
oxybutynin (ditropan)
Tolterodine (detrol)
Drug therapy for monosymptomatic nocturnal enuresis -third line
tricyclic antidepressant
imipramine (tofranil)
only thrid line therpy at tertiary care facilities- third line
Detrol notes
anticholinergic- second line treatment
kids 12 and up
detrol dosage
anticholenergic s/e and warnings
detrol (tolterodine) and ditropan (oxybutynin)
no not admin with fever, sweating is anticholinergic effect
caution in kids who play vigerously, exericse, hot days
s/e: dry mouth, blurred vision, facial flushing, CONSTIPATION, poor bladder emptying, mood changes
imipramine dose
imepramine notes
TCA- thrid line treatment
has anticholenergis s/e as well as a CNS stimulant
allows children to awaken to sensation of full bladder
use with caution can cause seizures or cardiac arrythimas with OD
