Paeds: Enuresis

Question 1

Nocturnal enuresis

Epi

Answer 1

• Quite common 6% of 5-years-olds and 3% of 10-year-olds are not dry at night.
• 2:1 boys:girls

Question 2

Nocturnal enuresis

Organic causes

Answer 2

• Urinary tract infections
• Faecal retention severe enough to reduce bladder volume and cause bladder neck dysfunction
Polyuria from osmotic diuresis e.g. DM or renal concentrating disorders e.g. chronic renal failure

Question 3

Nocturnal enuresis Investigation

Answer 3

Urine sample for glucose and protein and check for infection

Question 4

Nocturnal enuresis Management of night-time enuresis

Answer 4

• Straight forward management painstaking to succeed.
• After the age of 4 years, enuresis resolves spontaneously in only 5%of affected children each year
In practice treatment is rarely undertaken before 6 years of age.

Question 5

Nocturnal enuresis Explanation of management

Answer 5

1. Explain to both child and parent that the problem is common and beyond conscious control.
2. Parents should stop punitive procedures as these are counterproductive
3. Star chart:
   - praise and a star each morning if the bed is dry
   - wet beds are treated in a matter-of-fact way and the child is not blamed for them.
4. Enuresis alarm – if star chart is not helpful: wakes child who passes urine and helps to change the bed (only 1 alarm per night)
5. Desmopressin
   Self-help groups

Question 6

Nocturnal enuresis

Enuresis alarm

Answer 6

Takes several weeks to achieve dryness but is effective in most cases so long as the child is motivated and the procedure is followed fully.
1/3 relapse after a few months, in which case repeat treatment with the alarm usually produces lasting dryness.

Question 7

Nocturnal enuresis Desmopressin

Answer 7

Short-term relief from bedwetting e.g. for holidays or sleepovers can be achieved by the use of synthetic analogue of antidiuretic hormone.

Question 8

Daytime enuresis: Definition

Answer 8

A lack of bladder control during the day in a child old enough to be continent (over the age 3-5 years).

Question 9

Daytime enuresis:

Causes

Answer 9

• Lack of attention to bladder sensation: a manifestation of a development or psychogenic problem, although can happen in a normal distracted child.
• Detrusor instability (sudden, urgent urge to void induced by sudden bladder contractions).
• Bladder neck weakness
• A neuropathic bladder (bladder is enlarged and fails to empty properly, irregular thick wall and is associated with spina bifida and other neurological conditions)
• A UTI (rare in absence of other symptoms)
• Constipation
  An ectopic ureter, causes constant dribbling and child is always damp.

Question 10

Daytime enuresis:

Examination

Answer 10

• May reveal evidence of a neuropathic bladder i.e. the bladder may be distended, there may be abnormal perineal sensation and anal tone or abnormal leg reflexes and gait.
• Sensory loss in the distribution of the S2,3 and 4 dermatomes should be sought.
• Microscopy, culture and sensitivity
• US
• Urodynamic studies
• X-ray of spinal anomaly
• MRI scan (non-bony defect)

Question 11

Daytime enuresis: Girls that are dry at night but wet in the am

Answer 11

likely to have pooling of urine from an ectopic ureter opening into the vagina

Question 12

Daytime enuresis:

Management

Answer 12

• Affect children in whom neurological cause has been excluded may benefit from star charts, bladder training and pelvic floor excercises
• Constipation should be treated
• Enuresis alarm
  Anticholinergic drugs e.g. oxybutynin, to damp down bladder contractions

Question 13

Secondary (onset) enuresis:

Due to:

Answer 13

1. Emotional upset, the commonest cause
2. UTI
3. Polyuria from an osmotic diuresis in DM or a renal concentrating disorder e.g. CRF or sickle cell disease

Question 14

Secondary (onset) enuresis:

Investigations:

Answer 14

• Urine testing infection, glycosuria and proteinuria
• Assessment of urine concentrating ability by measuring osmolality of an early morning urine sample
• US of renal tract