Urinary Incontinence in Children Flashcards
At what age can we start diagnosing children with daytime urinary incontinence?
≥5 years of age
At least twice per week for at least 3 consecutive months
Which gender is usually potty-trained first? Which gender is affected by daytime incontinence more?
Girls are earlier than boys
Girls are affected twice as much as boys
What is daytime incontinence?
Repeated daytime voiding in urine into clothes
What are two types of causes of daytime incontinence?
Function or organic
What are examples of functional causes of daytime incontinence?
UTI
Stress
Urge syndrome
Deferral of voiding (holding)
Functional constipation
What are organic causes of daytime incontinence?
Neurogenic bladder
Partial urethral obstruction
Ectopic ureter
What is enuresis?
Bedwetting during sleep (inclusive of nap time)
At what age can you start diagnosing children with enuresis?
5+ years for girls
6+ years for boys
More than twice weekly
What is the difference between primary enuresis and secondary enuresis?
Primary- bladder control has never been achieved
Secondary- loss of bladder control after at least 6 months without bedwetting
Which of the two types of primary enuresis is more common in boys?
Primary enuresis
What are two types of primary enuresis?
Volume-dependent enuresis
Detrusor dependent enuresis
Which of the two types of enuresis is associated with nocturnal incontinence?
What’s the mechanism of action?
Volume-dependent enuresis
A normal nocturnal rise in antidiuretic hormone (ADH) does not occur
Which of the two types of enuresis is associated with daytime incontinence?
Detrusor-dependent enuresis
The two subtypes of enuresis are old classification methods. What is the new classification method for enuresis?
Monosymptomatic and non-monosymptomatic (daytime and nighttime incontinence)
What are non-pharm choices for incontinence in children?
- Encourage child to avoid deferral
- Advise caregivers to avoid punishing behaviour
- Avoid excessive intake of fluids within 2 hours of bedtime
- Enuresis alarms
Is there any evidence for complementary therapies such as hypnosis, chiropractic, or homeopathy?
No
What age can we start pharmacologic therapy for children?
≥5 years of age
What are the two classes of medications that can be used as pharmacologic choices?
Antidiuretic hormone analogues
Anticholinergic smooth muscle relaxants
Which drug is under the antidiuretic hormone analogue drug class?
Desmopressin
What’s the mechanism of action with desmopressin?
Analogue of human antidiuretic hormone (ADH).
Decreases urine production when given at bedtime
When does desmopressin come into play?
When a rapid response is required
How do we monitor desmopressin once we’ve started the therapy?
If therapy is effective, consider a 1 week interruption every 3 months to see if treatment is no longer needed
________ children with ____ urine output and ______ bladder capacity would benefit the most from desmopressin.
Older
Large
Normal
Patients with ____ urine output and _________ bladder capacity would require combo treatment with desmopressin and smooth muscle relaxant.
Large
Reduced
What is a serious adverse effect associated with desmopressin use?
Overhydration and hyponatremia
Can lead to seizures and death
How doe we avoid the risk of hyponatremia?
Limiting fluid intake 1 hour before and 8 hours after taking desmopressin
Hold dose during illness that can cause electrolyte imbalance (Ex: fever, vomiting, diarrhea)
What are signs of hyponatremia that would warrant discontinuation and need to referral for medical attention?
Headache, nausea, vomiting
Is nasal desmopressin indicated for treatment of nocturnal enuresis?
No, higher incidence of hyponatremia
Which drugs are in the anticholinergic smooth muscle relaxant drug class?
Oxybutynin
Tolterodine
Solifenacin
Propiverine
Which of the four medications is good for reducing bladder contraction in those with detrusor overactivity?
Oxybutynin
What’s the most common side effect with oxybutynin?
Constipation, dry mouth, and flushing
Of the four smooth muscle relaxants, which are selective agents?
Tolterodine
Solifenacin
If they’re selective and have fewer systemic side effects, why is its use limited?
Not indicated for use in children in Canada
What is its use limited to?
Reserved for cases in which oxybutynin is not tolerated
Oxybutynin and tolteridone is both available in immediate and extended release form. What is the benefit with extended release form?
Better efficacy in urinary incontinence
What makes propiverine an uncommon choice?
Weight based dosing
When do we consider combo therapy of desmopressin and anticholinergic?
Refractory cases
Which drugs are most commonly used for combo therapy?
Desmopressin and tolterodine
When combining the two drugs, what do we have to adjust for the dose?
Lower dose of desmopressin
- 200mcg tablets or 120mcg melts
If child has failed all other therapies, what other drug can they try?
Tricyclic antidepressant
- Amitriptyline
- Desipramine
- Imipramine
Why are TCAs last line?
Low quality evidence
Adverse effects include dizziness, GI discomfort, headache, mood changes
What is considered treatment of relapse?
> 1 symptom recurrence per month
No response to desmopressin (at maximum dosages), alarm therapy, or combo of alarm therapy and desmopressin.
If relapse occurs following desmopressin therapy, consider combo therapy
Summary:
What drug class do we use for enuresis?
Desmopressin
Summary: What drug class do we use for daytime incontinence?
Anticholinergic (muscle relaxant)
