Wetting and Soiling: Paediatric Incontinence

Question 1

What is enuresis?

Answer 1

Bed wetting during sleep after age of 5

Still very prevalent after 7

Question 2

What is meant by monosymptomatic NE?

Answer 2

Only wetting during the night, never during the day

Question 3

What is secondary NE?

Answer 3

NE that restarts around 6 months of dryness

Question 4

What specific factors do you take on Hx?

Answer 4

Day time wetting

Other daytime lower urinary tract symptoms

Question 5

What is the pathophysiology of NE

Answer 5

High nocturnal urine production
Small nocturnal functional bladder capacity
Inability to wake up to bladder fullness

Question 6

What is the diurnal pattern of urine production?

Answer 6

Circadian production of ADH so as to reduce urine production at night

Question 7

What are some non-ADH causes of nocturnal polyuria?

Answer 7

Increased intake

Abnormal renal sodium handling

Question 8

Which subgroup of children are more likely to have daytime symptoms?

Answer 8

Those with small, overactive bladders

Question 9

When do you start treating?

Answer 9

Usually at 7 when self esteem issues start to occur

Question 10

What can you tell a child with NE?

Answer 10

Reassure that it’s not their fault
Explain that it’s inherited
Discuss the prevalence

Question 11

How is MNE Mx, first line? What are the success rates?

Answer 11

Bedwetting alarms for 8-12 weeks

80%

Question 12

What is the second line treatment for NE?

Answer 12

If polyuric - consider desmopressin

If day symptoms - consider anti-cholinergics

Question 13

What do you tell parents when they take desmopressins?

Answer 13

Don’t drink fluids after taking it
Take one hour before bed
Pass dilute urine before sleeping

Question 14

Does fluid restriction work?

Answer 14

Nope

Question 15

At what age do you worry about daytime wetting?

Answer 15

After aged 4

Question 16

What are the causes of daytime wetting?

Answer 16

Overactive detrusor

Dysfunctional voiding

Question 17

How can the pattern of urine flow indicate pathology?

Answer 17

Stop and start - classic for dysfunctional voiding

Question 18

How are overactive bladders treated?

Answer 18

Anticholinergic - Oxybutynin 5mg bd

SE: Anti SLUD, mood change, blurred vision, blood nose

Question 19

How are dysfunctional bladders treated?

Answer 19

Pelvic floor physio

Question 20

What causes soiling?

Answer 20

Commonly constipation (incomplete emptying)

Rarely

• Neurological
• Congenital
• Inflammatory
• Psychogenic

Question 21

What are some red flags for constipation?

Answer 21

Onset before 1 month
Delayed passage of meconium
Ribbon stools
Abdominal distension and vomiting
Growth faltering
Protective concerns
Neurological - LL
Abnormality of anus, buttocks, sacrum

Question 22

Until what ages is faecal incontinence normal

Answer 22

4

Question 23

What is the pathophysiology of faecal incontinence?

Answer 23

Anismus/withholding
Rectal hyposensitivity
Toilet phobia

Question 24

What is the utility of AXR in constipation?

Answer 24

Not useful

Question 25

How is constipation Mx?

Answer 25

Regular toileting - maximise emptying, squat posture, feet supported, back straight, legs apart, bulge tummy, 15-20minutes after a meal

Laxatives to clear out and sometimes maintenance

Question 26

What laxatives do you use?

Answer 26

Lubricants - mineral oils
Stimulants - senna, bisacodyl,
Stool softers - coloxyl, paraffin
Osmotic laxatives - movicol or osmolax