Dr Natalie Torbolov

August 2013

WITTLE LEAKS

Case Presentation

• 10 year old girl

PSX

• Nocturnal Bedwetting– nightly

– rouseability

– Being toiletted 2 hourly

– No other urinary Sx

– Pull ups

– Dry by day since 3 years old

Case Presentation (cont.)

HPI

• Has only ever had a few dry nights in her life

• Social issues developing

PMHx - Nil, no problems at school

Reg Meds - Nil

Allergies - NKA

No positive family Hx

Examination

• Well looking

• Wt. 37.6 kg Ht. 132.2 cm

• No Sacral pit

• Abdo - NAD

• Normal Neurological examination

• External Genitalia - NAD

Management

• Discussion / explanation to mother of DX: Monosymptomatic Nocturnal Envresis

Trial of Envresis Alarm

• MSU - NAD

• Renal US - NAD

• Abdo - NAD

• Paediatric Consult – Confirmation of DX

- Assistance with Alarm

Childhood Nocturnal Enuresis

• Definition: Involuntary wetting while asleep 2 x week after 5 years of age

• 2nd most common chronic childhood complaint (after allergies)

• 18.9% of children

• 20% of 5 year olds

• 10% of 10 year olds

Childhood Nocturnal Enuresis (Cont.)

• Spontaneous remission 14% per year

• Self esteem & psychosocial function

• Suggestion of impaired cognitive performance which improves with treatment

• Only 34% seek professional help

• 2-3% persistent incontinence into adulthood

Classification

• Primary – never been dry for 6 months• Secondary – Enuresis after 6 months of being

dry– Psychological– Organic DS – eg DM, UTI

• Mono Symptomatic – no day time incontinence

– No urinary tract Sx• Non Monosymptomatic – daytime voiding & Sx

of urgency, frequency

Causes

• Family Hx – 4/10 with affected family member

- Genetic factors – links to Chrom8,12,13, 22 Auto Dom

• Bladder & Brain Connection

– Cortical arousal

– Inability to arouse to a full bladder sensation

–- Detrusor over activity

– Small capacity Bladder

Causes (Cont.)

• Nocturnal Polyuria - anti-direutichormone secretion

• Chronic Constipation – eg soiling

• Other Medical Conditions – OSA, DM, UTI, ADHD

• Sex M:F 2:1

Management of Nocturnal E

• Education & Reassurance – high rate of spontaneous remission

• Motivational Therapy – 1st line for <7 year olds who are not wetting nightly

- enlist co-operation of child eg. Record progress diary

- Rewards – don’t focus on dryness- For agreed upon behaviours

- Penalties – counter productive

Management of Nocturnal E (Cont.)

• Motivational Therapy (Cont.)

- 25% success rate ie. dry for 14 consecutive nights

- 70% - improvement

- No fault emphasis

- Trial 3 – 6 months before moving on

Enuresis Alarms

• 2 Types:

1. Pad & Bell

Enuresis Alarms (Cont.)

• Types (Cont.):

2. Undergarment sensor

Enuresis Alarms (Cont.)

• For motivated families• Frequent enuresis• Most effective

- 66% achieve 14 consecutive nights cf 4% of no Rx controls

• Child in charge of alarm- Testing- Setting- Follow up

Enuresis Alarms (Cont.)

• 12 – 16 weeks to achieve 14 dry consecutive nights

• Range 5 – 24 weeks

• Can be reinstated after relapse

Other Measures

• Monitoring Daily Fluid Intake (80% prior to 5PM)

• Avoid sugar drinks and caffeine, especially after 5 PM

• Treat Constipation• No Pull-ups – instead regular toiletting

schedule• Discourage parental toiletting of child

during night

Medical Treatment - Desmopression

• 200 – 400 mcg dose

• Children > 5 years

• Refractory to alternative methods

• Alternative for rapid or short term improvement

• When failed / refused alarm

Medical Treatment – Desmopression(Cont.)

• Indications

- Nocturnal Polyuria & normal functional bladder capacity

• Efficacy

- 30% - total dryness

- 40% - in wetting

- High relapse rate after cessation 60 -70%

Medical Treatment – Desmopression(Cont.)

• Administration & SFx

- 1 hour before bed

- Dose titrated to best effect

- Dilutional Hyponatrema – limit fluids 240ml 1 hour prior to bed

- Cease if NVD

Medical Treatment – Desmopression(Cont.)

• Administration & SFx (Cont.)

- Lack of response – due to nocturnal bladder capacity

- Taper rather than stop abruptly

- Can be used in combination with alarm

Medical Treatment – Tricyclic Antidepressants

- time in REM sleep

- Stimulate Vasopressin secretion

- Relax Detrusor mm

- 3rd Line

- SFx – Cardiac conduction disturbance

- Similar efficacy to Desmopressin

- Imipramine 10mg – 25mg 1 hour before bed

Medical Treatment – Anticholinergic Drugs

• Not effective in nocturnal enuress

• Better for day time wetting or if both persist

• Used with Desmopressin to increase bladder capacity

When to Refer

• Suspicion of neurological or urological anomalies

• Persistent Uti’s

• No response after 8-12 weeks

• Presence of significant daytime incontinence

Useful Resources

• Continence Foundation of Australia–www.continence.org.au

–Helpline – 1800 330 066

– Information on alarm purchase / hire

• The International Children’s Continence Society–www.i-c-c-s.org

Useful Resources (Cont.)

• Children’s Hospital Westmead– The nocturnal enuresis clinic (bedwetting

clinic)– http://www.chw.edu.au/site/directory/entrie

s/bedwetting.htm– Enuresis Clinic Wed & Thurs PM

Dr Patricia CauldwellPh 9845 1462Fax 9845 1491Referrals from GP or paediatricians by fax

References

• Bottomley G. Treating Nocturnal Enuresis in Children Practitioner June 2011 255 (1741) 23-6, 2-3

• Hjalmas K. Nocturnal Enuresis in Children Nord Med 1998 Jan 113(1) 13-5; 15

• Tan ND, Baskin LS, Management of Nocturnal Enuresis in Children Up to Date – Lit R/V to June 2013

• Caldwell P, Claudia NG, Management of Childhood Enuresis Medicine Today, August 2008, Vol9, Number 8, 16-22

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