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    Nocturnal Enuresis 021814

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    Tanvi Manjrekar
    The document discusses nocturnal enuresis or bedwetting, including a case study of an 11-year old boy presenting with frequent bedwetting and daytime urgency. It covers normal bladder function and development, definitions and epidemiology of bedwetting, potential causes, assessment, and management strategies such as alarms, medications, and behavioral techniques. The case study demonstrates assessing the patient's history and symptoms, developing a diagnosis of primary non-monosymptomatic nocturnal enuresis, and creating a collaborative management plan focused on reducing shame and addressing underlying issues like constipation.

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    Nocturnal Enuresis 021814

    Uploaded by

    Tanvi Manjrekar
    72 views33 pages
    The document discusses nocturnal enuresis or bedwetting, including a case study of an 11-year old boy presenting with frequent bedwetting and daytime urgency. It covers normal bladder function and development, definitions and epidemiology of bedwetting, potential causes, assessment, and management strategies such as alarms, medications, and behavioral techniques. The case study demonstrates assessing the patient's history and symptoms, developing a diagnosis of primary non-monosymptomatic nocturnal enuresis, and creating a collaborative management plan focused on reducing shame and addressing underlying issues like constipation.

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    The document discusses nocturnal enuresis or bedwetting, including a case study of an 11-year old boy presenting with frequent bedwetting and daytime urgency. It covers normal bladder function and development, definitions and epidemiology of bedwetting, potential causes, assessment, and management strategies such as alarms, medications, and behavioral techniques. The case study demonstrates assessing the patient's history and symptoms, developing a diagnosis of primary non-monosymptomatic nocturnal enuresis, and creating a collaborative management plan focused on reducing shame and addressing underlying issues like constipation.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    72 views33 pages

    Nocturnal Enuresis 021814

    Uploaded by

    Tanvi Manjrekar
    The document discusses nocturnal enuresis or bedwetting, including a case study of an 11-year old boy presenting with frequent bedwetting and daytime urgency. It covers normal bladder function and development, definitions and epidemiology of bedwetting, potential causes, assessment, and management strategies such as alarms, medications, and behavioral techniques. The case study demonstrates assessing the patient's history and symptoms, developing a diagnosis of primary non-monosymptomatic nocturnal enuresis, and creating a collaborative management plan focused on reducing shame and addressing underlying issues like constipation.

    Copyright:

    © All Rights Reserved
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    of 33

    Nocturnal Enuresis

    Melissa Martin
    Angela Steineck
    February 18, 2014
    Outline
    —  Case Study

    —  Normal Micturition

    —  Definitions

    —  Epidemiology

    —  Etiology

    —  General Assessment

    —  Management

    —  Impact
    Case Study
    11 y/o boy presenting with bedwetting >5 nights per week
    and episodes of daytime urgency.
    Micturition
    —  Relaxation of the pelvic floor and external urethral
    sphincter

    —  Contraction of the detrusor muscle surrounding the


    bladder

    —  Result = Forceful and continuous urine flow with


    complete bladder emptying
    Micturition
    —  Controlled by four specific parts of the nervous system:
    —  ganglion cells in the bladder wall and sympathetic chain
    (autonomic) and dorsal root chain (sensory)
    —  motor neurons and sensory interneurons in the caudal spinal
    cord
    —  the caudal brainstem
    —  the cortical and subcortical areas
    Micturition
    —  Cortical arousal is present during sleep in response to
    bladder distension

    —  Ages 1-2: Develop conscious sensation of bladder filling

    —  Ages 2-3: Develop ability to void or inhibit voiding


    voluntarily

    —  Ages 3-4: Develop adult pattern of urinary control and are
    dry during day and night
    Micturition
    —  Normal frequency of voiding in children= 4-7 times per
    day

    —  Normal residual urine volume in children <10% of


    maximal bladder capacity

    —  Reduced urine production at night in response to the


    circadian rhythm of the antidiuretic hormone (ADH)
    Nocturnal Enuresis
    —  Involuntary passage of urine during sleep
    —  Beyond 5 y of age
    —  Twice per week for 3 consecutive months
    —  Primary: lifelong
    —  Secondary: acquired after being dry for at least 6
    months
    —  Monosymptomatic: associated with normal daytime
    urination
    —  Polysymptomatic: associated with other urinary
    symptoms i.e. daytime symptoms, urgency,
    frequency
    Epidemiology
    —  Age 5: at least 20% of children wet the bed at least
    monthly

    —  Age 6: 10% of children

    —  Age 7 and beyond: 15% become dry each year

    —  M > F
    Etiology
    —  Physiologic
    —  Maturational delay
    —  Small badder
    —  Deep sleepers
    —  Genetic

    —  Psychologic

    —  Organic

    —  Association with sleep apnea


    Nocturnal Enuresis and ADHD
    —  ADHD is the most specific comorbid disorder in children
    with nocturnal enuresis.

    —  Robson et al in 1997: 20.9% of studied individuals with


    ADHD demonstrated nocturnal enuresis.

    —  NE in setting of ADHD is more difficult to treat


    Table 1.
    Frequency of elimination disorders and attention deficit symptoms by
    gender
    Disorder No. Girls (%) No. Boys (%) Total No. (%)

    Urinary incontinence:
    NE 41 (6.4) 95 (12.9) 136 (9.9)
    DI 19 (3.0) 30 (4.1) 50 (3.6)
    Overall 60 (9.3) 125 (17.0) 185 (13.4)
    FI (any/encopresis): 9 (1.4) 10 (1.4) 19 (1.4)
    Isolated 1 (0.2) 1 (0.1) 2 (0.15)
    With UI 8 (1.2) 9 (1.2) 17 (1.2)
    Constipation 4 (0.6) 9 (1.2) 13 (0.9)
    Constipation + FI 1 (0.2) 2 (0.3) 3 (0.2)
    ADHD symptoms (clinical/borderline range):
    Without UI 8 (1.2) 32 (4.4) 40 (2.9)
    With NE 6 (0.9) 7 (1.0) 13 (0.9)
    With DI 5 (0.8) 13 (1.8) 18 (1.3)
    With UI + FI 4 (0.6) 5 (0.7) 9 (0.7)
    Overall 19 (2.9) 52 (7.1) 71 (5.1)
    Totals 1379 (100) 645 (100) 734 (100)
    Table 4.
    Risk factors for clinically relevant CBCL inattentive scale symptom scores
    Independent Variable Wald Chi-Square p Value OR (95% CI)
    NE 3.1 0.08 2.0 (0.9-4.4)
    DI 8.3 0.004 4.4 (1.6-12.0)
    FI 0.2 0.688 1.3 (0.3-5.5)
    Age 1.3 0.249 1.4 (0.8-2.6)
    Gender 0 0.97 1.0 (0.5-2.0)
    Developmental disorder 42.7 <0.0001 9.6 (4.9-18.9)
    Migration 0 0.858 0.9 (0.4-2.1)
    Separation 11.9 0.0006 3.3 (1.7-6.7)

    Expected problems in schools 9.9 0.002 4.1 (1.7-10.0)


    General Assessment
    —  History
    —  Inquire whether child views wetting as a problem
    —  Pattern of wetting
    —  Associated symptoms
    —  Fluid intake
    —  Developmental Hx
    —  History of UTIs, constipation, airway obstruction, abuse,
    stress
    —  Previous interventions
    —  Family history of wetting
    General Assessment
    —  Physical Exam
    —  Abdominal, spinal, neurologic, and genital exam

    —  Labs
    —  U/A (everyone)
    —  Ucx only if sxs concerning for infection
    —  Further work-up directed by H&P: frequency/volume chart,
    uroflowmetry, urinary tract ultrasound, post-void ultrasound,
    spinal xray, abdominal xray

    —  Referral
    —  Genitourinary pathology or treatment failure after 8-12
    weeksà refer to urology
    —  Child’s social functioning impaired or family punishingà
    psychological counseling
    Uroflowmetry

    http://www.glowm.com/resources/glowm/cd/pages/v1/ch079/framesets/003f.html
    Case Study
    11 y/o boy presenting with bedwetting >5 nights per week and
    episodes of daytime urgency.

    HPI: Mom has tried restricting fluids after 5pm and putting
    boy on toilet during the night. He has never been dry for
    6 or more months. He is very embarrassed.

    PMH: constipation, occasionally soils

    FHX: Older sister had bedwetting


    Case Study
    —  Physical Exam: vitals normal; neurological, spinal,
    abdominal and perineal examination normal

    —  Labs: Urinalysis normal


    Case Study
    —  Plan: Ask mom to complete a 3 day frequency and
    volume chart
    Case Study
    Frequency and volume chart
    Case study
    Findings:
    —  Fluid intake is 650-800 ml/day (greater in the evening than
    during the day)
    —  Functional bladder capacity is 100mL (lower than expected
    for age)
    —  He withholds voids for hours then experiences urgency

    Additional Studies
    —  Uroflowmetry: normal urine flow curve
    —  Bladder U/S: no residual urine after voiding
    Case Study
    Diagnosis: Primary non-monosymptomatic nocturnal
    enuresis
    Management
    —  Child needs to be motivated for any intervention to be
    successful

    —  Goal #1: Resolve/alleviate problem and limit impact on


    child’s self esteem and relationships

    —  Goal #2 (equally important):


    —  Allow family to understand enuresis is common and is
    usually a developmental problem, child has little to no
    control.
    —  Punishments only LOWER self-esteem and does improve sxs
    —  Effective treatments available, but will require their
    cooperation
    Nocturnal Enuresis Management
    —  Alarms
    —  Preferred method: high efficacy, low cost, low regression
    rate
    —  Children >7 years old
    —  Avg use at least 2-3 months, up to 6 months
    —  Requires significant cooperation from parent, especially
    during 1st week when child may not awaken to alarm
    —  50% of children who achieved dryness with alarm, remain
    accident free after therapy discontinued
    —  Video: http://www.youtube.com/watch?v=S-hGcEjpcJ8
    Nocturnal Enuresis Management
    —  Medications
    —  DDAVP
    —  Effective in 60% of children with monosymptomatic nocturnal
    enuresis
    —  Average of 1.3 dryer nights per week
    —  High relapse rate after medication discontinued
    —  Concerns for hyponatremia from excess water intake
    —  Oxybutynin
    —  Increase bladder capacity and decrease overactivity
    —  Uncontrolled studies show improvement in sxs
    —  Side effects: constipation, flushing, dizziness, increased temp,
    urinary retention after voiding
    —  Combination therapy: DDAVP and anticholinergic agent
    requires very close monitoring
    Nocturnal Enuresis Management
    —  Behavior therapy: studies are inconclusive
    —  Bladder relaxation exercises
    —  Rewards
    —  Fluid restriction before bedtime
    —  Scheduled waking
    Daytime Incontinence
    —  If child presents with daytime and nighttime
    incontinenceà treat daytime incontinence first

    —  Treat any underlying pathology, if no organic cause


    identified then:
    —  Timed voiding: voiding q2hr, easy access to restrooms
    —  Medications for diurnal enuresis rarely used:
    anticholinergics and alpha blockers
    Impact
    —  Self-esteem

    —  Interpersonal relationships

    —  Risk of physical abuse

    —  Impact on schooling


    Education
    —  Discourage punishment

    —  Not a sign of emotional, psychological or medical


    dysfunction

    —  Encourage child to take responsibility for dryness


    —  “double bubble technique”: plastic sheet over mattress
    followed by sheets/blankets, repeat X 2
    —  Dry set of pajamas at bedside
    —  Practice what to do after accident
    —  Helps decrease family tension
    Case Study
    Diagnosis: Primary non-monosymptomatic nocturnal enuresis

    Management

    1.  Remove blame/shame from child/family

    2.  Recommend collaborative approach between child, parents, teachers, doctor

    3.  Encourage voiding prior to bed

    4.  To reduce daytime urgency: aim for a daily fluid intake of 1.5 L (caffeine-free),
    drink at regular intervals throughout the whole day (slowing down in the
    evening), void at least 5–6 times per day instead of holding on.

    5.  Address constipation/soiling

    6.  Return in 3-4 weeks for f/u


    Case Study
    —  6 weeks later:
    —  Patient had increased functional bladder capacity, resolved
    constipation, resolved urinary urgency, but continues to
    wet the bed on most nights
    —  Diagnosis: Monosymptomatic nocturnal enuresis
    —  Plan: Recommended alarm. Return in 8 weeks.
    References
    —  Caldwell PH, Edgar D, Hodson E, Craig JC.
    Bedwetting and toileting problems in children.
    MJA Practice Essentials- Pediatrics, 2005; 182:
    190-195.
    —  Schmitt, B. D. "Nocturnal Enuresis." Pediatrics
    in Review 18.6 (1997): 183-91.
    —  Zuckerman, Barry S., Marilyn Augustyn, and
    Elizabeth B. Caronna. The Zuckerman Parker
    Handbook of Developmental and Behavioral
    Pediatrics for Primary Care. Philadelphia:
    Wolters Kluwer/Lippincott Williams & Wilkins
    Health, 2011. Print.
    Thank you!
    "

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