Bedwetting or Nocturnal enuresis in children, pathophysiology, definition, bladder diary and management / treatment. Bedwetting alarms, minirin and imipramine use.
Bedwetting or Nocturnal enuresis in children, pathophysiology, definition, bladder diary and management / treatment. Bedwetting alarms, minirin and imipramine use.
Bedwetting or Nocturnal enuresis in children, pathophysiology, definition, bladder diary and management / treatment. Bedwetting alarms, minirin and imipramine use.
Bedwetting or Nocturnal enuresis in children, pathophysiology, definition, bladder diary and management / treatment. Bedwetting alarms, minirin and imipramine use.
DR ANKIT MANGLA HEAD OF DEPARTMENT PEDIATRIC NEPHROLOGY & CONSULTANT PEDIATRIC INTENSIVIST HOPE HOSPITAL JAIPUR DEVELOPMENT OF URINARY CONTROL
As voluntary bladder control matures bladder capacity also
Increases and voiding frequency decreases
ORDER OF CONTROL • Control of bowel at night • Control of bowel during the day • Control of bladder during the day (by 2 ½ years) • Control of bladder at night (by 3-4 years) INCONTINENCE Uncontrolled leakage of urine at an inappropriate time and place after 5 years of age
CONTINUOUS INCONTINENCE INTERMITTENT INCONTINENCE
Always ORGANIC pathology
• Neurogenic Bladder • Vesico-vaginal fistula • Ectopic ureters • Bladder exostrophy DAY TIME Nocturnal Incontinence or INCONTINENCE ENURESIS
Neveus T et al. The standardization of terminology of lower urinary tract function in children and adolescents: report from the Standardisation Committee of the International Children's Continence Society. J Urol. 2006 ;176(1):314-24. SUBDIVISIONS OF ENURESIS
Primary Nocturnal enuresis is enuresis in a Secondary enuresis is enuresis in a child
child who has previously been dry for less who has previously been dry for at least 6 than 6 months months
Monosymptomatic enuresis is enuresis in a Non-monosymptomatic enuresis is enuresis in
child without any (other) a child with (other) lower urinary tract lower urinary tract symptoms symptoms, such as daytime incontinence, (80%) urgency, frequency, holding maneuvers (20%)
Neveus T et al. The standardization of terminology of lower urinary tract function in children and adolescents: report from the Standardisation Committee of the International Children's Continence Society. J Urol. 2006 ;176(1):314-24. MONOSYMPTOMATIC NOCTURNAL ENURESIS
Monosymptomatic nocturnal enuresis (MNE) is defined as bedwetting in a child in the absence
of daytime bladder symptoms:
Non-monosymptomatic nocturnal enuresis (NMNE) is present when one or more of the above daytime symptoms occurs with nocturnal symptoms • Urgency • Incontinence • Increased/decreased voiding frequency • Voiding postponement • Holding maneuvres • Interrupted flow OTHER SYMPTOMS : Holding maneuvers
• Standing on tip-toes • Forcefully crossing legs and bending forward at the waist (Vincent’s curtsy sign) • Squatting with hand/heel pressed into the perineum • Applying pressure to urethra with hands ENURESIS
Prevalence • 15% of 5 year olds • 7% of 8 year olds • 5% of 10 year olds • 2% of 15 year olds Fewer than 1/3rd of the parents of a bedwetting child consults a doctor. SEVERITY OF BEDWETTING VERSUS AGE ‘WAIT AND WATCH’ MAY LEAD TO UNNECESSARY DISTRESS
If untreated, bedwetting can persist into adulthood1
The negative impact of bedwetting on child and family
is considerable2
Effective treatment can alleviate this burden,
allowing the child to enjoy normal social and emotional development 2
Early treatment (from 5–6 years) can prevent prolonged distress during formative years and should be initiated whenever the child is ready/wishes to be dry, especially if enuresis is severe (spontaneous resolution unlikely)2
Increasing age is correlated with reduced self-esteem and negatively correlated with QoL score
1. Yeung et al. BJU Int 2006;97:1069–1073; 2. Gozmen et al. Pediatr Nephrol 2008;23:1293–1296; 3. Ertan et al. Child Care Health Dev 2009;35:469–474 CHILDREN WHO BEDWET HAVE POOR SLEEP AROUSAL
Children affected by bedwetting may have lighter and
poorer quality sleep than other children
These children have lighter sleep with frequent cortical
arousals, but inability to awaken completely
This may have implications for daytime functioning
It is important to treat bedwetting and restore sleep
patterns to normal
Nevéus T. Pediatr Nephrol 2008;23:1201–1202
Primary Nocturnal Enuresis - Impact Psychological well-being: Parental Concern: • Emotional impact on child. • Substantial feeling of shame, anger and • Effect on the child’s social inferiority relationships. • Is the child normal? • Dangerous impairment of self-esteem. • Removing the smell from the bedroom
• Inability to socialize - • Keeping it a secret
Outdoor activities • The extra washing
• Fear of public discovery- • Is the parent to blame?
haunts sufferers IS GENETICS TO BE BLAMED IN CHILDREN WITH PRIMARY MONOSYMPTOMATIC NOCTURNAL ENURESIS??
• A family history of bedwetting strongly predicts
bedwetting in children. – 73% of children affected by bedwetting had first degree relatives with a history of bedwetting1 – The age of attaining dryness was delayed by 1.5 years if both parents had a history of bedwetting 2 – Risk of bedwetting was 5–7 times higher if one parent had a history of bedwetting and 11.3 times higher if both had3 Chromosome 8,12,13 ENURI 1 gene --AD CAUSES OF NOCTURNAL ENURESIS
• Maturational delay • Food containing Diuretics- Cola, chocolate, • Genetics tea, coffee • Small bladder capacity • Urinary Tract Infection - May lead to • Nocturnal polyuria enuresis • Role of ADH • Sleep disordered breathing • Constipation Habitual snoring • ADHD Obstructive sleep apnea hypopnea syndrome
Reddy NM et al. Nocturnal Enuresis in India: Are We Diagnosing and Managing Correctly? Indian Journal of Nephrology. 2017; PRIMARY NOCTURNAL ENURESIS - CAUSES Reduced Vasopressin Production at night
• Enuretics do not show normal
nocturnal rise in plasma vasopressin • Urine production continues at the same rate at night. • Bladder reaches its functional capacity long before morning KEY PATHOGENIC MECHANISMS UNDERLYING MNE
Nocturnal Polyuria • Nocturnal urine production >130% of expected bladder capacity (EBC) for age (normally decreases to 50% of daytime) +/- Reduced or abnormal bladder reservoir function at night Inability to wake in response to bladder signalling
Kamperis P et al. Optimizing response to desmopressin in patients with monosymptomatic nocturnal enuresis. Pediatr Nephrol. 2016; 32(2):217-226 Bladder Function Problems • Functional bladder capacity (FBC) is vital for NE • Bladder capacity : {Age (in years) + 2} x 30 ml • In enuretics, night time BC is lower, but in non enuretics: 1.6 – 2 times larger than day time BC • There can be detrusor over activity in absence of LUTS • Constipation can cause detrusor over activity • UTI can cause detrusor over activity Evaluation & therapeutic options for Bed wetting Approach to NE
• Detailed history through questionnaire
• Interpretation of the answers • Examination of the child • Relevant Investigations for that child • Define broadly the type of NE • Tailored therapy for that child & family History & Charting in Children • Detailed questionnaire to rule out daytime voiding symptoms • Chart the frequency & volume of Fluid intake & voided urine. Voiding diary – non invasive representative record of child fluid intake, urine output, frequency of micturition, pattern of voiding • Charting must start and continue thru therapy • Largest single micturition volume is FBC(MVV) • Record wetness episodes during day & estimate overnight u/o • Childs involvement in charting a must • Ideal is a 2 day 3 night FVC record over a weekend BLADDER DIARY FORMAT Investigations USG Bladder measurements: Full bladder Max. length : LS Max. transverse: TS Max. Anteropost. : AP Bladder Volume Index: BVI = LS X TS X AP Empty bladder BVI
Percentage: BVImax – BVI empty
BVI max >90%: child judged to have emptied normally <90%: incomplete emptying Normal empty bladder thickness: up to 5 mm Normal distended bladder thickness: up to 3 mm History & Charting in Children
Reddy NM et al. Nocturnal Enuresis in India: Are We Diagnosing and Managing Correctly? Indian Journal of Nephrology. 2017; DOI: 10.4103/ijn.IJN_288_16 Symptoms in NE Pull up/plastic sheets • Differentiate Primary & secondary NE Clothes washed/diaper • How family handles wet nights Child punished Teasing by sibs
• Dry spell – congratulate the child, signifies no structural GU anomaly
• Sleep hours, morning tiredness(teacher), s/o obstructive sleep apnea • Tonsils & Adenoids a cause of OSA • Mouth breathing snoring, restless sleep – OSA • NE during afternoon nap too – s/o detrusor overactivity during sleep Rule out Urological Cause • Abnormal Storage Symptoms Increased frequency, urgency, urge incontinence Continuous dribbling between voids Stress incontinence • Abnormal Voiding Symptoms Voiding with poor stream Bladder and/or Straining to pass urine Interrupted flow of urine Urethral problems CONSERVATIVE MANAGEMENT
• Timed voiding – voiding every 3-4 hours (discourage holding)
• Voiding immediately upon rising in morning and before bed • Adequate hydration • Distribute fluid intake (40% morning, 40% afternoon, 20% evening) CONSERVATIVE MANAGEMENT
• Treat constipation • Proper positioning on the toilet seat • Encourage child to take time on toilet to empty completely • Encourage physical activity – discourage TV / Computer for long duration • Star charts : motivational therapy ALARM THEARPY ALARM THERAPY
• 60-70% Effective but labour extensive
• Moisture sensor and alarm which rings when child wets • Conditioning - teaches child to wake to a full bladder before wetting • May be used in combination with DDAPV and/or oxybutynin • 30-40% discontinue therapy NON PHARMACOLOGICAL MANAGEMENT OF ENURESIS Dry Bed training Waking the child on a schedule of decreasing intervals over several nights The child is made to change clothes and bedding (if wet), and walk to the toilet if voiding is required
Motivational Therapy Combination of providing reassurance, emotional support, eliminating guilt, and rewarding the child for dry nights Cleaning after bedwetting should not be performed as a punishment Avoidance of dairy products, fruits juices, and fluids 2 hours before bedtime, voiding just before bed Reddy NM et al. Nocturnal Enuresis in India: Are We Diagnosing and Managing Correctly? Indian Journal of Nephrology. 2017 Jain S, Bhatt GC. Advances in the management of primary monosymptomatic nocturnal enuresis in children. Paediatrics and International Child Health, 36:1, 7-14 PHARMACOLOGICAL THERAPY OF ENURESIS: ANTICHOLINERGICS • Oxybutinin and Tolterodine
• Primarily to treat children with daytime urgency or frequency as well as night-time
enuresis • Small capacity bladder when Neurogenic component is ruled out • Children with PMNE only where primary treatment has failed • Act mainly by suppressing detrusor over activity Side effects include flushing, blurred vision, constipation, tremor, decreased salivation and decreased ability to sweat WHO & NICE has now endorsed that Imipramine cannot be recommended for treatment of PNE
Jain S, Bhatt GC. Advances in the management of primary monosymptomatic nocturnal enuresis in children. Paediatrics and International Child Health, 36:1, 7-14 PHARMACOLOGICAL THERAPY OF ENURESIS: DESMOPRESSIN
• Pharmacologic therapies for nocturnal enuresis decrease the frequency of
enuresis and temporarily resolve symptoms until spontaneous resolution occurs
• The response rate to desmopressin therapy is 60%–70%, but relapse rates are high The NE indication has been withdrawn from the intranasal spray in most countries due to unpredictability of dosing and increased risk of hyponatremia
The combination of an enuresis alarm with desmopressin may be superior to the
use of an desmopressin alone
Reddy NM et al. Nocturnal Enuresis in India: Are We Diagnosing and Managing Correctly? Indian Journal of Nephrology. 2017; DOI: 10.4103/ijn.IJN_288_16 PATHOPHYSIOLOGY OF AVP IN ENURESIS
Children with Nocturnal Polyuria are most likely to benefit from
desmopressin since lower nocturnal vasopressin levels have been demonstrated in a large percentage of patients , making substitution with desmopressin, a rational first-line treatment for children with MNE and NP Overview of Different Treatment Modalities for Enuresis
Jain S, Bhatt GC. Advances in the management of primary monosymptomatic nocturnal enuresis in children. Paediatrics and International Child Health, 36:1, 7-14 MELT TABS Features Benefit 1 Dissolves instantly when placed under tongue Avoid water intake at bedtime 2 Dissolves instantly No taste or swallowing issues 3 Bioavailability 60% greater than tablet Equivalent to tablets at 40% lower dose 4 Can be taken with food. It has a longer and more predictable Can be taken immediately post action meals 5 Contains no lactose/starch Suitable for lactose intolerant MEDICATIONS FOR COMORBIDITIES
