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Enuresis, Pediatric

Basics

Description

- Daytime incontinence and enuresis, day and night - As above. More concerning for underlying urologic and neurologic disorder - Urinary reflux into vagina with seepage after conclusion of voiding - Insertion of ureter into urethra or vagina - Stress incontinence with increased abdominal pressure (laughing, coughing, increased intravesicular pressure)

- Pattern of urination - Constantly wet pants (dribbling) - Frequent small amounts of urine - Presence of weak urinary stream - Dysuria - Frequency - Hesitancy - Urine holding maneuvers (e.g., pressing the heel into perineum) - Nocturia

- Family history - Social history - For whom does this pose problem-parent or child? - Effect on child - Ability to sleep away from home without embarrassment - Teasing at school - Emotional effects

- Urinalysis - Specific gravity (first morning void) - Glucose - Protein - Blood

- If the problem is affecting only the parents and child is not affected, the treatment should be education and support for the parents. - Avoid all negative interventions. - Minimize fluid intake during evening. - Encourage child to void regularly during the day and immediately prior to retiring to bed. - Alarm therapy - Most effective in motivated patient and family - Improves arousal and nocturnal bladder function as a reservoir through conditioning - Use nightly for at least 2-3 months until 14 consecutive dry nights are achieved. - "Overlearning"пїЅ (after dryness is achieved, have child drink modest amount of water 1 hour before bedtime) reduces risk of relapse if dryness is maintained for 1 month on this regimen. - High relapse rate; 2nd remission very frequent with reintroduction of alarm system; 2nd relapse rare

- Caution against excessive fluid intake - Can be used intermittently or continuously - Drug holidays are advised to assess for resolution of symptoms.

- Anticholinergics (e.g., oxybutynin) - Often used in combination with DDAVP - Usual dose: 5 mg given at bedtime - Exclude postvoid residual bladder volume. - Adverse effects: constipation, decreases saliva (hence, stress proper dental hygiene), hallucinations/agitation

- Imipramine - Tricyclic antidepressant - 80% effective - No longer 1st- or 2nd-line choice for benign condition because of risk of QTc prolongation and controversial risk of sudden cardiac death and risk of ingestion by siblings.

- Hypnotism - Appears to work by increasing subconscious awareness of bladder pressure during sleep, allowing increased awareness during sleep of intravesicular pressure

- Emotional - Embarrassment - Poor self-esteem - Reluctance to sleep out with peers or nonimmediate family - Depression

  • Involuntary, urinary incontinence after age of expected bladder control; term generally reserved for children ≥5 years of age. May bePrimary: has never been dry for 6 months (80%)Secondary: patient previously dry for 6 months or longer
  • Classified asMonosymptomatic nocturnal enuresis (MNE)Nonmonosymptomatic nocturnal enuresis (NMNE) if there is evidence of lower urinary tract malfunction (e.g., delayed voiding, frequency, urgency, holding maneuvers)

Epidemiology

  • Male > female (3:1)
  • Prevalence of 10-15% in children at age 5 years, 7-15% at 7 years, 5% at 10 years, and 0.5-1% in teenagers and adults.

Genetics

  • 60-70% have a positive family history of enuresis.
  • Risk of severe enuresis is greater with maternal enuresis history compared with paternal history (odds ratio 3.6 vs. 1.8).
  • Risk is twice as high in monozygotic compared with dizygotic twins.
  • Autosomal dominant pattern seen in 50%, whereas 30% of cases are sporadic.
  • Several loci on chromosomes 13q, 12q, and 22q associated with a nocturnal enuresis phenotype, but no candidate genes have been identified.

Risk Factors

  • Constipation
  • Lower urinary tract dysfunction
  • Sleep disorders
  • Neuropsychiatric disorders

Etiology

  • Primary nocturnal enuresis: the interplay of one or more of the following:Nocturnal polyuriaDecreased functional bladder volumeIncreased arousal threshold when asleep
  • Daytime incontinence and enuresis, day and nightAs above. More concerning for underlying urologic and neurologic disorderUrinary reflux into vagina with seepage after conclusion of voidingInsertion of ureter into urethra or vaginaStress incontinence with increased abdominal pressure (laughing, coughing, increased intravesicular pressure)
  • Secondary enuresisAny condition causing polyuriaUrinary tract infection (UTI)EncopresisEmotional stress or trauma including physical and sexual abuse, parental divorce, depression, new sibling, household moving, new school

Commonly Associated Conditions

Neuropsychiatric comorbidities: ADHD, anxiety, and oppositional behavior are more commonly associated with secondary nocturnal enuresis. пїЅ

Diagnosis

History

  • OnsetNocturnal versus diurnalDry period (even if only weeks)Concomitant recent onset of polydipsia (sometimes accompanied by candidal infection) suggests new-onset diabetes.FrequencyA frequency-volume chart provides information on daily fluid intake and volumes and timing of voids; identifies subtle lower urinary tract symptoms and can aid in treatment approachPattern of urinationConstantly wet pants (dribbling)Frequent small amounts of urinePresence of weak urinary streamDysuriaFrequencyHesitancyUrine holding maneuvers (e.g., pressing the heel into perineum)Nocturia
  • Past medical historyObstipation/constipation/fecal incontinence (encopresis)History of UTIBehavioral/developmental historyToilet training historyMedicationsNeurologic symptomsOther medical problems
  • Family history
  • Social historyFor whom does this pose problem-parent or child?Effect on childAbility to sleep away from home without embarrassmentTeasing at schoolEmotional effects
  • Social changesDivorceNew significant other for parentNew siblingHousehold moveNew school

Physical Exam

  • Vital signs
  • Growth parameters and pattern
  • Neurologic examGait, tone, sensory, motor, deep tendon reflexes, cremasteric reflex
  • Funduscopy: to rule out raised intracranial pressure
  • Abdominal exam: to rule out masses, especially renal mass, fecal impaction, bladder distention
  • Genitalia: rule out adhesions, vulvovaginitis, balanitis, stenosis, foreign bodies
  • Urinary stream
  • Rectal exam: tone, perianal sensation, anal wink
  • Spine: bony defects, cutaneous signs of underlying spinal defects

Diagnostic Tests & Interpretation

Lab

  • UrinalysisSpecific gravity (first morning void)GlucoseProteinBlood
  • Urine culture: usually not necessary if no symptoms are present

Imaging

  • Rarely necessary in primary enuresis
  • Perform if suggestion of anatomic or functional abnormality of genitourinary tract
  • Ultrasound least invasive modality
  • Renal/bladder ultrasound with pre/post void bladder images to assess residual urine volume and look at bladder contour
  • Noninvasive uroflow with pelvic floor electromyography-done by pediatric urologists

Alert

Laboratory evaluation rarely yields a specific diagnosis. Balance risks and costs with unlikelihood of yield. Evaluation should generally not involve more than urinalysis. пїЅ

Differential Diagnosis

  • UTI/urethritis
  • Obstipation/constipation
  • Water intoxication
  • Type 1 or type 2 diabetes
  • Diabetes insipidus
  • Sickle cell disease or trait
  • Nephritis/nephrosis
  • Anatomic abnormalities of the urinary tract
  • Sleep disorders
  • Depression
  • Anxiety
  • Behavioral disorders
  • Medications (sedatives, soporifics, antihistamines, diuretics, caffeine, methylxanthines)
  • Spinal cord diseaseCognitive disordersSeizure disorders
  • Legitimate safety issues in going to bathroom alone
  • Substandard living conditions (cold bathrooms, poor facilities)

Treatment

General Measures

  • If the problem is affecting only the parents and child is not affected, the treatment should be education and support for the parents.
  • Avoid all negative interventions.
  • Minimize fluid intake during evening.
  • Encourage child to void regularly during the day and immediately prior to retiring to bed.
  • Alarm therapyMost effective in motivated patient and familyImproves arousal and nocturnal bladder function as a reservoir through conditioningUse nightly for at least 2-3 months until 14 consecutive dry nights are achieved."Overlearning"пїЅ (after dryness is achieved, have child drink modest amount of water 1 hour before bedtime) reduces risk of relapse if dryness is maintained for 1 month on this regimen.High relapse rate; 2nd remission very frequent with reintroduction of alarm system; 2nd relapse rare

Medication

  • Avoid medication use before age 6-8 years.
  • Desmopressin (DDAVP)Dose not based on age or weight.Standard dose 0.2-0.4 mg PO given 1 hour before bedtimeUse oral formulation only (nasal formulation is associated with increased risk of hyponatremia and seizures).Caution against excessive fluid intakeCan be used intermittently or continuouslyDrug holidays are advised to assess for resolution of symptoms.
  • Anticholinergics (e.g., oxybutynin)Often used in combination with DDAVPUsual dose: 5 mg given at bedtimeExclude postvoid residual bladder volume.Adverse effects: constipation, decreases saliva (hence, stress proper dental hygiene), hallucinations/agitation
  • ImipramineTricyclic antidepressant80% effectiveNo longer 1st- or 2nd-line choice for benign condition because of risk of QTc prolongation and controversial risk of sudden cardiac death and risk of ingestion by siblings.

Additional Treatment

  • Urotherapy: aims towards normalizing bladder emptying and storage by teaching relaxed voiding techniques (e.g., biofeedback programs)
  • Cognitive behavioral interventionsFormal programs developed and used by pediatric psychologists: high rate of success; involve "overcorrection techniques"пїЅ-frequent practice and rewards for voiding procedures along with enuresis alarmPositive reinforcement for dry nightsUse of praise, stickers, token economies
  • HypnotismAppears to work by increasing subconscious awareness of bladder pressure during sleep, allowing increased awareness during sleep of intravesicular pressure

Inpatient Considerations

Initial Stabilization

  • Specific therapy to address specific anatomic, infectious, or functional genitourinary problems
  • Address constipation and lower urinary tract dysfunction, as both may lead to treatment failure, whereas addressing these problems may result in spontaneous enuresis resolution.

Alert

Decision to treat is a balance of the effect on the child of nontreatment (social, emotional) with the potential side effects of medication. пїЅ

Ongoing Care

Prognosis

  • 99% of cases resolve without treatment.
  • Spontaneous resolution is ~15% per year after age 5 years.

Complications

  • PhysicalVulvovaginitisDiaper dermatitis
  • EmotionalEmbarrassmentPoor self-esteemReluctance to sleep out with peers or nonimmediate familyDepression

Additional Reading

  • Franco пїЅI, von Gontard пїЅA, De Gennaro пїЅM, International Children's Continence Society. Evaluation and treatment of nonmonosymptomatic nocturnal enuresis: a standardization document from the International Children's Continence Society. J Pediatr Urol. 2013;9(2):234-243. пїЅ[View Abstract]
  • Maternik пїЅM, Krzeminska пїЅK, Zurowska пїЅA. The management of childhood urinary incontinence. Pediatr Nephrol. 2015;30(1):41-50.
  • Neveus пїЅT, Eggert пїЅP, Evans пїЅJ, International Children's Continence Society. Evaluation of and treatment for monosymptomatic enuresis: a standardization document from the International Children's Continence Society. J Urol. 2010;183(2):441-447. пїЅ[View Abstract]
  • von Gontard пїЅA, Heron пїЅJ, Joinson пїЅC. Family history of nocturnal enuresis and urinary incontinence: results from a large epidemiological study. J Urol. 2011;185(6):2303-2306.
  • International Children's Continence Society: www.i-c-c-s.org

Codes

ICD09

  • 788.30 Urinary incontinence, unspecified
  • 788.36 Nocturnal enuresis
  • 307.6 Enuresis
  • 788.30 Urinary incontinence, unspecified

ICD10

  • R32 Unspecified urinary incontinence
  • N39.44 Nocturnal enuresis

SNOMED

  • 8009008 Nocturnal enuresis (disorder)
  • 450845009 primary nocturnal enuresis (finding)
  • 450846005 secondary nocturnal enuresis (finding)

FAQ

  • Q: Do the medications cure the enuresis?
  • A: None of the medications cure the problem. DDAVP increases reabsorption of water in the kidney, resulting in decreased bladder volumes. Tricyclic antidepressants cause urinary retention by the noradrenergic effects on bladder contraction and detrusor relaxation. Oxybutynin decreases detrusor irritability, resulting in larger bladder capacity before emptying. The medications result in nonemptying of the bladder during sleep but do not affect the underlying cause. Any resolution that occurs after cessation of medication treatment is probably from the natural resolution of the problem with age.
  • Q: Isn't it important to treat the enuresis when the parents bring it up as a problem?
  • A: Developmental resolution of nocturnal enuresis occurs at a range of ages, and in almost all cases, the enuresis resolves spontaneously. It is important to elicit for whom the enuresis is a problem. If the child is not affected by the enuresis, and it is only the parents who desire a cure, the important intervention is to educate them on the natural history of the problem and to let them know about the available interventions and their success rates for when the child desires a cure.
  • Q: Are there any other interventions available for use only on sleep-out nights?
  • A: One helpful tip is to allow the child to take a sleeping bag with him or her on sleep-outs. Place a pull-up inside the sleeping bag. When the child gets into the sleeping bag, he or she can change into the pull-up without anyone knowing. In the morning, the child puts his or her underwear back on, leaving the damp pull-up in the sleeping bag; the parent can take it out when the child gets home.