Nocturnal enuresis

NOCTURNAL ENURESIS

1. Nocturnal Enuresis
Dr.TALAL BALLOUT
UROLOGIST

2. Agenda
Definitions
Pathophysiology
Treatments

3. Definitions (1)
Enuresis(bedwetting), is defined as
involuntary voiding; when it occurs at night it is
termed
Nocturnalenuresis,
and daytime incontinence is termed
diurnal enuresis. Because urinary
incontinence occurs normally in infants and
young children, its significance depends on the
age of the
Only children who are at least fiveyears of age.

4. Definitions (2)
Monosymptomatic. enuresis. Most of these
children have isolated nocturnal enuresis
Non-monosymptomatiCenuresis
is in the presence of increased or decreased voiding frequency, day-time
incontinence
dysfunctional voiding( Day/night wetting )
dysfunctional elimination ( Encopresis )
Nocturiais defined as waking up at night to void.
-Relevant from five years of age.
,

5. M Nocturnal Enuresis
(MNE)
Involuntary voiding of urine during
sleep of > 3 times a weekin healthy
children above 5 years of age
a)Primary NE
-never been dry for a period of at
least 6 months
b)Secondary NE
-previously consistently dry for at
least 6 months

6. Primary Nocturnal Enuresis
Common Problem
15 % by 5 years
5 % by 10 years
1 % by 15 years
Boys by night & girls by day
2 to 1
Enuresis is both a symptom and a condition.
Good prognosis
15 %per year spontaneously resolve

7. Incidence of NE0
10
20
30
40
50
60
70
80
90
100
123456789101112
Boys
Girls
Age in years

8. Disrupted sleep
Laundry fatigueSocial stigma

9. CAUSES
Maturational delay
Geneticsfctors
Small bladder capacity
ADH secretion
Sleep/Arousal Disorder

10. Maturational delay
—In almost all cases,
M nocturnal enuresis resolves spontaneously.
-This observation suggests that delayed maturationof a
normal developmental process plays a role
Some studies have demonstrated an increased incidence of
delayed language and gross motor development among
children with enuresis The hypothesis that there is a
difference in the C.M.Smaturation in children with
ENURESIS compared to controls is supported by
neurophysiologic data

11. a locus on chromosome 13q13-q14.3
Genetics fctors

12. ADH secretion
Normal childrenhave a diurnal rhythm of plasma
vasopressin and urinary output with a nocturnalincreasein
ADHdecreasein urinary excretion rate, and increasein urine
osmolarity
Enureticshave an abnormal rhythmof plasma vasopressin
and urinary output with nocturnal low vasopressin, large
urinary excretion rate, and lower urinary osmolarity
The relationship between ADH secretion and nighttime
urinary flow rates remains controversial.
abnormalities in ADH secretion
appear to play a role in at least some patientswith nocturnal
enuresis.

14. Sleep/Arousal Disorder
Enuretic children are heaviersleepers compared with non-
enuretics
Sleep pattern of the enuretics is similarto that of normal
children
Enuresis occurs in all sleep stages
Enuretic episodes are associated with characteristic
urodynamic and (EEG) findings. that suggest increased
C.N.Srecognition of bladder fullness and the ultimate ability
to suppress the onset of bladder contraction].

15. Sleep/Arousal Disorder

16. Small bladder capacity
At birth, bladder volume is approximately 60 mL; it increases with age at a
relatively steady rate of approximately 30 mL per year
Children with nocturnal enuresis, have been noted to have a smaller bladder
capacitythan age-matched children who do not have nocturnal enuresis
The reduced bladder capacity appears to be functionalrather than
anatomical
with enuresis, the maximal voided volume during the night was
significantly smaller than the maximal daytime bladder capacity, suggesting
that inability to hold urine during sleep plays a role in
nocturnal enuresis

17. Balance between Bladder
capacity and Nocturnal urine vol

18. EVALUATION
history
physical examination
INVESTIGATIONS

19. HISTORY
Drinking habits
Bowel habits
Previous treatment
Motivation for
treatment
Establish NE
Primary or
secondary?
Family history
Any incontinence?
Any UTI?

20. INVESTIGATIONS
Urinalysis/ specific gravity
Urine culture
Imaging studies NOT INDICATED
unless present of:
DVS
UTI
Incontinence
Abnormal neurological signs

21. TREATMENT OF NE
General measures
-restrict fluid 3-4 hours before
bedtime
-empty bladder before retiring to bed
-encourage child to make bedtime
resolution
-keep a chart of wet and dry nights
-reward for dry nights
-Avoid punishment/criticism

22. TREATMENT OF NE
Non-pharmacological
-Reassurance and counselling
-Bladder training programme
-Enuresis alarm

23. Pharmacological
-Desmopressin
-Oxybutynin
-Imipramine
TREATMENT OF NE

24. Pharmacological treatment
Imipramine-rarely used now in children
Used in children over 6-can TX for 3-6 mo
effective in 10-50% (author 24%)
60%relapse
Side effects-, toxicity, sleep and appetitedry
mouth
Desmopressin-DDAVP
Synthetic analog of antidiuretic hormone
vasopressin
Dose-1 spray in each nostril-up to 2 each(tabs
also)
Rapid response 1-2 weeks
50%-90% relapse after D/C
Side effects-HA, congestion, water intoxication
Oxybutyninein patients proven to have DI

25. Evidence Based Medicine
Conclusion
Enuresis alarms are the most
effectivetreatment for primary
nocturnal enuresis with lasting
effects.
Drug treatment can be useful for
short termrelief of symptoms but
consider potential adverse effects

26. Conclusions
Nocturnal enuresis has a
multifactorial etiology
A 15% annual spontaneous cure rate
Treatment should match to etiologies
Balance between bladder functional
capacity and nocturnal urine output
appear to be the most important

27. THANK YOU