Nocturnal Enuresis

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Nocturnal Enuresis
Dr. IBRAHIM DAHER DEP. OF UROLOGY MILITARY
HOSPITAL HOMS
23- 8-07
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Agenda

• Definitions
• Pathophysiology
• Treatments

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Definitions (1)

• Enuresis (bedwetting), is defined as involuntary
  voiding when it occurs at night it is termed
• Nocturnal enuresis,
• 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 five years of age.

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Definitions (2)

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

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M Nocturnal Enuresis (MNE)

• Involuntary voiding of urine during sleep of gt 3
  times a week in healthy children above 5 years of
  age
• Primary NE
• - never been dry for a period of at least 6
  months
• Secondary NE
• - previously consistently dry for at least 6
  months

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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

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Incidence of NE
Percentage with NE
Age in years
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Laundry fatigue
Social stigma
Disrupted sleep
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CAUSES

• Maturational delay
• Genetics fctors
• Small bladder capacity
• ADH secretion
• Sleep/Arousal Disorder

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Maturational delay

• In almost all cases,
• M nocturnal enuresis resolves spontaneously.
• - This observation suggests that delayed
  maturation of 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

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

• Normal children have a diurnal rhythm of plasma
  vasopressin and urinary output with a nocturnal
  increase in ADH decrease in urinary excretion
  rate, and increase in urine osmolarity
• Enuretics have an abnormal rhythm of 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 patients
  with nocturnal enuresis.

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Sleep/Arousal Disorder

• Enuretic children are heavier sleepers compared
  with non-enuretics
• Sleep pattern of the enuretics is similar to 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.S recognition of
  bladder fullness and the ultimate ability to
  suppress the onset of bladder contraction.

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Sleep/Arousal Disorder
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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 capacity than
  age-matched children who do not have nocturnal
  enuresis
• The reduced bladder capacity appears to be
  functional rather 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

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Balance between Bladder capacity and Nocturnal
urine vol
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EVALUATION

• history
• physical examination
• INVESTIGATIONS

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HISTORY

• Drinking habits
• Bowel habits
• Previous treatment
• Motivation for treatment

• Establish NE
• Primary or secondary?
• Family history
• Any incontinence?
• Any UTI?

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INVESTIGATIONS

• Urinalysis/ specific gravity
• Urine culture
• Imaging studies NOT INDICATED unless present of
• DVS
• UTI
• Incontinence
• Abnormal neurological signs

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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

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TREATMENT OF NE

• Non-pharmacological
• - Reassurance and counselling
• - Bladder training programme
• - Enuresis alarm

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TREATMENT OF NE

• Pharmacological
• - Desmopressin
• - Oxybutynin
• - Imipramine

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• 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)
• 60relapse
• Side effects-, toxicity, sleep and appetite dry
  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
  Oxybutynine in patients proven to have DI

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Evidence Based MedicineConclusion

• Enuresis alarms are the most effective treatment
  for primary nocturnal enuresis with lasting
  effects.
• Drug treatment can be useful for short term
  relief of symptoms but consider potential adverse
  effects

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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

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THANK
YOU