Nocturnal Enuresis

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Nocturnal Enuresis

• Dr Adnan Masood

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What is it?

• Enuresis- involuntary discharge of urine by day
  or night in a child aged five or over, in the
  absence of congenital or acquired defects of the
  nervous system or urinary tract
• Primary NE- when bladder control never achieved
• Secondary NE Bladder control achieved for six
  months and lost

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Causes

• Genetic
• Stressful life events
• Diuretic drinks
• Constipation
• UTi
• Organic pathology- rare, consider if daytime
  wetting

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How common?

• 15 - 5 year olds
• 5 - 10 year olds
• 2 - 15 year olds
• 1 - Adults
• Twice as common in boys
• Less than half patients consult doctor

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Making a diagnosis

• History
• Examination- Normal in Nocturnal enuresis
• Ix minimum urine dipstick culture
• If Hx suggests Consider USS Kidneys and urinary
  tract or direct referral.
• Consider organic diagnosis
• UTI/acute illness
• Chronic constipation
• DM/renal failure
• Congenital abnormality PUV
• Neurological disorders

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Complications and prognosis

• Prognosis- Spontaneous remission 15 per year
• Relapse rate- after all forms of treatment 10-20
• Complications
• Child Older child more disabling and distressing

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Treatment(1)

• Various modalities/settings Providing
  information and Reassurance is key in Primary
  care
• Enuresis resource and information centre
  (www.eric.org.uk) Info and equipment
• Consider referral to local enuresis
  clinic/adviser
• Refer to appropriate hospital specialist if
  organic cause suspected

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Treatment(2)

• BMJ Nov 2001 (Evidence based management of
  enuresis) Good R/V
• Prodigy Guidelines (www.prodigy.nhs.uk)
• Detailed guidelines.
• Two main treatment types
• Alarms, dry bed training and star charts
• Drug treatment

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Alarms, Dry bed training and star charts

• Children given alarms 13 times more likely to
  become dry(95 CI 5.6-31)
• Dry bed training involves waking up child to go
  to toilet at shorter intervals progressively
  until waking him/herself. As effective with alarm
  as alarm alone.
• Little evidence on Star Charts

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Drugs

• Desmopressin- 4.5 times more likely to become
  dry. After treatment stopped mean No of wet
  nights is no different to Placebo group
• TCA- Imipramine 4.2 times more likely to stay dry
  cf Placebo. No reliable data on stopping
  treatment
• Imipramine versus Desmopressin- One RCT 36
  children Effects of two drugs did not differ
  significantly during treatment or follow up.

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Combination Therapy

• One trial (Acta Padiatrica 1997) involving 76
  children showed 76 with Desmopressin and alarm
  became dry cf 46 using alarm alone. Relapse rate
  similar 15 and 19

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Conclusion

• Patients with primary NE no daytime wetting no
  apparent psychological problems and supportive
  parents have a good prognosis with either alarm
  or desmopressin or combination of the two.
• Any alarm features in the history should prompt
  Ix and appropriate referral
• Reassurance and information needs to be provided.