Dr. Debasis Maity

Consultant Uro-Surgeon

Medical Discussion

Nocturnal Enuresis

(Defined as an involuntary discharge of urine that occur at night during sleep)

Bed wetting at night has become night mare to patients,to the parents of children and also to many physicians. But do not worry about this, most of the cases are benign condition and easy to manage these problems.

I am trying to discuss the causes,pathological changes of its and how to deal this condition by plotting some questions and answer, for your better understandings.


Q. A 7-year-old boy suddenly develops daytime urinary frequency every 20 minutes without incontinence. His symptom is limited to daytime only, and no enuresis was reported. Medicosurgical history,physical examination, urinalysis, and ultrasound of the kidneys and bladder are normal. What is the most appropriate management option?

Ans : The daytime urinary frequency syndrome is a benign condition, which occurs in normal children who have no associated daytime incontinence or nighttime symptoms. The etiology is generally unknown. Conservative approach is justified. Symptoms usually resolve in 2 to 4 months and are characteristically unaffected by anticholinergic drugs.


Q. Urinary overproduction in enuretic children would be due to what?

  • Abnormal circadian secretion of vasopressin( ADH).
  • Increased natriuretic factor secretion.
  • Increased dietary sodium.
  • Defect in renal aquaporin-2 receptors in the kidney.

Q. An 6-year-old boy wets his 2-3 times a week at night. He has no urinary symptoms during the daytime. What is the most likely cause of his nocturnal enuresis?

  • The more recent theories about nocturnal enuresis suggest there are 3 causes: overproduction of urine, smaller than expected bladder capacity for age, and difficulty in arousal from sleep.
  • Nocturnal enuresis has historically been thought to be due to maturational delay.
  • Anatomic abnormalities such as ureterocele may rarely be responsible for both diurnal and nocturnal wetting.

Q. What is the first event in the development of bowel and bladder control?

The usual sequence of development is-

  1. nocturnal bowel continence
  2. daytime bowel continence
  3. daytime bladder continence, and
  4. after several months, nocturnal control of bladder function.

Q. What percentage of nocturnal enuresis patients have a problem with arousal from sleep?

1/3rd cases.


Q. How many patients with nocturnal enuresis will demonstrate overactive bladder?

2/3rd.


Q. What percentage of nocturnal enuresis patients have a significantly smaller bladder than normal for their age?

20%.


Q. What percentage of children at age 5 are enuretic?

15% of normal children will still wet at night at 5 years of age.

Nocturnal enuresis occurring after the age of 5 or by the time the child enters grade school is generally considered a cause for concern.


Q. The mother of a 5-year-old boy who still wets his bed at night was concerned about the chance of recovery by the age of 15. What is the percentage of recovery you can tell this mother?

99%


Q. What is the spontaneous resolution rate for nocturnal enuresis without treatment?

15% per year.


Q. What percentage of patients with nocturnal enuresis have a positive family history for the same condition?

Between 50% and 75%.


Q. What is the most effective treatment for enuresis currently available?

The most effective therapy of treating enuresis is = conditioning therapy, as in the bell alarm (buzzer alarm) method. Superior results have been reported with this method compared to other forms of behavioral therapy, as well as pharmacologic therapy with DDAVP.

Imipramine is used as a second-line therapy.

Bladder training was developed to increase functional bladder capacity, but has not seen much success.

Another method of alternative behavior modification is responsibility reinforcement, such as reward and motivation. This also requires active and willing participation of the child to succeed.


Q. A 7-year-old boy has been taking imipramine (depsonil) for 3 months due to enuresis. What is the most potent pharmacologic effect of imipramine on the lower urinary tract?

3 major actions of imipramine in the urinary tract are antimuscarinic action, direct inhibition of bladder smooth muscle, and analgesic effect.

It also causes CNS sedation and blockade of norepinephrine reuptake.

The most important bladder action is the direct relaxant effect.

Imipramine significantly alters sleep patterns by decreasing the time spent in REM sleep and increasing the time spent in light NREM sleep.


Q. The only diagnosis that can be excluded in a 4-year-old boy with incontinence based on history alone is what?

Primary enuresis. The diagnosis of enuresis can only be made after 5 years of age.


Q. A 6-year-old girl has been suffering from marked urinary frequency and urgency for 2 weeks. Physical examination is normal, and her urinalysis and culture are normal. The next step should be?

Observation.

In most cases, spontaneous improvement is the rule.


Q. How well does imipramine work in the treatment of enuresis and how frequently is it used?

Imipramine, a tricyclic antidepressant, is the most widely used antienuretic agent worldwide, but it’s currently recommended only as a secondary agent.

Enuresis can be eliminated in more than 50% of children and will be improved in another 15% to 20%, however, up to 60% of patients will relapse upon discontinuation.

Its peripheral effects increase bladder capacity by

  • weak anticholinergic activity (ineffective in abolishing uninhibited detrusor contractions).
  • direct antispasmodic activity (not apparent at clinically effective antienuretic doses); and
  • complex effect on sympathetic input to the bladder (prevents norepinephrine action on alpha receptors and enhances its effect on beta receptors by inhibiting norepinephrine reuptake).

Q. A 20-year-old army recruit was referred to an Army hospital after his confession of enuresis. He had not been free of bed-wetting throughout his life. What advise can you give him regarding diet to help minimize his problem?

This patient has primary enuresis. Enuresis is found in more than 1% of the adult population, often with overt abnormalities on urodynamic studies such as uninhibited bladder activity.

Cessation of compounds that might increase nocturnal urine output, such as caffeine, should be strongly advised before recommending other forms of treatment.


Q. True or False: Nocturnal enuresis is generally considered a sleep disorder.

False.

Recent studies indicate that enuretic sleep patterns are not different form the sleep patterns of normal children, and that most enuretics do not wet as a consequence of sleeping too deeply.


Q. what is the formula used to estimate pediatric bladder capacity?

The most widely accepted formula for the predicted bladder capacity in children is:

Bladder capacity (mL) = [age (years) + 2] × 30.


Q. A 6-year-old boy with enuresis, frequency and urgency, uninhibited detrusor contractions, and decreased functional capacity had been taking various remedies for his enuresis. After a thorough evaluation of his condition, the physician recommended anticholinergics. For which of his conditions has anticholinergictherapy proven most effective?

Anticholinergic medication in this setting will have greatest impact on uninhibited bladder contractions but will probably not help his nocturnal enuresis very much.


Q. A 6-year-old boy had been taking various remedies for his enuresis. He has evidence of bladder hyperactivity,frequency and urgency, detrusor instability, day and night incontinence, as well as pure nocturnal enuresis. For which of his conditions has anticholinergic therapy been proven most ineffective?

Pure nocturnal enuresis.

Anticholinergic drug therapy has only been effective for enuresis in just 5% to 40%.


Q. Is limiting fluid intake before bedtime a reasonable first step in controlling enuresis?

Simply limiting fluids to reduce urine output is not generally effective.

Measurements of urinary and serum ADH demonstrate an absence or reversal of the normal circadian rhythm in enuretics who have lower than normal excretion of nocturnal ADH.

Desmopressin (DDAVP), a synthetic analog of ADH, effect lasting 7 to 10 hours.

DDAVP has effective rate up to 60%, especially in older children.

Patients on DDAVP are 4.5 times as likely to stay dry overnight as controls.

Limitations: high cost of the drug and the potential for recurrence upon discontinuation.


Q. A 6-year-old girl is being evaluated for both nocturnal and diurnal enuresis. Workup with history and physical examination, neurologic examination, urinalysis, and urine culture are normal. What is the next appropriate step?

Ultrasound examination of the kidneys,ureters and bladder before and after voiding.


Q. A 7-year-old girl with urgency and diurnal incontinence wets her bed about 3 times a week. Workup with history and physical examination, neurologic examination, urinalysis and urine culture are normal.

Radiographic imaging studies including abdominal ultrasonogram and voiding cystourethrogram are negative. What is the primary treatment?

Diurnal enuresis occurs in 5% of 7-year-old children.

In most children, the underlying problem is = infrequent voiding.

Timed voiding programs alone will be successful in the majority of children but require several months to be effective.

Anticholinergics such as oxybutynin can be tried along with timed voiding.


Q. A 6-year-old girl with diurnal enuresis also has severe constipation and fecal soiling. However, radiographic studies of her spine and neurologic examination are normal as well as urinalysis and no residual urine is noted. What is the most appropriate treatment?

This girl presents typical findings of 'dysfunctional elimination syndrome'.

Large fecal impaction may induce significant detrusor instability and other bladder dysfunctions, which in turn will result in urgency, UTI and reflux.

A high incidence of enuresis in children with UTIs and constipation has been reported.

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Timed voiding along with treatment of constipation can improve not only fecal soiling but also diurnal enuresis.

Anticholinergics in this condition are not recommended as they are likely to aggravate constipation and may causeurinary tract infections.


Q. A 4-year-old girl who is toilet-trained complains of urinary incontinence. She says her underwear become sweat right after she finishes voiding. What is the most likely diagnosis?

The most likely diagnosis is vesicovaginal reflux.

This best describes postvoid dribbling, which is typically when urine gets trapped in the vagina during voiding and dribbles out soon after standing.

Vesicovaginal reflux itself is harmless and tends to resolve with age but it can create a damp environment prone to infection.

Therefore, the child may be taught to empty her vagina by simply voiding with her thighs apart and leaning forward after voiding before getting up.


Q. What percentage of secondary nocturnal enuresis is due to psychological factors and what specific disorder is involved most often?

50%. Anxiety-provoking factors predominate.


Q. What percentage of children with attention deficit hyperactivity disorder (ADHD) also have nocturnal enuresis and is it reasonable that they would occur together?

20% of ADHD cases also have enuresis.

Both problems are believed to involve the same brain stem area abnormality so it's likely they would occur together.


Q. What percentage of ADHD children with nocturnal enuresis will have urodynamic evidence of overactive bladder dysfunction?

Approx 50%.


Q. Overactive bladder associated with nocturnal enuresis responds best to which therapy?

Buzzer alarm behavioral therapy works best, except in children who also have ADHD.

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