Enuresis, Non Medical Treatment Dr Hajebrahimi Professor of urology Department

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Children with PNE have never experienced a dry period No

pathophysiology – bladder function This slide illustrates the potential outcomes of overproduction of urine and reduced bladder capacity: If arousal occurs the patient will experience nocturia If arousal does not occur the patients will experience enuresis

Diurnal Variation in Plasma Vasopressin pathophysiology – urine production Diurnal Variation in Plasma Vasopressin (p-AVP) This slide (Rittig et al. 1989) illustrates the diurnal variation in plasma vasopressin secretion between nocturnal enuretics and normal children. Enuretic children have much lower levels of plasma vasopressin between 22:00 hrs and 06:00 hrs than normal children; whose vasopressin secretion increases at night. J.P. Nørgaard et al. 1985 S. Rittig et al. 1989

Urine production rate Urine osmolality pathophysiology – urine production Urine production rate Urine osmolality This slide illustrates the findings of Rittig et al. (1989). This controlled study compared the rate of urine production and urine osmolality in enuretic and normal children. Normal children demonstrated a greater decrease in urine production from day to night which often resulted in a significant increase in urine osmolality. Enuretic children did not display significant changes in urine production or urine osmolality between day and night. S. Rittig et al. 1989

Enuresis: terminology Nocturnal enuresis: bedwetting in a child over 5 years (or equiv. developmentally) Diurnal enuresis: wetting during the day in children 5 years and over Primary enuresis: where a child has never been dry longer than 6/12 months Secondary enuresis: children who have been dry longer than 6/12 months & begin wetting again

Incidence : Age in years 3 4 5 6 7 8 9 14 % who wet the bed 20 15 12 (15-20) 12 8 (7) 6 5 4 (15 yr 1-2%)

Incidence : More boys wet beds than girls Seek help at ages 5 – 7 years

Prevalence and prognosis 10% of 5-year olds 5% of 10-year olds ‘Cure’ rate without treatment occurs in approximately 15% per year of those still wet during that year Treatment with an enuresis alarm will cure approximately 75% if used properly. Drugs are nowhere near as effective in producing long-term cure

pathophysiology – genetics

Normal development Infants: urinate often, small amounts, reflex 1-2 years: child notices full bladder, void less often, larger amounts Age 3: child holds for longer periods, can get to toilet Preschooler often cannot empty bladder unless it is full (eg can’t go before a car trip on request)

Theories of bedwetting Deep sleep Problems with ADH secretion Decreased bladder capacity Immature bladder control Emotional disturbance

Known facts Enuresis runs in families It is more common in boys It is more common in disadvantaged families Emotional disturbance can contribute Physical causes are rare but important

Causes of enuresis : Often a family history of bed-wetting: genetic Developmental delay Emotional stresses may lead to secondary enuresis (but rarely severe emotional problems) Medical reasons occasionally (eg urinary tract infection, epileptic seizures, central nervous system or bladder)

Causes of enuresis (continued): High production of urine at night, associated with insufficient arginine vasopressin (avp) release at night (Wetting soon after going to bed, large wet patches) Small functional bladder capacity (fbc) associated with bladder overactivity. (Nighttime: multiple bedtime wettings, small wet patches) Possibly a difficulty with arousal from sleep when bladder reaches its maximum capacity

General assessment Family information and history Can child: Stay dry during the day Tell when they need to go Able to dress/undress Sit on toilet Hold on Empty bladder completely

Assessment (and clinical interview) Need medical review to exclude bladder infections, constipation, renal problems Monitor nighttime wetting (frequency, timing, amount, etc) Measure functional bladder capacity if seems indicated

General assessment What is the attitude of the parents? What is the attitude of the child? What have they tried? Other symptoms

Medical assessment Urinary symptoms e.g. polyuria, dysuria, UTI? ,stone and Urinary tract anomalies Soiling / constipation / Encopresis Examination including neurology: Have they had a dry night? Dribbling? Always wet?

Social assessment Sharing a room Bunk beds Access to toilet Family position

Role of Psychologist Educational, simple strategies Refer to specialist or clinic

Assessment (and clinical interview) Measure functional bladder capacity if seems indicated Need medical review to exclude bladder infections, constipation, renal problems Monitor nighttime wetting (frequency, timing, amount, etc)

These may be enough in up to 20% of cases Management Explanation and education about enuresis Institute record keeping for at least 2 weeks and preferably for 4 weeks These may be enough in up to 20% of cases

Use it as national monument

This slide presents the key question highlighting the cause of enuresis.

Forms of treatment Encouragement and reinforcement Keep a record of wet and dry beds Reward (small and as soon as possible after the dry bed) Not suitable for a child who invariably wets: too difficult and demoralising Toilet routine: practice getting out of bed and going to toilet a number of times, make sure easy access Lifting, fluid restriction before bedtime: not effective Caffeine Some studies suggest eliminating caffeine from diet helpful

Behavior Therapy Modification of behavior to control enuresis has varying success, when determinedly applies motivated child, produce the most effective rate of sustained care and should be considered first – line approach Decreasing fluid and awakening the child during the night to sophisticated medical treatment

Bladder training OR: Retention control training, increase the functional capacity of bladder The goal of therapy is to increase interval between voiding and reduce bed wetting. when retention therapy is combined with conditioning therapy, results can be highly successful. Both cure in initial arrest of wetting (92%) and ultimate.

Bladder training Behavior modification techniques are successful in treatment but they require a motional child , conscientious parents and good relation between physician and family. The child keeps a progress record of gold star chart by trying determine what factor was responsible for wetting

Drinking / voiding chart DATE: …………… VOIDING DRINKING WET NIGHT DRY NIGHT WAKE UP ☻ BREAK LUNCH DINNER TREATMENT: ………... …………………………… BED TIME Drinking / voiding chart

Toilet training 20 – 24 months a good age to begin in normally developing child. Older age, easier to learn Signs of readiness: Being able to sit on potty or toilet seat (coordination) Able to understand simple instructions, cooperative Able to hold urine for 1-2 hours without leakage Regular bowel movements, no soiling during sleep Summer easier in cold climates Avoid times of stress (eg birth of sibling)

Principles of toilet training All approaches emphasize importance of: No undue pressure, calm, matter of fact approach Minimal attention and no negativity about mistakes Positive attention for success (praise, maybe stickers) (Remember age of child: tends to be oppositional!)

Useful suggestions Increase fluid to increase rate of learning Once not in nappy at home, remove nappy altogether Plastic sheet covered with towel for car seat Take potty everywhere initially Keep child in uncarpeted areas Boys to sit down initially, learn to stand later

Forms of treatment (where bladder overactivity, frequency of urination) Bladder stretching exercises (if child is passing urine often and in small amounts) Control training: helps children gain more control over their muscles by stop and start flow of urine when using toilet

Toilet training children with disabilities Intellectual, physical disabilities: Similar issues of readiness (likely to be older) More specific training, based on careful observation and monitoring of child’s current routine of eating/drinking; elimination, routines; behaviours prior to elimination Role of occupational therapists where physical difficulties

Sleep factors Historically, enuresis has been considered a disorder of sleep and more precisely a consequence of deep sleepers. Controlled sleep research studies indicate that children with enuresis might correlate with level of sleep and inability to awaken from deep sleep. Two large sleep studies have demonstrated that neither of this hypotheses deep sleep nor aroasal is an accurate description enuretics sleep structure.

Psychologic factors The emotional disturbances in enuretic children is slightly higher than normal population. But most enuretics don’t suffer significant psychologic disease

Organic Disorders of urinary tract UTI: children with enuresis particularity girls are predisposed to develop urinary tract infection. Most of these children have diurnal symptoms due to un -inhibited bladder contractions Un- Inhibited bladder activity may be exist without any other pathologic factors.

Organic urinary tract disease Congenital or acquired urinary anomalies should be excluded in enuretic children These consist of : PUV (posterior urethra valve) Meatal stenosin Neurogenic bladder Myelodysplasia, myelocel and myelominingocel Urinary tract infection(UTI) Urinary stones

Conditioning Therapy Conditioning is using the urinary alarm that evolved from bed. Consisted of detector is activated by urine and child is awakened by a bell Four randomized control trials have shown this conditioning is the most effective means of eliminating bet wetting. If the alarm that awakens the child, Initiate the inhibition of micturition is repeatedly followed by onset of normal voiding, the ultimately coming the reflex of micturition The most important cause for failure of the alarm is the lack of parents understanding and cooperation.

Enuresis: Treatment Behavioral interventions Developmentally appropriate clean up. Fluid restriction after 6pm. Scheduled times to go to the potty. Sticker charts. http://chartjungle.com/behavior/behaviorchart7day.html Enuresis alarm

Initial assessment Find out exactly what the problem e.g. an alarm will not help a child who is wet only 1 night per week Think of physical causes i.e. neurological, anatomical, infection

Important to explain to parent and child Alarms Important to explain to parent and child How it works i.e. helps you to learn when to wake up Don’t restrict drinking Warn them the first 2 weeks may show no change and the whole learning process may take 3-4/12 Records help to show progress Provide regular support during treatment

Signs of progress Smaller wet patches More to ‘do’ in toilet Wetting later at night Wet fewer times per night Waking better (though not waking is OK if not wet) Self-waking MORE DRY NIGHTS!

Problems with alarms Not waking False alarms Switching alarm off (sabotage) Alarm doesn’t go off although wet

Miscellaneous Therapy Hypnotherapy and psychotherapy are effective for selected patients when have stress full emotional cause. Certain children may have food allergy and will show marked improvement following recognition and elimination of dietary ingredient. Enuretics have higher incidence of EEG abnormalities compared with normal children. Seldom onset enuresis and urinary frequency in little girls may be due to pinworm.

Daytime Enuresis Different aetiology to nocturnal enuresis: Organic causes: structural abnormalities and functional disorders of the urinary tract

Should always refer if: Primary enuresis with no dry nights Primary enuresis with soiling Daytime enuresis Personal or family history of infection Those who may benefit from medication Those not responding to treatment despite apparent compliance

Forms of treatment (where bladder overactivity, frequency of urination) Bladder stretching exercises (if child is passing urine often and in small amounts) Control training: helps children gain more control over their muscles by stop and start flow of urine when using toilet

Forms of treatment (where lack of avp release & difficulty arousing with full bladder) Scheduled waking if wets at same time each night Bell and Pad (bedwetting alarm; pad & buzzer) Cochrane review of 52 trials: About 2/3 became dry during alarm use 50% remained dry after treatment Relapse rates reduced when over-learning (giving extra fluids at bedtime once successfully dry) occurred More effective than medications NB Higher rates of success reported in other studies. More children successful if have second trial.

Forms of treatment (Medication) Desmopressin (also called Minirin) is a synthetic hormone which concentrates the urine. Safe and free of side effects. Used at RCH for children who do not become dry with the alarm. Anticholinergics for bladder overactivity Tricyclics such as Imipramine, poor efficacy, side effects Drug treatment on its own is rarely an effective long-term treatment, high rates of relapse

Primary Nocturnal Enuresis Children with PNE have never experienced a dry period Has the child always wet the bed? Further investigate if patient has been dry for at least 6 months in the past No Yes Normal urinary tract on investigation? Further investigate underlying pathologies that may interfere with urinary tract function No Yes Large volumes of urine at night? Further investigate - cause of nocturnal enuresis may involve bladder-emptying reflex No Yes Primary Nocturnal Enuresis Probably caused by nocturnal polyuria Suitable for treatment with Desmotabs®

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