TRY for DRY Healthcare Training Instructor Max Maizels, MD Division of Urology Children’s Memorial Hospital – Chicago Professor of Urology Northwestern Medical School Managing Enuresis – Lesson 5

NIGHT DRYNESS IMPEDED BY: DEEP SLEEP REDUCED FUNCTIONAL BLADDER CAPACITY FOOD SENSITIVITIES OBLIGATORY POLYURIA CONSTIPATION UTI’S UROLOGICAL BIRTH DEFECTS PEDIATRIC ENUROLOGY

“Multi-modal” treatment works better than single agent treatment TRY for DRY

Multi-modal treatment T = Thumb = Try for Dry Alarm

Multi-modal treatment I =Index finger = Inducements Star chart and moderate encouragement.

Multi-modal treatment M = Middle Finger =Meds Oxybutynin Desmopressin

Multi-modal treatment R = Ring Finger = Right Food Elimination Diet

Multi-modal treatment P = Pinkey = Poo Bowel Management

STRATEGY OF THE TRY for DRY EVALUATION 1 Month Later EVALUATE PROGRESS DRYNESS by 3-6 months OUGHT TO BE ACHIEVED PEDIATRIC ENUROLOGY INTAKE INFORMATION PRE-OFFICE INFO 1 st OFFICE VISIT > WORKING Dx >ENURESIS > TFD MULTIMODAL TREATMENT 2 nd OFFICE VISIT > CONTINUE TFD or PEDIATRIC UROLOGY REFERRAL 3 rd OFFICE VISIT > IF NOT DRY ….. SPECIALIST REFERRAL

STRATEGY OF THE TRY for DRY EVALUATION PEDIATRIC ENUROLOGY 1 o or 2 o NOCTURNAL ENURESIS MANAGEMENT 1 st OFFICE VISIT TRY for DRY ALARM - Review Instructions Explain Star Chart INDUCEMENTS Review MEDS Rx - Oxybutynin TID \ HS Depends on bladder size - DESMOPRESSIN 10+ years old Review Elimination Diet - RIGHT FOODS - Review Bowel Program if Defecation is Irregular - POO

STRATEGY OF THE TRY for DRY EVALUATION PEDIATRIC ENUROLOGY 1 o or 2 o NOCTURNAL ENURESIS MANAGEMENT 1 st OFFICE VISIT DON’T TREAT ENUROLOGICALLY UNTIL DEFECATION IS REGULAR

STRATEGY OF THE TRY for DRY EVALUATION PEDIATRIC ENUROLOGY 1 o or 2 o NOCTURNAL ENURESIS MANAGEMENT 1 st OFFICE VISIT DDAVP CONSIDERATIONS BOTH PARENTS WORK SPECIAL NIGHTS (SLEEP OVERS) PARENTAL FEAR OF ALARM ALARM FAILURES IN CONJUNCTION WITH OXYBUTYNIN

TREAT KIT START AFTER 1 ST OFFICE VISIT TFD #2 …. “Panda” taper treatments Calendar tracks day\night dryness Video alarm instructions “happy bladder” diet TFD alarm

bladder

T = Thumb = Try for Dry Alarm DAY WET - Alarm worn on belt line NIGHT WET – Alarm worn on shoulder

 As Mono Treatment Effective in About 50%  Delayed Results ( 3-6 months ).  May not be routinely accepted by child.  Time intensive for child, family and physician.  Considered most effective treatment for long term remission of enuresis.

I =Index finger = Inducements Reinforce Dryness Star Chart - Treats – Read a Story – Grab Bag Add star chart Rewards used for day or night wetting

M = Middle Finger =Meds SMALL BLADDER CAPACITY Wet by day – R x D itropan (Oxybutynin)  ANTICHOLINERGIC.  REDUCES UNINHIBITED BLADDER CONTRACTIONS.  HELPS DAY WETTING.  NO BENEFIT WHEN USED ALONE FOR BEDWETTING. DITROPAN (OXYBUTYNIN)

M = Middle Finger =Meds SMALL BLADDER CAPACITY Night Wet – Youth = Ditropan  AGE  BLADDER CAPACITY  SENSITIVITY to MED.  HOME or SCHOOL SCHEDULE for TIME to ADMINISTER DITROPAN (OXYBUTYNIN) Strategy

DITROPAN DOSEAGES & TITRATION 5-7yo PEDIATRIC ENUROLOGY

DITROPAN DOSEAGES & TITRATION 8-12yo PEDIATRIC ENUROLOGY

DITROPAN DOSEAGES & TITRATION >12yo PEDIATRIC ENUROLOGY

FACIAL FLUSHING CRABBINESS NOSE BLEED DRY MOUTH ERRATIC BEHAVIOR STOMACH ACHES NIGHTMARES PEDIATRIC ENUROLOGY DITROPAN (OXYBUTYNIN) Adverse Effects

M = Middle Finger =Meds SMALL BLADDER CAPACITY Night Wet – Teen = Ditropan + DDAVP DDAVP Reduces Nocturnal Polyuria. Can be used as mono therapy.

R = Ring Finger = Right Food Elimination Diet Avoid: - Milk - Citrus - Sugars - Carbonated Drinks

We have found that certain foods appear to inhibit dryness in approximately 10% of children who wet.

P = Pinkey = Poo Rx ALL PATIENTS Daily AM toileting Patients w/ HARD bowel movements Rx = mineral oil Patients w/ Irregular emptying Rx = stimulant (Senkot)

P = Pinkey = Poo Rx ALL PATIENTS Daily AM toileting Patients w/ HARD bowel movements Rx = mineral oil Patients w/ Irregular emptying Rx = stimulant (Senkot)

STRATEGY OF THE TRY for DRY EVALUATION PEDIATRIC ENUROLOGY 1 o or 2 o NOCTURNAL ENURESIS MANAGEMENT 2 nd OFFICE VISIT At second visit, 80% of patients show improved dryness Expect Remission in 3-6 months (Goal 14 Consecutive Dry Days &Nights) Relapse Rate 15% ( 2 Wet episodes\ month) “CURE” = REMISSION FOR 1 YEAR If wetting has not improved consider urological issues. Follow-up 1 Month after initial office visit

STRATEGY OF THE TRY for DRY EVALUATION PEDIATRIC ENUROLOGY 1 o or 2 o NOCTURNAL ENURESIS MANAGEMENT 2 nd OFFICE VISIT FOLLOW UP VISITS prn WITH PEDIATRICIAN POSTCARD FROM FAMILY TO CONFIRM: REMISSION NO RELAPSE AFTER STOP TFD Rx Patients with improved dryness

STRATEGY OF THE TRY for DRY EVALUATION PEDIATRIC ENUROLOGY 1 o or 2 o NOCTURNAL ENURESIS MANAGEMENT 2 nd OFFICE VISIT Patients with NO improved dryness USING ALARM CORRECTLY? ACTUALLY WEARING IT? PLACEMENT OF SENSOR? FEAR OF ALARM? TITRATE DOSE OF DITROPAN.

STRATEGY OF THE TRY for DRY EVALUATION PEDIATRIC ENUROLOGY 1 o or 2 o NOCTURNAL ENURESIS MANAGEMENT 2 nd OFFICE VISIT Patients with NO improved dryness BM’s NOT REALLY DAILY. SNEAKING ON ELIMINATION DIET. NEED PSYCHOLOGICAL REFERRAL? NEED PEDIATRIC UROLOGICAL REFERRAL?

STRATEGY OF THE TRY for DRY EVALUATION PEDIATRIC ENUROLOGY 1 o or 2 o NOCTURNAL ENURESIS MANAGEMENT PEDIATRIC UROLOGICAL CONSIDERATIONS UA C\S ULTRASOUND: thick detrusor -> void dysfunction, posterior urethral valves, hydronephrosis -> ectopic ureter symmetric renal growth -> VUR fecal plug residual urine BM’s NOT REALLY DAILY KUB - SPINA BIFIDA OCCULTA CONSIDER CYSTOSCOPY AND VCUG

STRATEGY OF THE TRY for DRY EVALUATION PEDIATRIC ENUROLOGY 1 o or 2 o NOCTURNAL ENURESIS MANAGEMENT PEDIATRIC UROLOGICAL CONSIDERATIONS URODYNAMICSNEUROGENIC BLADDER VCUGVUR CYSTOSCOPYPOSTERIOR URETHRAL VALVES MRITETHERED CORD

STRATEGY OF THE TRY for DRY EVALUATION PEDIATRIC ENUROLOGY 1 o or 2 o NOCTURNAL ENURESIS MANAGEMENT INCONTINENCE - 3% OF CASES 60% SPINA BIFIDA OCCULTA DAY\NIGHT WET & STOOL PROBLEMS UTI COMMON 30% POSTERIOR URETHRAL VALVES SLOW FLOW HYDRONEPHROSIS \ DILATED BLADDER 10% ECTOPIC URETER DAY AND NIGHT WETTING IN A GIRL PEDIATRIC UROLOGICAL CONSIDERATIONS

nuresis nfection ncopresis E Try for Dry commonly applied to other clinical problems involving wetting PEDIATRIC ENUROLOGY

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