Children with “Diurnal Enuresis”: How do we help them? Dr Jonathan Evans Consultant Paediatric Nephrologist Nottingham Children’s Hospital

Normal & abnormal bladder function Classification & causes of urinary incontinence Assessment Management

Diurnal Enuresis is….. Urinary Incontinence EXCLUDING Bedwetting Plumbing Problems Neurogenic Bladder Not urinary incontinence Non Organic wetting Less of a problem than incontinence Useful terminology to help guide management A patronising term used by health care professionals who have failed to make a proper diagnosis

The Master control – inhibits voiding (conscious or subconscious) until it choses Co-ordinates micturition - inhibited by cortex Storage/Filling – under SYMPATHETIC control: β/ β3+ suppresses detrusor & parasymp/muscarinic/cholinergic α+ stimulates internal sphincter Voiding/Micturition – by SYMPATHETIC inhibition – α- relaxes internal sphincter release of parasymp/muscarinic/cholinergic stimulation detrusor contraction

Normal bladder function in children in utero cyclical emptying 1st yr cyclical, small bladder 2nd/3rd yr when bladder is FULL... recognise need to pee! defer micturition briefly voluntary micturition when full bladder 4th/5th yr from any fullness…. Can defer or initiate micturition, but usually void at strong desire Adult? Planned micturition … DRY by day / night

Normal Bladder Function 5yr+ Storage Detrusor relaxation + urethral closure maintained by INVOLUNTARY control of detrusor and bladder neck/internal sphincter smooth muscle Micturition reflex can be supressed by CNS control (central inhibition) Expected Bladder Capacity = 30(Age+1yr) in mls! Store urine for several hours at low pressure Able to store urine overnight

Normal Bladder Function 5yr+ Voiding Co-ordinated detrusor contraction and urethral relaxation no abdominal straining, completely empty bladder good, continuous urinary stream (“bell shaped curve”) Small post micturition dribble is common! micturition reflex at FBC can be deferred or initiated voluntarily pee 4-7 times per day and occasionally at night

What is abnormal bladder function? Depends on developmental age.. Storage Voiding Urgency Frequency or Nocturia Holding manoeuvres Incontinence Intermittent Night or Day Urge Stress Unaware Giggle Post micturition Continuous Hesitancy Straining Poor stream Intermittent/variable stream Explosive stream Incomplete emptying (other LUTS such as dysuria, haematuria!)

Causes of Abnormal Bladder Function Outcome L.U.T.S associated with Overactive Bladder Underactive Bladder Dysfunctional Voiding Dysfunctional Elimination Giggle Micturition Other! Input Genetics Uropathy Neurogenic CNS disorder Development (ADHD, ASD) Psychosocial Infection Constipation e.g SI with multiple causes including anatomical & neurogenic

Assessment History Examination Basic Investigations Voiding, Storage, Bowels, Co-morbidities, Psycho-social, Developmental, Attitudes, Values & Behaviours Examination General + Abdomen, Bladder, Ext Genitalia?, Spine, Reflexes, BP Basic Investigations Urinalysis, Freq/Vol chart, Stool Chart, Intermediate Investigations Bladder Scan, Uroflow, Renal tract USS Invasive Investigations MCUG, Urodynamics, MRI Spine.. All Few

Frequency Volume Charts Avoid over interpretation! Need 2-3 days to be representative Freq = 4-7/d EBC= 30 x (Age+1) MVV = 75% EBC Ignore first morning wee If you don’t drink you wont pee much!

dysfunctional voiding overactive normal Abdominal straining - Underactive bladder Outflow obstruction

Fluid Data Analyser

Pressure in Bladder (Measured) 84 ml 151 ml Pressure in Bladder (Calculated) Other Measurements Fill volume Urine flow rate Pelvic Floor EMG Intra abdominal Pressure (Measured) Time - minutes

Patterns of daytime incontinence Symptom Functional Disturbance Pathology Urge incontinence Overactive bladder Detrusor overactivity – functional or urological /neurogenic Giggle wetting Normal OAB Giggle micturition Dysfunctional voiding Underactive bladder Depends on associated symptoms Post micturation dribble Normal or Vaginal reflux of urine Normal, Vaginal reflux of urine Stress (e.g with cough, sneeze, exertion) Dysfunctional voiding, Underactive bladder, OAB +/- Neurogenic, Urological Continuous dribble Ectopic ureter Unaware Anything but Normal or OAB commonest! Anything including Urological / neurogenic

What is the evidence for widely used interventions? Fluids - more or less? Constipation - cause or effect? UTI - pathogenic or benign? Toileting - timed, prompted or hold on? Pelvic Floor - hold on or let go? Drugs - how effective? Neuromodulation - any evidence??

Treatment of Overactive Bladder Drink enough to avoid dehydration Caffeine avoidance Treat/prevent constipation Treat/prevent symptomatic UTIs Regular or timed voiding Reminder alarm Anticholinergics β3 agonist? (Mirabegron) Neuromodulation (sacral/tibial nerve)? Botulinum Toxin Bladder Augmentation All Few

Anticholinergic Drugs & the bladder Try more than one Start with oxybutinin Titrate to maximum dose Pure Antimuscarinic Propanthiline - weak action, few A/E Tolterodine - M3 selectivity – fewer A/E Trospium - ? fewer - CNS A/E Mixed actions Imipramine - other actions ++ CNS effects Oxybutinin - smooth muscle bladder relaxant Flavoxate - smooth muscle bladder relaxant Propiverine - calcium antagonist Solifenacin - long acting, M3 specificity Darifenacin - long acting, M3 specificity

Mirabegron (Betmiga) A β3 agonist – suppresses detrusor and augments the sympathetic inhibition of cholinergic receptors Efficacy similar to anticholinergics NICE TA290 (2013) - an option for adults in whom antimuscarinic drugs are ineffective, or have unacceptable side effects Anecdotal use in children…

Neuromodulation (sacral) Percutaneous - Tibial = NICE approved (adult) - Sacral = FDA approved Transcutaneous - Evidence less robust! - sacral = TENS machine

Treatment of Voiding Dysfunction Drink enough to avoid dehydration Caffeine avoidance Treat/prevent constipation Treat/prevent symptomatic UTIs Treat OAB (e.g anticholinergics) PLUS Regular or timed voiding, relaxed voiding, double voiding Biofeedback Alfa Blocker (e.g Doxazocin) Botulinum Toxin to ext sphincter? Intermittent self cathetersisation (ISC)

Biofeedback transcutaneous electrodes measure pelvic floor/sphincter and abdominal muscle activity Converts to visual / auditory signal Computer game controlled by pelvic floor & abdominal muscles!

Pediatric Animation Mode Pediatric Animation Mode. There are five different characters that the patient can choose from Top screen (Channel 1) monitors the patients pelvic floor. Bottom screen (Channel 2) monitors the patients abdominal muscles. Accumulating evidence of effectiveness in adults (and children) with voiding dysfunction but very varied models of biofeedback

α Blockers Inhibit smooth muscle in internal urinary sphincter and prostatic urethra Good evidence in benign prostatic hypertrophy! Case series, Anecdote and expert opinion says it is helpful as part of a multicomponent bladder rehabilitation package! Doxazocin vs (“me to”-ocins)! For expert use!

Treatment of Giggle Incontinence Treat underlying bladder dysfunction Timed voiding Pelvic floor training (awareness) Trial of anticholinergics Biofeedback Methylphenidate Evidence is limited to case series, expert opinion and anecdote!

Children with “Diurnal Enuresis”: How do we help them? CQC Domain To Help Children with URINARY INCONTINENCE Safe Understand bladder dysfunction Undertake a careful evaluation Work within your competencies Recognise warning signs (both medical & social) Effective Offer the correct treatments based on your evaluation Refer to specialist (MDT) for complex investigation & management Caring Empathy & Support, avoid being dismissive Responsive Listen to child and parent - adapt management to account for patient choice , ability and beliefs Well Lead Advocate, Support staff, Manage expectations, Know the services that are available…