1. Nocturnal Enuresis: Pathophysiology and treatment. Gamil Waly, Prof. of Pediatrics Cairo University, Egypt

2. Nocturnal Enuresis

3. Agenda Definitions Pathophysiology Treatments Non medical Managment Pit falls Medical

4. Definition (1) According to the international children continence society(1998):- The term enuresis is a normal void occurring at a socially unacceptable time or place Nocturnal enuresis is voiding in bed during sleep that is socially unacceptable

5. Definition (2) Involuntary voiding of urine during sleep of > 3 times a week in healthy children above 5 years of age a) Primary NE -never been dry for a period of at least 6 months b) Secondary NE - previously consistently dry for at least 6 months

6. Definition (3) Monosymptomatic enuresis. Patient without other lower urinary tract symptoms and without a history of bladder disfunction. Non-monosymptomatic enuresis is the presence of increased or decreased voiding frequency, day-time incontinence, urgency, hesitancy, straining, weak stream, intermittency, holding maneuevers, feeling of incomplete emptying, post micturition dribble and genital or lower urinary tract pain. Bedwetting in the presence of day-time incontinence is still termed enuresis.

7. epidemiology

8. My Interest in this subject I collected data over 40 years No. of studied cases (65,315) enuretic (5420) These cases collected from Egypt & other centers Enuretic cases of varying ages from 4-18 years of age & one case of 28 years 4100 boys & 1320 girls No of families father & mother or grand parents who voluntarily gave frankly the complaint of enuresis (3400) Cases who only admitted & confirmed the complaint after being questioned &urged (2010)

9. % No. of enuretics AgeNo. of subjects studied 937004-740000 71620above 725310 3200Above 10 6000 120Above 15 2000 Age Incidence

10. epidemiology AuthorCountryGirls (%)Boys (%) Gamil Waly et al 1998:2004 Egypt3.57.5 Järvelin et al. 1998 Finland3.98.6 Hellström et al. 1990 Sweden3.05.0 Bower et al. 1995 Australia4.06.0 Prevalence of PNE in Children Aged 5-7 Years

11. pathophysiology Pathophysiology

12. pathophysiology Pathophysiology Bladder function Sleep Urine production Genetics Psychopathology

13. pathophysiology – bladder function

14. pathophysiology – sleep

15. Sleep/Arousal Disorder

16. IUGA 9-12 August 2005 pathophysiology – sleep Enuretics have a polysomnographically normal sleep (still they may have an arousal defect)

17. pathophysiology – urine production Diurnal variation of urine excretion in normal and enuretic children

18. Balance between Bladder capacity and Nocturnal urine vol

19. pathophysiology – urine production J.P. Nørgaard et al. 1985 S. Rittig et al. 1989 Diurnal Variation in Plasma Vasopressin (p-AVP)

20. pathophysiology – urine production S. Rittig et al. 1989 Urine production rate Urine osmolality

21. pathophysiology – genetics

22. Age of Attaining Bladder Control 2 first order relatives with nocturnal enuresis 1.5 years delay in attaining nocturnal bladder control Ferguson et. al 1986

23. pathophysiology – genetics Urinary continence depends on two main factors: *one inherent, *one inherent, and and **one acquired.

24. I -*The inherent factor is the presence of an intact and strong internal urethral sphincter. is the presence of an intact and strong internal urethral sphincter. The internal sphincter is a The internal sphincter is a collageno--muscular tissue cylinder that extends from the bladder neck down to the perineal membrane. collageno--muscular tissue cylinder that extends from the bladder neck down to the perineal membrane.

25. II**The acquired factor: (Second stage of micturition) (Second stage of micturition) It is an acquired behavior gained by learning and training in early childhood how to maintain a high alpha sympathetic tone,(T10-L2), at the internal urethral sphincter, thus keeping it closed all the time until voiding is needed or desired. It is an acquired behavior gained by learning and training in early childhood how to maintain a high alpha sympathetic tone,(T10-L2), at the internal urethral sphincter, thus keeping it closed all the time until voiding is needed or desired.

26. pathophysiology – genetics At birth the parasympathetic system is the dominant division of the autonomic nervous system. At birth the parasympathetic system is the dominant division of the autonomic nervous system. As one grows up, repeated everyday life stresses increase the sympathetic tone, which gradually takes the upper hand. As one grows up, repeated everyday life stresses increase the sympathetic tone, which gradually takes the upper hand. This explains the reports of an annual spontaneous cure rate of about 15% in those suffering nocturnal enuresis. This explains the reports of an annual spontaneous cure rate of about 15% in those suffering nocturnal enuresis.

27. pathophysiology – genetics Nocturnal Enuresis - Psychology Most enuretic children are not psychiatrically disturbed Enuresis is associated with anxiety and low self-esteem Self-concept improves with successful treatment There is no symptom substitution after treatment

28. pathophysiology – psychopathology ”Enuresis affects self-esteem more than chronic illness” Total score Body image Relation to others Enuretics15.93.92.8 Children with chronic illness 18.94.33.9 Healthy children 22.55.34.8 Hinde, 1994

29. pathophysiology – psychopathology Hägglöf, 1996 Self-esteem during treatment for Enuresis Nocturna

30. Treatment Non medical General measures - restrict fluid 3-4 hours before bedtime - empty bladder before retiring to bed - encourage child to make bedtime resolution - keep a chart of wet and dry nights - reward for dry nights -Avoid punishment/criticism

31. 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 (e.g:- birth of sibling)

32. 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!)

33. 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

34. Treatment of NE Non-pharmacological - Reassurance and counseling - Bladder training program - Enuresis alarm

35. Pharmacological treatment --Imipramine : rarely used now in children (Tofranil) –Used in children over 6- can TX for 3-6 mo –effective in 10-50%. –60%relapse. –Side effects : toxicity, sleep and appetite dry mouth. --Oxybutynine : Anticolinergic (Uripan) – in patients proven to have DI.

36. Desmopressin - DDAVP --Synthetic analog of antidiuretic hormone vasopressin –Dose-1 spray in each nostril- up to 2 each(tabs also) –Rapid response 1-2 weeks –50%- 90% relapse after D/C _Minirin Melt easy accessible needs no water half dose of tablets

37. Conclusion Doctors ask mothers each visit if her child wets his bed or no after age 4 years. Wake up the child to empty the bladder with complete consciousness(? ?) Do not blame any body in the family or the child Continuity of the treatment & instructions - minimum 6 months. We can combine non medical with medical TTT from the start according to age & urgency. Psychological support during treatment.

38. Thank you

39. Good Boy THANK YOU