2. Enuresis, Non Medical Treatment
Dr Hajebrahimi
Professor of urology Department

3. عملی بصورت استفاده از فرمهای Logbook
اهداف درس:
آشنایی با تعریف و اتیولوژی شب شاشی
آشنایی با روشهای تشخیصی
آشنایی با روشهای درمانی
روش ارزیابی :
تئوری بیشتر بصورت MCQ
عملی بصورت استفاده از فرمهای Logbook

4. Children with PNE have never experienced a dry periodNo

5. 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

6. 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 S. Rittig et al. 1989

7. 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

8. 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

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

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

11. 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

12. pathophysiology – genetics

13. 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)

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

15. 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

16. 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)

17. 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

18. 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

19. 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

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

21. 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?

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

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

24. 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)

25. 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

26. Use it as national monument

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

28. 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

29. 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

30. 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.

31. 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

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

34. 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)

35. 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!)

36. 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

37. 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

38. 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

39. 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.

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

41. 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.

42. 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

43. 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.

44. Enuresis: Treatment Behavioral interventions
Developmentally appropriate clean up.
Fluid restriction after 6pm.
Scheduled times to go to the potty.
Sticker charts.
Enuresis alarm

45. 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

46. 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

47. 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!

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

49. 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.

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

51. 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

52. 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

53. 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.

54. 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

55. 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®

56. You have to “nod” it
Je zou er moeten