1. 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 2 www.TRYforDRY.com

2. ATTAIN DAY CONTINENCE - ACCEPTED NEWBORN CONTROL AT SPINAL LEVEL VOID REFLEXIVELY q 2h AT CAPACITY ABOUT 2oz. INFANT BEGINS TO SENSE FULLNESS WHILE AWAKE CAN “WILLFULLY” “HOLD BACK” VOIDING BY CENTRAL INHIBITION OF DETRUSOR REFLEX VOLITIONALLY CONTRACTS EXTERNAL SPHINCTER AND PELVIC FLOOR MUSCLES TODDLER INCREASED WILLFULLNESS IMPROVES CONTINENCE FURTHER, GRADUALLY INCREASES BLADDER CAPACITY VOIDS BY CONTRACT DETRUSSOR & INHIBIT SPHINCTER CONTINENT- INHIBIT DETRUSSOR & CONTRACT SPHINCTER YOUTH PEDIATRIC ENUROLOGY

3. ATTAIN NIGHT CONTINENCE - UNKNOWN SENSE THEN: INHIBIT DETRUSOR CONTRACTION CONTRACT PELVIC FLOOR MUSCLES NOCTURNAL OLIGURIA INCREASED NOCTURNAL PRODUCTION OF VASOPRESSIN PEDIATRIC ENUROLOGY

4. DELAYS IN ATTAINING NIGHT DRYNESS FAMILY HISTORY INVOLVING 1 st ORDER RELATIVES DELAY DEVELOPMENT @ 1 & 3 y.o. MILESTONES PROLONGED SLEEP IN INFANCY DAY TRAINING NOT STARTED UNTIL AFTER 18 mo old MALE GENDER PEDIATRIC ENUROLOGY

5. % STILL TO ATTAIN BLADDER CONTROL AGE OF CHILD PEDIATRIC ENUROLOGY

6. NOT RELATED TO DELAY IN ATTAINING NIGHT DRYNESS FAMILY SOCIAL BACKGROUND STRESSFUL LIFE EVENTS CHANGES IN PARENT FIGURES CHANGES IN RESIDENCE PEDIATRIC ENUROLOGY

7. “ HEAVY SLEEP” The children don’t even realize they wet the bed. The deluge from Springfield’s burst dam floats Ralph Wiggum, in his bed, to Homer’s front door

8. WHEN TO PURSUE TREATMENT OF ENURESIS? AFTER 3 years old? AFTER 5 years old? AFTER 7 years old? AFTER 10 years old? ON PARENT’S REQUEST? PEDIATRIC ENUROLOGY

9. WHEN TO PURSUE TREATMENT OF ENURESIS? Getting night dryness - B. Schmitt, MD 3 yo -self awaken hints limit evening liquids void before sleep praise for dry mornings 6 yo -concentrate on self-awakening motivational techniques 8 yo -alarm bladder stretch exercise medications ? PEDIATRIC ENUROLOGY

10. DEFINITIONS PEDIATRIC UROLOGY SURGICAL PROBLEM = INCONTINENCE PEDIATRIC ENUROLOGY ENUROLOGICAL PROBLEM = ENURESIS CHILDHOOD WETTING MAY INVOLVE: PEDIATRIC ENUROLOGY

11. 3% of 12 Year Olds Have Never Been Dry at Night

12. Close Screen Return to Lesson