1. Interesting Case Rounds Nadim Lalani R5 08.21.08

2. Which of the following are/were “Famous Bedwetters”?

3. “Fergie Wets Pants!” “I was late... I didn’t go to the restroom before I went onstage. It was horrible. But, whatever. It happened... everyone knows I wet my pants on-stage and had a crystal-meth addiction. That sucks. You have to laugh.”

4. Objectives o Management of primary nocturnal enuresis Case Background Treatment Alarms Pharmacotherapy Behavioural therapy Other o NOT discussing DIURNAL or SECONDARY

5. Case o 11 yo Boy brought to you by parents because of bedwetting. o History? Primary vs Secondary Nocturnal vs diurnal Fam hx [enuresis, DM, DI, kidney, neuro, Sickle] UTI? Sz? Polyuria/Polydypsia? Constipation?encop? Sleep? [terrors, OSA] Psychosocial. Developmental. Sexual ab? Parental response. Meds [SSRI]

6. Case o Physical? General [growth chart] Abdo [distended bladder, stool in rectum] GU [ectopic ureter, labial adhesions, Sexual ab] Neuro exam[ Sacral dimples or tufts of hair] o Diagnostics? Urinalysis. First void SG Unless secondary or treatment failure [see algorithm]

7. Case conclusion o Child had primary NE Parents working with GP Tried various methods [albeit suboptimally] o Child had normal urinalysis o Had ++ hx behavioural problems/anxiety/depression/hydrophobia o Was on Citalopram o Refered to Community pediatrician

8. Background: o Definition: Involuntary discharge of urine at night. Beyond age of bladder control. > Twice per week for 3 months Uncomplicated [85%] vs Complicated* [10%] o Epidemiology: Boys >> girls [2:1] 15% of 5yo  [8% of 8yo]  1% 15yo 5% are due to organic pathology * Have other symptoms [const/encop]

9. Pathophysiology o Often no clear etiology o Causes: Maturational delay of voiding coordination Sleep arousal dysfunction: [kids unable to wake up when they senses that the bladder is full] Small functional bladder capacity: habit polydipsia : [i.e. the child sips drinks all night long]. Secondary nocturnal enuresis : related to stressors at home/school DM/UTI/Neuro dis/Bladder dysfxn/ Meds [SSRI, diuretix]

10. Pathophysiology o Genetics: Risk: 43% [one parent with NE] 77% [both parents with NE] 75% of kids with NE have a first-degree relative who had enuresis Linkage studies have shown associated genetic loci on chromosomes 8q, 12q, 13q, and 22q11

11. General Measures o Clarify the goal of getting up at night and using the toilet. o Assure the child’s access to the toilet. o Avoid caffeine-containing foods and excessive fluids before bedtime [ 100 lb]. o Have the child empty the bladder at bedtime. o Take the child out of diapers. o Include the child in morning cleanup in a nonpunitive manner. o Preserve the child’s self-esteem. o Best for those < 6yo

12. Treatment o Alarms Invented in 1907. Many different kinds. “mini alarms” [wear device] Alarm/light/buzzer goes off when urine present Least effective <5yo. Most after 7 -8 yo More effective than drugs Trial minimum 4 months Continue until 14 consecutive dry nights Overlearn by drinking 2 cups water  7 dry nights Relapse  back to alarm for 14 dry nights

13. Cochrane review 2005 o 56 studies. Over 3200 children o RCT’s & quasi-RCT’s involving alarms [2400 pts] o Excluded diurnal Results: o Alarm 60% effective at stopping bedwetting o 50% relapse. Less relapse with overlearning and dry bed training. o No difference in alarm types [but kids prefer wearable ones] o DDAVP faster than alarm but not sustainable o TCA no different, but also not sustainable

14. Alarms o Overall cure rate of 50% o Requires buy in from whole family as it’s disruptive o Impractical for ‘sleepovers’ and camp o No need to go high-end, kids like mini o Don’t buy second-hand [don’t work well after 2-3 pts]

16. Treatment o Pharmacotherapy : DDAVP Studied since 1970s Enuretic kids have decreased nighttime ADH secretion  produce more urine. Side effects  water intoxication Expensive IN preparation pulled by FDA/health Canada HYponatremia 5 cases /10 million doses IN vs 1/10 million PO

17. Cochrane review in 2002 47 studies >2200 kids used DDAVP Results: o Compared with no treatment : 1.3 fewer wet nights/week 20% reduction in bedwetting at end of treatment o DDAVP no different to TCA [TCA more side effects] o DDAVP + alarm better than DDAVP during Rx, but same relapse rate

18. DDAVP o Do not use IN preparation o Can use 200-600 mcg tablets before bedtime o Avoid water after 6pm o CPS: Useful only for sleep overs or camp

19. Pharmacotherapy o TCA Imipramine best studied Mechanism unclear. Anticholnergic? Side effects [mood/weight/OD/Cardiac/Sz] CPS Position Statement: Short-term Distressed, Older kids Reliable parents

20. Cochrane review 2003 o 58 studies that used TCA > 3000 kids Results: o Compared with no treatment: 1 free night/week 20% dry during Rx, but relapsed o Not enough evidence to compare other TCA/doses o Equivalent to Alarm during therapy, but relapse more than alarm after. o Equivalent to DDAVP during Rx. But relapse more o Better than simple behaviour/diet. Worse than complex behav/hypnosis.

21. Treatment o Simple Behavioural Night time Fluid Restriction Lifting Picking up asleep child and taking to BR before they wet bed. Scheduled Awakening Star Charts & reward systems Retention Control training Daytime overload of bladder and attempt to delay micturation.

22. Cochrane Review 2004 o 17 studies > 700 kids [380 got behaviour training] Results: Star charts, Lifting and Waking better than nothing Might be worth initiating 1st Drop out associated with frustration and family strife.

23. Treatment o Complex behavioural Dry Bed Training: Intensive 1 st night  woken Q1h If bed wet  clean bed [cleanliness] & practice going to BR Subsequent nights awoken once/night [getting earlier and earlier] Full spectrum Home Training: o Alarm + cleanliness + retention control + overlearning

24. Cochrane Review 2004 o 18 trials >1000 kids o Results: o Complex training better than nothing o No better than alarm alone

25. Behavioural Therapy o CPS Position: Insufficient evidence Labor intensive and can contribute to frustration and conflict Might do more harm than good Shouldn’t be recommended without careful consideration

26. Treatment o Other modalities Include: 31 other drugs have been studied Hypnosis Psychotherapy Accupuncture Chiropractic adjustment. o Not enough evidence to recommend.

27. Summary o Distinguish NE from Diurnal and secondary o Most important to have supportive environment & minimise impact o Conditioning using alarm most efficacious o Special situations can use DDAVP o Difficult circumstances  imipramine o Judicious use of behavioural therapy o Should be handled by paediatrician o Persistence  urology referral

28. Feri-Feri

30. Management of primary nocturnal enuresis Canadian Paediatric Society (CPS) Paediatrics & Child Health 2005;10(10): 611-614 Practice Parameter for the Assessment and Treatment of Children and Adolescents With Enuresis Journal of the American Academy of Child and Adolescent Psychiatry - Volume 43, Issue 12 (December 2004)

31. Parent Handout http://www.caringforkids.cps.ca/growing&learni ng/Bedwetting.htm