2. Aims Understand aetiology of nocturnal enuresis Understand aetiology of nocturnal enuresis Be aware of treatments available in Primary Care Be aware of treatments available in Primary Care Known when to refer Known when to refer

3. Aetiology 1/6 of 5 year olds will bed-wet, this is normal (although the parents may not think so) 1/6 of 5 year olds will bed-wet, this is normal (although the parents may not think so) Enuresis more common in boys (2:1) Enuresis more common in boys (2:1) Genetic predisposition (70% have a 1 st degree relative) Genetic predisposition (70% have a 1 st degree relative) UTI – a history is more common in enuritic children UTI – a history is more common in enuritic children

4. Rates of enuresis Age 5: 20% Age 5: 20% Age 6: 10–15% Age 6: 10–15% Age 7: 7% Age 7: 7% Age 10: 5% Age 10: 5% Age 15: 1–2% Age 15: 1–2% Age 18–64: 0.5–1% Age 18–64: 0.5–1%

5. Secondary Causes Diabetes (mellitus or insipidus) Diabetes (mellitus or insipidus) Renal failure Renal failure Structural abnormality of urinary tract Structural abnormality of urinary tract Impaired night-time arrousal Impaired night-time arrousal Neurogenic bladder Neurogenic bladder A secondary cause must be suspected if enuresis is new onset A secondary cause must be suspected if enuresis is new onset Drugs – valproate, SSRIs, also caffeine Drugs – valproate, SSRIs, also caffeine

6. Assessment - history Detailed! Detailed! Urinary symptoms Urinary symptoms Bowel habit Bowel habit Developmental history Developmental history Family history Family history Secondary causes (see previous slide) Secondary causes (see previous slide)

7. Assessment - examination Growth parameters Growth parameters Lower limb neurology Lower limb neurology Abdominal examination Abdominal examination Blood pressure (raised in renal disease) Blood pressure (raised in renal disease) Consider examining genitalia especially if you suspect physical cause Consider examining genitalia especially if you suspect physical cause

8. Investigation In primary care, relatively simple: In primary care, relatively simple: –Dip urine and send for culture –Biochemical testing to rule out diabetes.

9. Management Rule out all other causes first Rule out all other causes first Assess parental expectation Assess parental expectation Non-pharmacological measures – 1 st line Non-pharmacological measures – 1 st line –Bedwetting alarms (see next slide) –Bladder training in the day –Star charts to award progress and dry nights Pharmacological measures – 2 nd line, should not be used in <7s Pharmacological measures – 2 nd line, should not be used in <7s

10. Bedwetting Alarms Most effective treatment - 70-90% cure Most effective treatment - 70-90% cure Pad senses wetting and sounds alarm Pad senses wetting and sounds alarm Teaches child to recognise full bladder Teaches child to recognise full bladder Requires parental effort Requires parental effort 6 month training period, 1 month training for relapse 6 month training period, 1 month training for relapse Considered successful once 14 consecutive dry nights are achieved Considered successful once 14 consecutive dry nights are achieved Available for lone from ‘local continence advisor’ – probably school nurse, advise there may be a waiting list. Also available to buy Available for lone from ‘local continence advisor’ – probably school nurse, advise there may be a waiting list. Also available to buy

11. Desmopressin Synthetic vasopressin Synthetic vasopressin Limits amount of water excreted by kidneys Limits amount of water excreted by kidneys 12-40% cure, 80% have some benefit 12-40% cure, 80% have some benefit Can be used as ‘one-off’ dose (i.e. for if staying over at a friend’s house) Can be used as ‘one-off’ dose (i.e. for if staying over at a friend’s house) Use for over 3 months not recommended unless supervision by specialist Use for over 3 months not recommended unless supervision by specialist Risk of hyponatraemic convusions – need to avoid fluid overload Risk of hyponatraemic convusions – need to avoid fluid overload High relapse rate High relapse rate

12. More pharmacology TCAs TCAs –Imipramine main drug used –Antimuscarinic effect –Treatment success and relapse rate similar to desmopressin, however risk of SEs higher. –2004 review states risks outweigh benefits Oxybutynin Oxybutynin –Sometimes used if symptoms of bladder insability

13. Referral criteria Majority of cases can be managed in primary care Majority of cases can be managed in primary care Referral criteria as follows: Referral criteria as follows: 1.Failure of treatment in primary care 2.Complex psychological difficulty – consider referral to a child psychologist 3.Suspicion of a physical abnormality – these cases rarely have problems only at night

14. The last word Most of the presentation based on guidance in CKS 2005 Most of the presentation based on guidance in CKS 2005 HOWEVER, NICE are issuing their first guidelines on nocturnal enuresis in October 2010 HOWEVER, NICE are issuing their first guidelines on nocturnal enuresis in October 2010 Unfortunately this presentation has come a bit too early! Unfortunately this presentation has come a bit too early!