Bedwetting is a problem for children and parents a problem largely to be tackled by an EBDM approach Johan Vande Walle Pediatric nephro-urologic centre, University Hospital, Ghent 14/07/2012

Bedwetting is a problem for children and parents a problem largely to be tackled by an EBM approach Johan Vande Walle Pediatric nephro-urologic centre, University Hospital, Ghent 14/07/2012

Parents : Ideas on nocturnal enuresis Psychological problems Lack of motivation To deep sleep To much drinking Self healing condition Organic Mismatch Nocturnal diuresis bladdervolume heriditary Doctors / care givers : Ideas on nocturnal enuresis

Parents : Ideas on nocturnal enuresis Psychological problems Lack of motivation To deep sleep To much drinking Self healing condition Organic Mismatch Nocturnal diuresis bladdervolume Heriditary Persistent ½ severe cases Doctors / care givers : Ideas on nocturnal enuresis

Parents : Ideas on nocturnal enuresis Psychological problems Lack of motivation To deep sleep To much drinking Self healing condition Organic Mismatch Nocturnal diuresis bladdervolume Heriditary Persistent ½ severe cases Doctors / care givers : Ideas on nocturnal enuresis : 70%

Parents : Ideas on nocturnal enuresis Psychological problems Lack of motivation To deep sleep To much drinking Organic Mismatch Nocturnal diuresis bladdervolume heriditary alarm Desmopressin

Parents : Ideas on nocturnal enuresis To deep sleep Psychological problems Lack of motivation To much drinking If the child would wake up Stress,.. If he would be motivated Less fluid intake Wrong conclusion Its the problem of the child It is not a disease… not needing medical treatment Internet and population “wisdom”

Vande Walle 2001

Vande Walle 2001

If the child drinks to much .. Not drinking after 5 o clock

Vande Walle 2001

If the child sleeps to deep .. Wake him up to void Vande Walle 2001 If the child sleeps to deep .. Wake him up to void

If the child sleeps to deep .. Wake him up to void Vande Walle 2001 If the child sleeps to deep .. Wake him up to void

Vande Walle 2001

? 11-6-2001 Vande Walle enuresis fabels

Vande Walle 2001 PSYCHOLOGICAL?

Vande Walle 2001 PSYCHOLOGICAL?

Psychology : rimary or secondary? Enuresis Psychological problems Risk factors

Enuresis → psychological problems *Impact child: self-esteem ↓ stress ↑ Emotional reactions Sadness Moodiness Feeling upset Embarrassment Humiliation Guilt Dreaded anticipation before sleep *University Hospital Ghent studies: Theunis et al 2002, Van Hoecke et al 2006, Van Hoecke et al 2004

Enuresis → psychological problems Impact child: self-esteem ↓ stress ↑ Social impact Being teased Having a secret Feeling different No sleepovers No camps

Enuresis → psychological problems *Impact family: Parental intolerance? parental stress ↑ Tolerant Concern External attribution Effort Empathy Intolerant Burden Financial Practical Guilt Helpless Child is blamed - Child is punished *University Hospital Ghent study: De Bruyne et al 2009

Psychological problems → enuresis (Secondary) enuresis Stressfull life event Parental divorce Birth of sibling Parental sickness/death Removal Natural disaster

Evaluate the impact/psychological problems individually How? Good history + clinical observation! SSIPPE Short Screening Instrument for Psychological Problems in Enuresis

Emotional problems If > 2 times YES: full psychological screening

ADHD problems If > 2 times YES: full psychological screening

20-30%: psychiatric disorder(s) (ICD-10 / DSM-IV) General population: 10-15% Externalizing Internalizing Others At risk: older age, male, low SES, admission to specialized clinics, NMNE, SNE

Baeyens et al 2004-2007 2y FU 73% of ADHD diagnoses confirmed 65% still had NE 4y FU 64% of ADHD diagnoses confirmed 42% still had NE

Is WAIT and SEE attitude defendable?

Yes, if all the following conditions are fulfilled It cures spontaneously, always, fast It is an idiopathic condition or a maturation defect, and not a disease It has no negative influence on cognitive functions There is no effective therapy or there is one fantastic therapy with 100 % success It has no psychological consequences For the child For the parents It is cheaper not to treat

Profound psychological and social impact Anxiety Stress Parental stress Social isolement 1.A. Von Gontard , J Urology 2011 april (185),1432-1437 2. De Bruyne E, J of urology,182,2012-2021

”Enuresis affects self-esteem more than chronic illness” Total score Body image Relation to others Enuretics 15.9 3.9 2.8 Children with chronic illness 18.9 4.3 Healthy children 22.5 5.3 4.8 Hinde M et al. Lakartidningen. 1995 Sep 6;92(36):3225-9

Treatment of enuresis Improves self concept of the child parents perception of childs behaviour . Longstaffe et al. Pediatrics 105,935-940

Bedwetting is a problem for children and parents an impact not identified by caregivers and society