A short review

We struggle to determine the age at which enuresis can be defined.  The age at which schooling starts is one determinant.  The age at which motivation and longer term goal setting is achievable.

 Trial removal of the trainer wheels (pull-ups).  Reward systems.  Reassurance

 Restrict fluids  Lift child to toilet during night  Punish  Resort to medications without medical assessment (including ‘alternative therapies’)  Desmopressin – indications limited

Bedwetting Assessment Urinary Infection Constipation Mono symptomatic Nocturnal Enuresis enuresis Child less than 7 yrs Not motivated Treat as per UTI guidelines Treat Inform, Advise and Reassure Episodic Needs ( 6 yrs or older) Offer Desmopressin Cure! Complex Enuresis Refer to Urologist or Paediatrician Enuresis Alarm with support program failed Bedwetting persists Relapse Repeat Spontaneous

 A simple history will suffice for the majority of children. Invasive examination or investigations are not required.  Identification of those with small bladders or large nocturnal urine outputs has not given useful management prediction.  Alarm based treatments have proven efficacy and low relapse rates

 Child and Parent buy in  Goal setting and Progress Charts  Choice of alarms

A randomized controlled clinical trial 2007 for treatment of 130 children with primary nocturnal enuresis  Physio-psychological treatment and drug treatment are suitable for Chinese enuretic children, both of them showed good curative effects.  Physio-psychological treatment is more suitable for widespread use to treat PNE in China

An evaluation of different modes of combined therapy in 43 children with enuresis Sept 2009  Comparison between alarm vs combined alarm and desmopressin therapy  Combined therapy proved effective in children with enuresis after 6 months, with no statistically significant differences between the two different orders of treatment

Evaluation of the long-term success of the enuretic alarm device in 62 patients with monosymptomatic primary nocturnal enuresis  65.9% of the patients maintained a full response after enuretic alarm treatment in the 12 to 30 month follow-up.  Another 16% responded to combination therapy.

Combination desmopressin and oxybutinin therapy -60 children  68% response rate to desmopressin  Of those who did not respond to desmopressin alone a further group responded to both desmopressin and oxybutinin  A response was a 50% decrease in wet nights  No mention of relapse rates

Adherence to Guidelines over a 4 month period -41 children 2009 Jrnl Paed Uro  1. Compliance with a drinking schedule 2. Going to the toilet with adequate body 3. Adherence to medication intake 4. Compliance with a voiding schedule  the authors were pleased to have achieved over 70% parental and child compliance.  Treatment results were not mentioned

 Landmark study  Forsyth and Redmond Royal Belfast Children’s Hospital  1129 Irish bedwetters aged 5 and over  Aim was to determine natural cure rates  Intensive history, examination and investigation  A variety of treatments  Results and conclusions still stand

 5 to 10% of enuretics have incidental urological abnormalities but less than 1% have an organic cause for enuresis  Rewards, lifting, exercises, psychotherapy and drugs trialled did not improve outcomes.  Treating UTIs does not cure enuresis  In 830 children there was no correlation between bladder size and enuresis  Spontaneous cure rates are 14 to 16%  3 % still bed-wetting at age 20.