1. Hot Topic Enuresis

2. Definition Uncontrolled/Involuntary passage of urine by day/night/both Children aged 5 or over In absence of physical disease DSMM defines nocturnal enuresis as wetting at least x2/wk in the above group

3. Day or night? 85% nocturnal enuresis Daytime enuresis more likely associated with pathology Potentially large effect on family Bullying, problems with schoolwork, social life

4. Nocturnal enuresis Common - approx 15% of children experience it, rising to 75% if both parents had it. Disorder of sleep arousal, a low nocturnal bladder capacity and nocturnal polyuria History needs to distinguish b/w primary and secondary nocturnal enuresis. Primary - bladder control has never been achieved Secondary - lost after having had bladder control for at least 6 months

5. Nocturnal enuresis 15% of 5 year olds 5% of 10 year olds Teenagers 1-2% occasionally wet the bed Yearly spontaneous remission rate is 15% Usually can be considered a variation of the normal rate of maturation Girls usually ahead of boys 23% of nocturnal enuresis is associated with encopresis and daytime incontinence

6. Contributing factors Genetics - 70% have +ve family history Caffeine Emotional stress ADHD, premature delivery Organic pathology Disturbed sleep, mother young or smoker

7. Organic causes 1-2% have underlying physical cause UTI Chronic constipation Bladder overactivity Diabetes Renal failure Congenital anomalies eg ectopic ureter Neurological disorders eg neural tube defect Sleep apnoea

8. Assessment - History Age of child Nocturnal or daytime or both? Primary or secondary? Other urinary symptoms? (UTI, bladder overactivity) Hx of constipation/soiling? Sx of diabetes or of sleep apnoea? Family history? Girls: early morning wetting? (ectopic ureter) PMHx

9. Assessment - history How many dry nights past wk/month? Any potential causes of emotional distress Fluid intake at bedtime Diet - caffeine containing foods eg chocolate Impact on family Any strategies tried so far, ways parents respond to the wetting

10. Examination Abdo exam - distended bladder/mass/constipation Inspect perineum/genitals Spine Check lower limb neurology Growth chart

11. Investigations Urine for glucose, protein, C&S in more or less all. If daytime enuresis - consider USS abdo to exclude anatomical abnormalities/residual volume

12. Management If indication of underlying cause manage/refer as appropriate Eg deal with constipation/UTI Most children with enuresis are normal <5 yrs no need to treat <7 yrs and parents/child coping ok often no need to treat >10 treat promptly Advice

13. Management - advice Primary enuresis - occurs because the volume of urine produced at night exceeds the bladder capacity and the sensation of a full bladder doesn’t wake the child Not done out of defiance/contrariness Try not to be angry with the child, stress aggravates the situation Try to reinforce success Give it time if child is young

14. Simple advice for all Empty bladder before bed Avoid drinking after 1hr before bed Otherwise don’t restrict fluids - encourage regular intake throughout the day but avoid any containing methylxanthines Check access to bathroom at night Waterproof covers for bed Involve child in cleaning up mess but not as punishment

15. Enuresis alarms Tx of choice for long-term Mx. Children >7yrs. Needs to be a well-motivated child and family; Usually needed for 3-5 months. 30-50% of children relapse Sensor in pad under child or attached to underwear Alarms if gets wet - child has to get up to stop it. Parents must hear it too (eg baby monitor). Child to help with cleaning up. Child learns to waken before alarm sounds or to sleep through night without passing urine

16. Enuresis alarms If dry for 14 nights in a row can stop alarm Can be used together with drug treatment of needed Treat relapses promptly “Overlearning” - once dryness achieved encourage drinking at bedtime to “over- condition” bladder, stop once 14 dry nights. Avoid if child shares a room, more than one child has enuresis at once, unmotivated parents.

17. Star charts Alternative to enuresis alarm Involves a wall calendar and star stickers If dry in the morning child gets a sticker on the chart and praise as a reward Child responds to rewards - reinforce success As wetting less frequent can increase rewards value If bed is wet - no punishment but stay calm and practical

18. Desmopressin 2nd line treatment In general practice use as short-term measure School trips, sleepovers, holidays Effective in 70% but high relapse rate once stop use Can be used longer term but not initiated in primary care May be useful adjunct to alarm treatment

19. Desmopressin Synthetic version of antidiuretic hormone Reduces amount of urine produced - increased water resorption from distal tubules and collecting ducts Taken at night as tablet or a melt SEs - headache, nausea, congestion, nosebleeds, sore throat, cough, mild abdo cramps Risk of water overload - need to counsel parents and child - limit fluid intake to 1 cup from 1hr before to 8hrs after taking tab

20. Desmopressin Preferably use in >7yr olds Never use for daytime enuresis due to risk of fluid overload Usual dose 200mcg tab/120mcg sublingual tab at bedtime To determine dose and effectiveness trial of 2wks desmopressin. If not enough can try 2wks at double dose Once effective dose established can prescribe it for intermittent use when needed eg school trip

21. Secondary enuresis If wets after being dry for min 6 months Look for underlying cause physical/emotional Treat when able but consider referral for some causes or if can’t identify cause - enuresis clinic/paediatrics/child psychologist

22. Daytime enuresis Rule out organic causes Refer on to secondary care MSU + dipstix Usually USS Star charts/bladder training/pelvic floor exercises

23. When to refer Most cases can be managed in primary care Failed trials of alarm/star chart/desmopressin If parents not coping If suspicion of underlying cause Older children Daytime enuresis Severe psychological distress Secondary nocturnal enuresis if caused by emotional distress, cause not clearly identified or enduring/big impact

24. Who can you involve? Health visitor if child is pre-school School nurse Local enuresis clinic Voluntary groups eg ERIC for support and advice for parents

25. Resources ERIC - Education and Resources for Improving Childhood Continence www.eric.org.uk Clinical Knowledge Summaries www.cks.nhs.uk Tayside intranet - Bedwetting leaflet in Children’s hospital section wih local clinic details Oxford Handbook of General Practice DXS has selection of leaflets/evidence