1. MANAGEMENT AND ASSESSMENT OF WETTING ISSUES IN CHILDREN; ENURESIS
Dr Fiona Cameron
Community Paediatrician
Motherwell

2. Enuresis Definitions Aetiology Anatomy and physiology Impact
Assessment
Treatment options
Summary

3. DEFINITIONS IN ENURESIS

4. Definitions; ICCS THE INTERNATIONAL CHILDRENS CONTINENCE SOCIETY
The journal of Urology July 2006
Volume 176. number 1.
New definitions and standardised terminology in the field of the lower urinary tract

5. URINARY INCONTINENCE Continuous incontinence Intermittent incontinence
Day-time incontinence
Nocturnal incontinence, Enuresis

6. Definition ENURESIS Intermittent incontinence whilst sleeping
This is regardless of whether voiding is normal or not, what the suspected cause is, or the presence or absence of daytime wetting

7. PRIMARY ENURESIS; A child who has never been dry for more than six months
SECONDARY ENURESIS; A child who has previously been dry for more than six months

8. MONO-SYMPTOMATIC ENURESIS
Enuresis in a child with no day time bladder symptoms,
NON MONO-SYMPTOMATIC ENURESIS
Enuresis in a child with day time
bladder symptoms,

9. Prevalence in school children
Yeung et al. BJU Int 2006;97:1069–73 25
Male (n=7455)
Female (n=9057) 20
All (n=16512) 15
Prevalence (%) 10 5 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19
Age (years)

10. PREVALENCE ACCORDING TO AGE:
At 5 years = 16.1%
At 7 years = 10.1%
At 9 years = 3.1%
At 19 years = 2.2%
SPONTANEOUS REMISSION RATE
15% PER YEAR

11. AETIOLOGY
GENETICS
EXPERIENCES
PSYCHOLOGICAL DISTURBANCE

12. AETIOLOGY OF ENURESIS

13. AETIOLOGY; FAMILY HISTORY
15% risk where there is no parental history of enuresis
40% if siblings also had PNE
43% risk where only one parent had been enuretic as a child
77% risk where both parents had been enuretic as a child
75% risk where both parents have been enuretic as children
Bakwin. Am J Dis Child 1971;121;222–5; Jarvelin et al. Acta Paediatr Scand 1988;77:148–53

14. AETIOLOGY; Formula feeding and low birth weight UTI
Developmental delay
Emotional upset
Urinary tract abnormalities
Diabetes Mellitus
Recurrent UTI
Kidney disease
ADHD and other behavioural difficulties
Sleep Apnoea (Snoring)

15. HOW THE CHILD VIEWS ENURESIS
1998 Study youngsters aged 8–16 years rated bedwetting as the third most traumatic event following divorce and parental fighting.
ALSPAC study year old children were asked to rate difficulty of life events Enuresis was rated fourth out of twenty one .

16. ALSPAC
The Avon Longitudinal Study of Parents and Children (ALSPAC) was formerly called the Avon Longitudinal Study of Pregnancy and Childhood.
ALSPAC is also known locally as Children of the 90s.
ALSPAC recruited more than 14,000 pregnant women with estimated dates of delivery between April 1991 and December These women, the children arising from the index pregnancy and the women's partners have been followed up since then and detailed data collected throughout childhood.
ALSPAC is a two-generational resource available to study the genetic and environmental determinants of development and health.

17. IMPACT OF ENURESIS

18. These are potential effects and by no means universal
IMPACT
These are potential effects and by no means universal
Some children are not adversely affected and have no long term sequelae
However some do….

19. IMPACT ON CHILD THE CHILD CAN Feel ashamed Fear bullying Feel guilty
this can lead to restriction in activities
no sleepovers or with only certain family members
No school trips

20. IMPACT ON CHILD Impaired self image and self esteem
Impaired emotional state
Avoidance behaviour
Attention span,
Achievement
Performance IQ
Children with non mono-symptomatic enuresis are more vulnerable to adverse psychological effects.

21. IMPACT ON PARENTS Feel helpless Worry about health of child
Upset about impact on child’s life
Upset about impact on their life
Significant financial cost
Last straw……

22. IMPACT ON FAMILY RELATIONSHIPS
STRESS ON CHILD AND FAMILY CAN LEAD TO….
PARENTAL INTOLERENCE where the child is seen as lazy and disinterested
CHILD ABUSE

23. EFFECTS OF TREATMENT
THERE ARE A RANGE OF EVIDENCE BASED TREATMENTS AVAILABLE
SIGNIFICANT IMPROVEMENT in psychological functioning follows treatment
ALL ASPECTS BENEFIT from treatment; attention, achievement, Social, emotional, avoidance behaviours, low self esteem

24. Treatment is for Everyone
SPECIAL NEEDS
For the majority of children with mild to moderate learning difficulties in the absence of any neurological difficulties there is no reason why they should not be toilet trained and even those with more severe problems have been found to respond to training (Louiselli, 1994)

25. ANATOMY AND PHYSIOLOGY IN ENURESIS

26. URINARY TRACT

27. KIDNEY; FUNCTION
BLOOD is brought to the kidneys through the renal arteries
KIDNEYS filter blood at a rate of a litre a minute (20% of blood circulating volume per minute.)
THE FILTRATE is then modified by the kidneys depending on the requirements of preservation or excretion of the body
URINE REGULATION a minimum urine production is an absolute necessity

28. URINE PRODUCTION
KIDNEYS; regulate urine production to maintain disposal of waste products and maintain fluid balance in the face of…..
OSMOTIC PULL e.g. naturesis, acid base balance, fluid load etc
HYPOTHALAMUS/PITUITARY who maintain water regulation
ALDOSTERONE which maintains salt regulation
etc etc etc

29. NEPHRON STRUCTURE

30. CONCENTRATION OF URINE
SODIUM is actively reabsorbed in the proximal tubule and 70% of water in the filtrate is reabsorbed with it.
The remaining 30% of WATER is reabsorbed in the distal tubule and collecting ducts.
This reabsorbtion is dependent on ANTI DIURETIC HORMONE (ADH) also known as Vasopressin
Without ADH only dilute, hypo-osmolar urine is produced.

31. BLADDER; URINE STORAGE AND RELEASE

32. URINE STORAGE BLADDER WALL; DETRUSOR MUSCLE;
Relaxes during bladder filling and contacts during bladder emptying (autonomic control)
BLADDER; NECK INTERNAL SPHINCTER
Contracts during bladder filling and relaxes during bladder emptying (autonomic control)
EXTERNAL SPHINCTER; PELVIC FLOOR
Contracts to maintain bladder and bowel integrity (voluntary control)

33. BLADDER TRAINING Bladder awareness begins in infancy.
Modification of bladder function over time leads to the brain taking control of bladder function usually by age 3 to 4 years.
BLADDER-BRAIN-KIDNEYS
Working in harmony
For toilet training

34. DAY TIME CONTINENCE Successful toilet training requires…
Recognition of a full bladder or bowel
Appropriate access to toilet facilities
Ability to indicate need
Will to act upon need
The ability to “hold on”
Generally 2 ½ to 3 ½ yrs

35. NIGHT TIME CONTINENCE DRY NIGHTS ARE ACHIEVED
When a bladder doesn’t need to empty when you are asleep.
Or if a bladder does need to empty and
you can wake to void.
Generally 5 years and above

36. Bladder-Brain Relationship

37. Impaired arousal response
THREE SYSTEMS MODEL
Nocturnal
polyuria
(Lack of ADH Release)
Reduced nocturnal
functional bladder
capacity
Nocturnal enuresis
Impaired arousal response
to bladder fullness
from sleep

38. Impaired arousal response
THREE SYSTEMS MODEL
Nocturnal enuresis
Impaired arousal response
to bladder fullness
from sleep

39. AROUSAL and SLEEP
Pontine Micturition centre; fills bladder to capacity overnight
Micturition Control centre; recognises bladder is full and defers
Arousal centre; wakes you up

40. Therefore AROUSAL is the problem
AROUSAL and SLEEP
Children with Enuresis have the same number of stages and the same amount of the different depths of sleep as other children
Wetting can occur during all stages of sleep and not always during “deep” sleep yet many parents have reported their children to be a “deep sleepers”
Even though sleep may lighten and children may become restless there is not wakening to a full bladder
Therefore AROUSAL is the problem

41. SLEEP
Several studies have now shown that patients with enuresis have elevated arousal thresholds
Elevated sleep threshold is associated with increased bladder activity
Sleep architecture becomes normal and sleep arousal thresholds return to normal post treatment

42. THREE SYSTEMS MODEL Nocturnal enuresis Nocturnal polyuria
(Lack of ADH Release)
Nocturnal enuresis

43. (defined by ICCS as 130% of Expected Bladder Capacity)
NOCTURNAL POLYURIA
Where nocturnal urine production exceeds normal nocturnal bladder capacity.
(defined by ICCS as 130% of Expected Bladder Capacity)

44. NOCTURNAL POLYURIA WATER REGULATION/FLUID BALANCE is controlled by
The HYPOTHALAMUS and PITUITARY.
The Hypothalamus monitors changes in extra cellular fluid volume, the sodium concentration and osmotic pressure of plasma. It then signals the post pituitary to release Vasopressin/Anti-Diuretic Hormone into the bloodstream.

45. NOCTURNAL POLYURIA
ADH/Vasopressin released when water conservation is required. It acts on the collecting ducts to reduce water loss from kidneys.
ADH/Vasopressin is suppressed when increased water loss is required from kidneys.

46. VASOPRESSIN AND URINE Vasopressin levels pg/ml
Urinary excretion rate ml/hr
Non enuretic child
Non enuretic child
Enuretic child
Enuretic child
5.0 80 70
4.0 60 50
3.0
pg/ml
ml/hour 40
2.0 30 20
1.0 10
0.0
Day
Night
Rittig S et al. Am J Physiol 1989;256:F664–71

47. THREE SYSTEMS MODEL Nocturnal enuresis Reduced nocturnal
functional bladder
capacity
Nocturnal enuresis

48. REDUCED FUNCTIONAL NOCTURNAL BLADDER CAPACITY
Generally associated with day-time symptoms/ low bladder capacity but not always
Low bladder capacity; ICCS definition; where actual day time voided volumes are less than 70% of Expected Bladder Capacity
(EBC=Age +1x30)

49. ASSESSMENT OF ENURESIS

50. HISTORY Family Situation Fluid intake Voiding habits Bowel habits
Sleep habit
Co-existing conditions
History of bedwetting inc. family history
Previous experiences
Daytime symptoms

51. HISTORY; VOIDING HABITS
Frequency
Increased frequency 8 or more voids a day
Decreased frequency 3 or less voids a day
Particularly ensure voiding just before falling asleep
Include nocturia
……….Remember access to toilet

52. History needs to include
HISTORY; STOOL HABIT
Constipation can be difficult as people have differing ideas of normality
Rome iii Criteria
History needs to include
Frequency of stool
Type of stool (Size and consistency)
Associated pain
Faecal incontinence

53. HISTORY; VOIDING SYMPTOMS
Urgency; can be normal in younger children
Refusal to void
Hesitancy
Interrupted stream
Dysuria
Holding manoeuvres

54. HISTORY; TRIGGERS TO WETTING
Urge incontinence
-Wetting when rushing to go to the toilet
Giggle incontinence
-Wetting when you laugh a lot
Preoccupied wetting
-Wetting when you don’t notice
Incontinence immediately post void
-Wetting as soon as you have been for a pee
Stress incontinence
-Wetting when coughing or sneezing

55. HISTORY; DAYTIME WETTING
OVERACTIVE BLADDER
Urgency
Increased voiding frequency
Urge incontinence
UNDERACTIVE BLADDER
Low voiding frequency
May need to increase intra abdominal pressure to void

56. HISTORY; DAYTIME WETTING
DYSFUNCTIONAL VOIDING
Habitual contraction of the external sphincter during voiding
Often unable to empty bladder against the resistance of the sphincter so is associated with residual volume in bladder left after voiding

57. EXAMINATION Good history Height and weight Ankle reflexes
Abdomen checking for masses
Spine; pigmentation, hair etc
Genitalia only if indicated

58. INVESTIGATION
IN ALL CASES
DIPSTIX URINE: MSSU if indicated BP

59. INVESTIGATION for selected cases
Bladder diary
Detailed renal and bladder ultrasound
Residual bladder volume
Flowmetery
Urodynamics
Nb Plain x-ray abdomen

60. FURTHER INVESTIGATIONS RESIDUAL VOLUME.
What is left after voiding is called POST VOID RESIDUAL VOLUME, it is usually near to zero however a normal residual volume is up to 10% of Estimated Bladder Capacity (EBC)
Greater than 10% of EBC suggests incomplete bladder emptying

61. TREATMENT OPTIONS IN ENURESIS

62. Treating nocturnal enuresis
“Good clinical practice would thus recommend that a 5-year-old child who is bothered by his or her bedwetting, and motivated to receive treatment, should indeed receive adequate interventions to help them overcome their wetting”

63. TREATMENT OF ENURESIS SUPPORT CONSTIPATION STANDARD MANAGEMENT
FLUID INTAKE
VOIDING
INCENTIVE CHARTS
MEDICATIONS
ALARMS

64. SUPPORT
Treatment failures are known to be associated with a greater emotional impact
Good support will lessen the emotional impact
No treatment is 100% successful for everyone
1% of adults have nocturnal enuresis
Other co-moribidities exist
We are human we need it!

65. Severity of PNE versus age (A)20
<3 wet nights/week
3–6 wet nights/week 16
7 wet nights/week 12
Prevalence (%) 8 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19
Age (years)
Yeung et al. BJU Int 2006;97:1069–73

66. STANDARD TREATMENT Lifting and waking Nappies
Adjustments to fluid intake
Adjustments to voiding habits

67. LIFTING AND WAKING
Some concern it may programme the child to void during sleep therefore recommended the child is as awake as possible and that the time is varied
Can work well in some families but if not successful within a week recommended to stop

68. NAPPIES
AVOID PUNITIVE
MEASURES
Can save the sanity
of some parents

69. FLUID INTAKE Predominately clear fluids 6-7 drinks or 1 to 1 ½ litres
evenly spread throughout the day
Avoid….
Early morning drought
Caffeine containing or carbonated drinks
Milk late at night
?Blackcurrant

70. VOIDING Regular relaxed voiding
Go to the toilet as soon as you first feel the need for it
Even better, go to the toilet at regular intervals before your bladder tells you to about 6 to 7 times a day.

71. MEDICATION VASOPRESSIN ANALOGUE; DESMOPRESSIN
ANTI CHOLINERGIC; OXYBUTYNIN
IMIPRAMINE

72. DESMOPRESSIN Analogue of vasopressin (ADH) Potent antidiuretic
Concentrates urine
Available in Tablet or Melt formulation
The spray formulation was withdrawn for Nocturnal enuresis in 2007

73. DESMOPRESSIN TREATMENT REGIMEN
Desmopressin initial dose:
0.2 mg oral, 120µg melt or for 2 weeks No
Increase dose by 0.2 mg, 120 µg to max.
0.4 mg, 240 µg evaluate after 2 weeks
Dry nights?
Yes
Yes
Desmopressin
for 3 months
Dry nights?
1-week drug-free period.
Dry without desmopressin?
Yes
Stop treatment No
Continue desmopressin for 3 months

74. DESMOPRESSIN OVERALL SUCCESS 50-70%
Desmopressin can be given long term with breaks approximately every three months to ensure treatment is still required
Full response %
Partial response %
There is no increase in adverse affects with long term use

75. DESMOPRESSIN MORE LIKELY TO USE IF
There is a high nocturnal urinary output
There is Parental intolerance
A “quick fix” needed

76. OXYBUTYNIN
Has both anti-cholinergic and direct smooth muscle relaxant effects on the bladder. Provides local anaesthetic effect on irritable bladder. Urodynamic studies have shown that Oxybutynin increases bladder size, and delays initial desire to void

77. OXYBUTYNIN
Anecdotally it works for children with a small bladder capacity
However in Cochrane review of day time wetting there was little evidence that Oxybutynin on it’s own was any better than placebo. It may need better study!
It has been found to be useful in combination 70% response compared to 50% (Caione et all 1997)

78. IMIPRAMINE Has anti-cholinergic action
Affects sleep centres in the brain
Antidiuretic effects
20% dry on treatment but relapse rate is high
Can still used on a very selected group
NOT RECOMMENDED AS FIRST LINE
due to cardio-toxicity

79. ALARM TREATMENT
ENURESIS ALARMS have been around in some form since the early part of the last century. They were developed into the Bell and Pad in the 1950’s
ALARMS are a pad which detects moisture attached to a device to alert the wearer.
THE PAD can be a bed mat or small enough to wear in underpants
THE ALERT can be by sound, vibration and/or light

80. ALARM TREATMENT: Overall success rates – 30–87% MORE LIKELY TO WORK
-In small bladder capacity
-if child motivated
-if family supportive
-If wets once per night
-if wakes easily
Can relapse

81. ALARM USE Only give the alarm if family are ready to use it
Can be used at an earlier age but generally recommended to be from 8 years upwards
Best age is probably 9 or 10 years
May take 4 to 6 months to achieve maximum success

82. ALARM USE ATTACH ALARM just before bedtime and after last micturition.
ATTACH ALARM under bed sheet or between two pairs of pants.
WHEN ALARM SOUNDS turn off alarm only after child is awake. The child goes to the toilet to try micturition. When returning to bed re-attach alarm.

83. ALARM USE
CONTACT; Works best with good support. This will require regular contact e.g. every 2 weeks in the beginning
EXPECTATIONS; dry night may take 18 wet nights to appear. Early signs may be quicker waking with a reduction the in amount or frequency of wetting

84. ALARMS NOCTURNAL VOIDING PATTERNS
Study of 60 Children with Enuresis
Successful treatment resulted in
65% sleeping through the night without wetting
35% developing nocturia
43 children had a 75% or greater reduction in wetting.
Mean duration was 65 days or about 9 wks.

85. COMPLIMENTARY THERAPIES
Acupuncture
Bowen
Homeopathy
Chiropractice
No definite evidence exists for efficacy but studies are ongoing

86. SUMMARY

87. HOW TO PICK YOUR THERAPY Available therapies
Good sleep habits
Regular bowel habit
Fluids
Toileting
Desmopressin
Oxybutynin
Alarm

88. Refer to specialised service
8 MINUTE CONSULTATION
Ensure Primary Enuresis
Exclude constipation
Exclude day time symptoms
Check urine
Check BP
Fluids; clear fluids in early part of the day with no fizzy, caffeine or milk at night.
Toilet last thing
Refer to specialised service

89. How to decide?
Weigh up
Clinical acumen
Give informed choice

90. Further supports www.urinecontrol.co.uk www.eric.org.uk