ENURESIS

DEFINITION
• Repeated voiding of urine into clothes or bed at least
twice a week for at least 3 consecutive months in a
child who is at least 5 year of age.
• Diurnal enuresis-wetting while awake(10-25%)
• Nocturnal enuresis-voiding during sleep(75-90%)

• CLASSIFICATION:
PRIMARY-Children who have never been
consistently dry through the night.
SECONDARY- When bed wetting after at least 6
months of dryness.
• Monosymptomatic enuresis- without any other
symptoms.
• Non-monosymptomatic enuresis(Functional
voiding disorder)-Enuresis along with other LUT
symptoms like altered voiding frequency, daytime
incontinence, urgency, hesitancy, straining, weak
stream, intermittency, holding maneuvers, a
feeling of incomplete emptying, post micturition
dribble and genital or LUT pain.
 EPIDEMIOLOGY
• At age 5 year, 7% boys and 3% girls have enuresis.
• At age 10 year, 3% boys and 2% girls have
enuresis.
• At age 18 year, 1% for men and less then 1% for
women.
• Primary enuresis- 85% cases
• More common in lower socioeconomic groups
and larger families.
• Diurnal enuresis is more common in girls and
rarely after 9 years.
• 75% enuresis are nocturnal enuresis alone and
25% enuresis are combined day and night
incontinence.
• Several condition must be present to achieve
conscious bladder control:
-Awareness of bladder filling
-Cortical inhibition of reflex bladder contractions
-Ability to consciously tight the external sphincter
-Normal bladder growth
-motivation by the child to stay dry
 ETIOLOGY
• GENETIC-44% risk if one parent had it & 77% if both
parents had it.

• PHYSIOLOGICAL-secretion of less ADH at night

-sound sleep
-delayed maturation of sphincter
control

• PSYCHOLOGICAL FACTORS- acute stressful condition or

traumatic experience.
SECONDARY CAUSES- UTI
-Constipation
-Overactive bladder
-Detrusor-sphincter dyssynergia
-Non-neurogenic neurogenic bladder
-Vaginal voiding
-Cystitis
-Bladder outlet obstruction
-Spina bifida
-Ectopic ureter and fistula
-Sphincter abnormality
-Overflow incontinence
-Traumatic
-POLYURIA-Diabetes mellitus
Diabetes insipidus
-Chronic kidney disease
-Hypercalcemia
-Chemical urethritis
-Sickle cell anemia
-Seizures
-Pinworm infection
-Spinal dysraphism
-Neurogenic bladder
-Hyperthyroidism
-Drugs(SSRI, valproic acid, clozapine)
-Giggle or stress incontinence
 ASSESSMENT
• QUESTION TO BE ASKED:
-Pattern of incontinence-Frequency, urine volume
-Association with urgency, giggling
-Incontinence after voiding or continuous
-Sensation of incomplete bladder emptying
-Other urologic problems-UTI, reflux, neurologic
disorders, duplication anomalies in family, bowel
habits.
• PHYSICAL EXAMINATION-
-Short stature
-Hypertension
-Enlarged kidney/Bladder
-Constipation
-Labial adhesion
-Ureteral ectopy
-Sacral anomalies
-Neurological abnormalities
• INVESTIGATION:
-Urinalysis
-USG KUB
-Postvoid residual urine volume
-Uroflow with or without EMG
-MRI
-Voiding cystourethrogram
-Urodynamics-To distinguish GSI from detrusor instability
-For classification of neurogenic bladder
dysfunction
-To distinguish bladder outflow obstruction
from idiopathic detrusor instability
-To investigate incontinence or other lower
urinary tract symptoms.
• TREATMENT: According to etiology.
EXAMINATION/TEST OBSERVATION INFERENCE
GENERAL PHYSICAL POOR GROWTH POSSIBLE CHRONIC
EXAMINATION KIDNEY DISEASE

GENITAL EXAMINATION HYPOSPADIAS, PHIMOSIS, S/O ANATOMICAL

INCLUDING EXAMINATION LABIAL FUSION ANOMALIES
OF UNDERWEAR
FECAL SOILING OR WET S/O FECAL OR URINARY
UNDERWEAR INCONTINENCE
INSPECTION OF OCCULT SPINAL DYSRAPHISM: S/O NEUROLOGICAL
LUMBOSACRAL SPINE DIMPLE, LIPOMA, ABNORMALITIES
HYPERTRICHOSIS OR SACRAL
AGENESIS
URINE BIOCHEMISTRY GLUCOSURIA CONSIDER DM
PROTEINURIA(++ OR MORE) CONSIDER KIDNEY
DISEASE

URINE MICROSCOPY >10 WBC/hpf CONSIDER UTI

APPROACH TO A CHILD WITH BED-WETTING
BED-WETTING IN CHILD>5 YEAR

HISTORY AND EXAMINATION

URINE ANALYSIS

ABNORMAL FREQUENCY VOLUME CHARTING

HISTORY OF NON-MONOSYMPTOMATIC ENURESIS

YES NO

MONOSYMPTOMATIC
REFER TO PEDIATRICIAN
NOCTURNAL ENURESIS

TREAT WITH RECORDS AND

REWARDS

POOR RESPONSE

GOOD
 TREATMENT
• REGULATED ORAL FLUID INTAKE
• MOTIVATIONAL THERAPY
• ALARM THERAPY
• PHARMACOTHERAPY
• REGULATED ORAL FLUID INTAKE-
-withholding fluid in the evening, random
awakening of the child.
-Diuretic drinks like tea, coffee should be avoided
in the evening.
-Adequate intake of fluids should be taken mostly
during first half of the day.
• MOTIVATIONAL THERAPY- The child is reassured,
provided emotional support and every attempt is made
to remove any feeling of guilt.
-Make a dedicated calendar for the child by parents.
-Dry nights should be marked with a star.
-Wet nights should be blank.
-Any negative motivation like black marks or punishments
should be discouraged.
-At the end of the week, the child should be rewarded for
the dry nights.
• ALARM THERAPY- 75-95% success rate.
-40% relapse rate require second alarm course.
-Use of an alarm device to elicit a conditioned response of
awakening to the sensation of voiding with bladder distention.
-The alarm device consists of a small sensor attached to the
child’s underwear or under the bed sheet & alarm attached
to the child’s collar or bedside.

• Few important point for successful alarm therapy:

-A parent should help him get up when alarm goes off
during first week of treatment.
-It should be continuous, no weekend alarm holidays.
-Instructor should provide frequent follow-up.
-If no positive effect after 6-8 week, then treatment
should be stopped. Otherwise, it should continue until
at least 14 consecutive dry nights have been achieved.
• eg:Rodger wireless bedwetting alarm-2200/-
Drybuddy EZ- $29.99
Dry-me- $49.95
Malem-wireless bedwetting alarm system- $189.95
Wet-stop3bedwetting alarm- $49.95
One drop detection intelliflex sensor for chummie
bedwetting alarm- $19.95
• PHARMACOTHERAPY-
MEDICATION DOSE DURATION SIDE EFFECTS PRECAUTIONS
OF USE
DESMOPRESSIN o.2mg POqhs, 4 WEEK DRY WATER INTOXICATION RESTRICT FLUIDS
max upto 0.6 AND THEN HYPONATREMIA, WT 3 hrs BEFORE
mg TAPERED GAIN, HEADACHE, THE DOSE
OFF OVER 3 EPISTAXIS, SEIZURES,
WEEK ABDO PAIN, NAUSEA
OXYBUTININ 10-20 mg/day 3-6 MONTH DRYNESS OF MOUTH, ADEQUATE ORAL
STOMACH PAIN, FLUIDS AND
PALPITATIONS, PREVENT
CONSTIPATION, CONSTIPATION
BLURRING OF VISION
TOLTERIDONE 2-4 mg/day 3-6 MONTH SAME AS
BEFORE OXYBUTYNINE BUT
BEDTIME LESS INTENSE
IMIPRAMINE 1.5-2 mg /kg 2 3-6 MONTH ANXIETY, MOOD ECG TO RULE
hr BEFORE THEN DISTURBENCES, OUT LONG QT
BEDTIME TAPERED PERSONALITY SYNDROMES. 2
NOT TO EXCEED CHANGE, WK OFF
2.5 mg/kg OR PALPITATIONS MEDICATION
75mg MAX EVERY 3 MONTH
• BRAND NAME & COST-
• Desmopressin- Minirin tab-0.1mg:200/-
-Minirin nasal spray:400/-
-D-void nasal spray:980/-
• Oxybutinin-Nocturin-5mg: 50/-
-Oxybutin-2.5 mg: 42/-
-5 mg: 49/-
-Oxyspas-2.5 mg: 42/-
-5 mg: 49/-
-Tropan XL-5 mg: 80/-
-10 mg: 149/-
-Tropan syp(100 ml)- 90/-
• Tolteridone-Dezrola-1 mg: 55/- ; 2 mg: 90/-; 4 mg: 155/-
-Roliten-1 mg: 68/-; 2 mg: 99/-; 4 mg: 199/-
-Terol LA-1 mg: 55/-; 2 mg: 80/-; 4 mg: 160/-

• Imipramine-Depsonil-25 mg: 10/-

-Min-50 mg: 17/-
-Imprin 25 mg: 7/-
-Antipress-25 mg: 8/-
-50 mg: 15/-
-75 mg: 18/-
-Antipres-50 mg: 15/-
-75 mg: 18/-
-Depnil-25 mg: 6/-
-75 mg: 15/-
 BEST THERAPEUTIC OPTION
• Normal UOP and normal bladder capacity- should
first offered the alarm.
• Smaller than expected bladder capacity for age will
likely be Desmopressin-resistent and more sensitive
to alarm along with an anticholinergic medication
like Oxybutynine and Tolteridone.
• Nocturnal polyuria and normal bladder volume will
be more sensitive to Desmopressin.
• Both excessive UOP and reduced bladder capacity
may find combined therapy of alarm and
desmopressin to be successful.
 OUTCOME
• In monosymptomatic enuresis success rates up to 82%
with alarm therapy and 77.8% with Desmopressin.
• Relapse rates are much higher with Desmopressin and
Imipramine and least with alarm therapy.
• Identification of non-monosymptomatic enuresis is
essential because timely treatment has good outcome
and if left untreated may result in complications like poor
self esteem, scholastic backwardness and recurrent UTI.
 SUMMARY

• Enuresis risk is 44% if one parent had it and 77% if both

parents had it.
• Annual spontaneous cure rate-15%
• Complete physical examination and relevant investigation
should be done to rule out secondary causes.
• Best treatment option is motivational therapy.
 REFERENCES
• NELSON TEXTBOOK OF PEDIATRICS
• IAP JOURNAL SEPTEMBER 2013
• GHAI TEXTBOOK OF PEDIATRICS
THANK YOU