A PHYSICIAN’S GUIDE
TO THE MANAGEMENT
OF BEDWETTING
Boris Chertin
The Department of Urology,
Shaare Zeddek Medical Centre
Primary Nocturnal Enuresis (PNE) –© Dr Boris Chertin 2004
Edited & Prepared for Jerusalem Academic Family Practice Website by BHS .
For private study only
-1-
OBJECTIVES
•
•
•
•
•
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Definition and Terminology
Etiology
Epidemiology
Patho-Physiology
Treatment outcome
Recommendations
Primary Nocturnal Enuresis (PNE) –© Dr Boris Chertin 2004
Edited & Prepared for Jerusalem Academic Family Practice Website by BHS .
For private study only
Definition of Primary
Nocturnal Enuresis
(PNE)
1. A disorder of humanity
2. Enuresis is complete and normal
micturation taking place at an
inappropriate or socially unacceptabe
time or place
3. Primary Nocturnal Enuresis (PNE) is
bedwetting during sleep in healthy
children from the age of 5-6 years.
Primary Nocturnal Enuresis (PNE) –© Dr Boris Chertin 2004
Edited & Prepared for Jerusalem Academic Family Practice Website by BHS .
For private study only
NOCTURNAL ENURESIS (NE)
• Mono-Symptomatic Nocturnal Enuresis with no
daytime symptoms
• Primary NE with no dry periods for at least 6 months
• Secondary
May be worth seeking treatment in child with 1-3 wet
nights in month
For research purposes inclusion criteria usually require
14 nights of bedwetting
Primary Nocturnal Enuresis (PNE) –© Dr Boris Chertin 2004
Edited & Prepared for Jerusalem Academic Family Practice Website by BHS .
For private study only
Terminology
25%
75%
60%
40%
Primary Nocturnal Enuresis (PNE) –© Dr Boris Chertin 2004
Edited & Prepared for Jerusalem Academic Family Practice Website by BHS .
For private study only
ETIOLOGY
• Hereditary disorder
• Autosomal dominant
– If both parents affected risk = 77%
– If one parent affected risk = 45%
– Sporadic bedwetting in 30%
• Hereditary trait leads to delay maturation but
not to permanent damage
• Genetic mapping is not completed
Primary Nocturnal Enuresis (PNE) –© Dr Boris Chertin 2004
Edited & Prepared for Jerusalem Academic Family Practice Website by BHS .
For private study only
Incidence1 (%)
NOCTURNAL ENURESIS
Epidemiology
50%
45%
40%
35%
30%
25%
20%
15%
10%
5%
0%
43%
30%
20%
15%
10%
3
4
5
6
7
Age (years)
Primary Nocturnal Enuresis (PNE) –© Dr Boris Chertin 2004
Edited & Prepared for Jerusalem Academic Family Practice Website by BHS .
For private study only
7%
8
5%
3%
9
12
2%
>18
NOCTURNAL ENURESIS
Epidemiology
Primary Nocturnal Enuresis (PNE) –© Dr Boris Chertin 2004
Edited & Prepared for Jerusalem Academic Family Practice Website by BHS .
For private study only
SPONTANEOUS RESOLUTION
• 20-25% at age 4 yrs
• 5-10% at age 7 yrs
• spontaneous resolution rate
– 14% between age 5 and 9 yrs
– 16% between age 10 and 19 yrs
• 1.5-3% have persistent NE
• Frequency and severity of wetting episodes
progress with age
– 14% wet every night at age 5
– 37% wet every night at age 19
Primary Nocturnal Enuresis (PNE) –© Dr Boris Chertin 2004
Edited & Prepared for Jerusalem Academic Family Practice Website by BHS .
For private study only
NOCTURNAL ENURESIS
Impact of Enuresis on Children
• Psycho-social impact:
• Shame
• Guilt
• Low self-esteem
• Interferes with age appropriate activities
• As child matures, feelings may evolve
into behavioural abnormalities in 40% of affected
children( von Contard et al)
Primary Nocturnal Enuresis (PNE) –© Dr Boris Chertin 2004
Edited & Prepared for Jerusalem Academic Family Practice Website by BHS .
For private study only
PSYCHOLOGICAL IMPACT
•
•
•
•
•
•
Social avoidance
Emotional state
Personality ( sense of difference)
Self-concept
Behaviour
Treatment effects
Primary Nocturnal Enuresis (PNE) –© Dr Boris Chertin 2004
Edited & Prepared for Jerusalem Academic Family Practice Website by BHS .
For private study only
PSYCHOLOGICAL ASPECTS
• Physicians should generally treat NE as a biobehavioral problem without a psychiatric component
• Substantial feelings of shame of inferiority
• Serious psychological components are caused by NE
• Small but significant risk of social adjustment in NE
in children older than 10 yrs
• Many parents are tolerant to their children’s
bedwetting but up to one third punish them
Primary Nocturnal Enuresis (PNE) –© Dr Boris Chertin 2004
Edited & Prepared for Jerusalem Academic Family Practice Website by BHS .
For private study only
NOCTURNAL ENURESIS
Effect of Treatment (Alarm or DDAVP) and Self-Esteem2
Self-Esteem: Before Treatment
Bedwetters << Controls
Self-Esteem: After 3 Months
Bedwetters < Controls
Self-Esteem: After 6 Months
Bedwetters = Controls
“After 3 months of treatment, a pronounced improvement in self-esteem was observed in enuretic
patients and 6 months of treatment led to the normalization of self-esteem in the enuretic group.”
2. Häglöff et al., Scand J Urol Nephrol, 1997
Primary Nocturnal Enuresis (PNE) –© Dr Boris Chertin 2004
Edited & Prepared for Jerusalem Academic Family Practice Website by BHS .
For private study only
PATHOPHYSIOLOGY




Bladder function
Sleep
Urine production
Other causes
• Psychopathology
• Upper airway
obstruction
• Constipation
Primary Nocturnal Enuresis (PNE) –© Dr Boris Chertin 2004
Edited & Prepared for Jerusalem Academic Family Practice Website by BHS .
For private study only
NOCTURNAL POLYURIA
Primary Nocturnal Enuresis (PNE) –© Dr Boris Chertin 2004
Edited & Prepared for Jerusalem Academic Family Practice Website by BHS .
For private study only
Diurnal Variation in Plasma Vasopressin
Primary Nocturnal Enuresis (PNE) –© Dr Boris Chertin 2004
Edited & Prepared for Jerusalem Academic Family Practice Website by BHS .
For private study only
BLADDER DYSFUNCTION IN NE
• One third of NE children have bladder over-activity
• Those who are not responders to Desmopressin
• 63% of adult patients with idiopathic detrusor
instability had childhood bedwetting
• Similar figures in both sexes
• Should be considered in failed desmopression and
alarm trail
–
–
–
–
41 children with mean age 10 yr old failed desmo.
None had nocturnal polyuria
All had nocturnal overactive bladder
44% had normal day urodynamic
Primary Nocturnal Enuresis (PNE) –© Dr Boris Chertin 2004
Edited & Prepared for Jerusalem Academic Family Practice Website by BHS .
For private study only
Young et al J Urol., 162;1049, 1999
SLEEP, AROUSAL & NE
• “ Sleeps very deeply”
• Impaired arousal in NE patients
• Noradrenalin network is responsible for arousal (near
locus coeruleus)
• It is activated by bladder over-distention in deep sleep
• EEG of Enuretic child does not show any changes during
enuresis or change from deep to light sleep
• Inadequate inhibition of micturition reflex
Primary Nocturnal Enuresis (PNE) –© Dr Boris Chertin 2004
Edited & Prepared for Jerusalem Academic Family Practice Website by BHS .
For private study only
DIAGNOSIS
 Family history of PNE
 Milestones in development
 Daytime symptoms
 Wetting frequency
 Other diseases
 Previous treatment
 Other investigations
Primary Nocturnal Enuresis (PNE) –© Dr Boris Chertin 2004
Edited & Prepared for Jerusalem Academic Family Practice Website by BHS .
For private study only
MANAGEMENT
• Determine the child’s motivation and exclude
confounding psychological factors
• Provide information and instruction regarding
fluid intake, voiding and resting routines
• Alarm or Medical treatment
Primary Nocturnal Enuresis (PNE) –© Dr Boris Chertin 2004
Edited & Prepared for Jerusalem Academic Family Practice Website by BHS .
For private study only
MOTIVATION & SOCIAL PROBLEMS
•
•
•
•
Parents are concerned, the child may not be
Do you want to be dry?
Prolonged course of treatment
Social misery and child behavioral problems
should be identified at initial stage
Primary Nocturnal Enuresis (PNE) –© Dr Boris Chertin 2004
Edited & Prepared for Jerusalem Academic Family Practice Website by BHS .
For private study only
DAILY HABITS
• Eating & drinking habits
• Low sodium and calcium dinner diet
• Voiding patterns (delay micturition e.g. by
avoiding school toilets )
• Active participation of school staff
• Establishing regular drinking and voiding
schedule
Primary Nocturnal Enuresis (PNE) –© Dr Boris Chertin 2004
Edited & Prepared for Jerusalem Academic Family Practice Website by BHS .
For private study only
PHARMACOLOGICAL TREATMENT
Subgroup of patients with nocturnal polyuria
• Swedish Enuresis trial
–
–
–
–
393 children
Intranasal desmopressin 10-40 µg
50% reduction in wet episodes in 62% of children
31% completely dry, mostly in the first 6 months
• Positive predictive factors are few wet nights, one
enuretic effect in night and age 8 and higher
• Morning osmolality has no predictive value
• No serious side effects seldom to interrupt study
Primary Nocturnal Enuresis (PNE) –© Dr Boris Chertin 2004
Edited & Prepared for Jerusalem Academic Family Practice Website by BHS .
For private study only
NOCTURNAL ENURESIS
But which Minirin® format to use?
Minirin Nasal Spray
‫מאושר בכל קופות החולים‬
‫בסבסוד מקסימלי‬
Minirin Tablets 0.1 & 0.2mg
‫ לאומית‬,‫מאושר בקופות החולים מכבי‬
‫ומאוחדת בסבסוד מקסימלי‬
Primary Nocturnal Enuresis (PNE) –© Dr Boris Chertin 2004
Edited & Prepared for Jerusalem Academic Family Practice Website by BHS .
For private study only
NOCTURNAL ENURESIS
Minirin® 0.2 mg Tablets:
 Easy to teach
 Easy to learn
 Easy to administer
 No issue with colds or allergies
 More discreet
Primary Nocturnal Enuresis (PNE) –© Dr Boris Chertin 2004
Edited & Prepared for Jerusalem Academic Family Practice Website by BHS .
For private study only
Long-term effects show that:
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Full blood count
Liver function tests
Prolactin levels
Electrolytes and creatinine
Thyroxine
Follicle stimulating hormone
Cortisol
Blood urea
Luteinizing hormone
Vasopressin concentration
Primary Nocturnal Enuresis (PNE) –© Dr Boris Chertin 2004
Edited & Prepared for Jerusalem Academic Family Practice Website by BHS .
For private study only
were
normal in
all patients
PREDICTORS OF OUTCOME
pharmacological therapy
•
•
•
•
•
•
•
•
Older child
Less severe NE in terms of number of wet nights/week
Normal functional bladder capacity
When enuretic episodes occur during first 2 hours of sleep
Primary NE
Family history
Increased urine production during the day
Increased birth-weight
Primary Nocturnal Enuresis (PNE) –© Dr Boris Chertin 2004
Edited & Prepared for Jerusalem Academic Family Practice Website by BHS .
For private study only
ENURETIC ALARM
• All designs are similarly effective
• It should continued up to 6-8 weeks if no effect is
initially achieved
• Cure may be achieved in 43% of the patients
• Compliance remains a problem
• Cured in Childhood Adults (26%) report alarm as
embarrassed and awkward
• In some cases it wakes a family but not the child!
• Development of a new technically superior model is
essential
Primary Nocturnal Enuresis (PNE) –© Dr Boris Chertin 2004
Edited & Prepared for Jerusalem Academic Family Practice Website by BHS .
For private study only
ENURETIC ALARM
Mechanism of action
•
•
•
•
Increased expectation of success
Avoidance conditioning
Increased bladder capacity
Increased production of AVP in response to
stress of waking to alarm
• A conditioning support (pelvic floor
contraction in the presence of detrusor
contraction)
Primary Nocturnal Enuresis (PNE) –© Dr Boris Chertin 2004
Edited & Prepared for Jerusalem Academic Family Practice Website by BHS .
For private study only
PREDICTORS OF OUTCOME
enuresis alarm
• Discontinuation
– Parental intolerance
– Low self esteem
– Family history
• Failure
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–
–
–
–
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Severe bedwetting
Multiple wetting
Lack motivation
Behavioural problems
Family difficulties
Social problems
Primary Nocturnal Enuresis (PNE) –© Dr Boris Chertin 2004
Edited & Prepared for Jerusalem Academic Family Practice Website by BHS .
For private study only
OTHER MODALITIES
• Combination of alarm & desmopressin
• Detrusor-relaxing drug
– In children who do not show satisfactory response to desmo
– Novitropan or detrusitol
– Never as monotherapy
• Tricyclic antidepressant
– not recommended for general use due to serious side effects
– cure only in 17%
– better in patients with Attention-Deficit hyperactivity
disorders
– careful monitoring by child psychiatrist
Primary Nocturnal Enuresis (PNE) –© Dr Boris Chertin 2004
Edited & Prepared for Jerusalem Academic Family Practice Website by BHS .
For private study only
OTHER THERAPY
• Urotherapy, Bladder training
–
–
–
–
Scheduled drinking and voiding
Voiding charts
To coach child to take control of the bladder
Symptoms may disappear in 70-75% of patients
• Use NSAIDs in order to decrease sodium excretion
• Prevention of relapse use of withdrawal program
• I am not dry because I have been treated but
because I am dry
Primary Nocturnal Enuresis (PNE) –© Dr Boris Chertin 2004
Edited & Prepared for Jerusalem Academic Family Practice Website by BHS .
For private study only
Primary Nocturnal Enuresis (PNE) –© Dr Boris Chertin 2004
Edited & Prepared for Jerusalem Academic Family Practice Website by BHS .
For private study only
ENURESIS CLINIC OF SHAARE ZEDEK
• To create a team of specialists with unified approach
• Supervision by pediatric urologist in order to pick up
patients with dysfunctional voiding early
• Close contact between patient, family physician
• Compliance in the change of treatment modalities
Primary Nocturnal Enuresis (PNE) –© Dr Boris Chertin 2004
Edited & Prepared for Jerusalem Academic Family Practice Website by BHS .
For private study only
EARLY EXPERIENCE
n=34
• Mostly children with primary mono-symptomatic
nocturnal enuresis
• High incidence of Meatal Stenosis
• No underlying disease in US examination
• 43% initial response only to change to voiding habits and
urotherapy
• Initial treatment with Minirin
• Non responders or partially responders add Novitropan
• Overall respond rate 78%
• Long-term follow up and increased number of patients is
required
Primary Nocturnal Enuresis (PNE) –© Dr Boris Chertin 2004
Edited & Prepared for Jerusalem Academic Family Practice Website by BHS .
For private study only
WITHDRAWAL PROGRAM
Primary Nocturnal Enuresis (PNE) –© Dr Boris Chertin 2004
Edited & Prepared for Jerusalem Academic Family Practice Website by BHS .
For private study only
BEDWETTING:
A COMMON,
TREATABLE CONDITION
Primary Nocturnal Enuresis (PNE) –© Dr Boris Chertin 2004
Edited & Prepared for Jerusalem Academic Family Practice Website by BHS .
For private study only