Interesting Case Rounds
Nadim Lalani R5
08.21.08
Which of the following are/were
“Famous Bedwetters”?
“Fergie Wets Pants!”
“I was late ... I didn’t go to the
restroom before I went onstage.
It was horrible. But, whatever. It
happened ... everyone knows I
wet my pants on-stage and had
a crystal-meth addiction. That
sucks. You have to laugh.”
Objectives
o Management of primary nocturnal enuresis
• Case
• Background
• Treatment
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•
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Alarms
Pharmacotherapy
Behavioural therapy
Other
o NOT discussing DIURNAL or SECONDARY
Case
o 11 yo Boy brought to you by parents because
of bedwetting.
o History?
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Primary vs Secondary
Nocturnal vs diurnal
Fam hx [enuresis, DM, DI, kidney, neuro, Sickle]
UTI? Sz? Polyuria/Polydypsia? Constipation?encop?
Sleep? [terrors, OSA]
Psychosocial. Developmental. Sexual ab? Parental
response.
• Meds [SSRI]
Case
o Physical?
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•
•
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General [growth chart]
Abdo [distended bladder, stool in rectum]
GU [ectopic ureter, labial adhesions, Sexual ab]
Neuro exam[ Sacral dimples or tufts of hair]
o Diagnostics?
• Urinalysis. First void SG
• Unless secondary or treatment failure [see algorithm]
Case conclusion
o Child had primary NE
• Parents working with GP
• Tried various methods [albeit suboptimally]
o Child had normal urinalysis
o Had ++ hx behavioural
problems/anxiety/depression/hydrophobia
o Was on Citalopram
o Refered to Community pediatrician
Background:
o Definition:
Involuntary discharge of urine at night. Beyond age
of bladder control. > Twice per week for 3 months
Uncomplicated [85%] vs Complicated* [10%]
o Epidemiology:
• Boys >> girls [2:1]
• 15% of 5yo  [8% of 8yo]  1% 15yo
• 5% are due to organic pathology
* Have other symptoms [const/encop]
Pathophysiology
o Often no clear etiology
o Causes:
• Maturational delay of voiding coordination
• Sleep arousal dysfunction: [kids unable to wake up when
they senses that the bladder is full]
• Small functional bladder capacity:
• habit polydipsia : [i.e. the child sips drinks all night long].
• Secondary nocturnal enuresis :
• related to stressors at home/school
• DM/UTI/Neuro dis/Bladder dysfxn/ Meds [SSRI, diuretix]
Pathophysiology
o Genetics:
• Risk: 43% [one parent with NE] 77% [both parents with NE]
• 75% of kids with NE have a first-degree relative who had
enuresis
• Linkage studies have shown associated genetic loci on
chromosomes 8q, 12q, 13q, and 22q11
General Measures
o Clarify the goal of getting up at night and using the toilet.
o Assure the child’s access to the toilet.
o Avoid caffeine-containing foods and excessive fluids
before bedtime [<2 oz after 6pm [<75 lb], 3 oz for 75–
100 lb, & 4 oz for >100 lb].
o Have the child empty the bladder at bedtime.
o Take the child out of diapers.
o Include the child in morning cleanup in a nonpunitive
manner.
o Preserve the child’s self-esteem.
o Best for those < 6yo
Treatment
o Alarms
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•
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Invented in 1907.
Many different kinds. “mini alarms” [wear device]
Alarm/light/buzzer goes off when urine present
Least effective <5yo. Most after 7 -8 yo
More effective than drugs
Trial minimum 4 months
• Continue until 14 consecutive dry nights
• Overlearn by drinking 2 cups water  7 dry nights
• Relapse  back to alarm for 14 dry nights
Cochrane review 2005
o56 studies. Over 3200 children
oRCT’s & quasi-RCT’s involving alarms [2400 pts]
oExcluded diurnal
Results:
oAlarm 60% effective at stopping bedwetting
o50% relapse . Less relapse with overlearning and dry bed
training.
oNo difference in alarm types [but kids prefer wearable ones]
oDDAVP faster than alarm but not sustainable
oTCA no different, but also not sustainable
Alarms
o Overall cure rate of 50%
o Requires buy in from whole family as it’s
disruptive
o Impractical for ‘sleepovers’ and camp
o No need to go high-end, kids like mini
o Don’t buy second-hand [don’t work well after
2-3 pts]
Treatment
o Pharmacotherapy : DDAVP
• Studied since 1970s
• Enuretic kids have decreased nighttime ADH
secretion  produce more urine.
• Side effects  water intoxication
• Expensive
• IN preparation pulled by FDA/health Canada
• HYponatremia
• 5 cases /10 million doses IN vs 1/10 million PO
Cochrane review in 2002
47 studies >2200 kids used DDAVP
Results:
oCompared with no treatment :
•1.3 fewer wet nights/week
•20% reduction in bedwetting at end of treatment
o DDAVP no different to TCA [TCA more side effects]
o DDAVP + alarm better than DDAVP during Rx, but same
relapse rate
DDAVP
o Do not use IN preparation
o Can use 200-600 mcg tablets before bedtime
o Avoid water after 6pm
o CPS:
• Useful only for sleep overs or camp
Pharmacotherapy
o TCA
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Imipramine best studied
Mechanism unclear . Anticholnergic?
Side effects [mood/weight/OD/Cardiac/Sz]
CPS Position Statement:
• Short-term
• Distressed, Older kids
• Reliable parents
Cochrane review 2003
o58 studies that used TCA > 3000 kids
Results:
oCompared with no treatment:
• 1 free night/week
•20% dry during Rx, but relapsed
o Not enough evidence to compare other TCA/doses
oEquivalent to Alarm during therapy, but relapse more than
alarm after.
oEquivalent to DDAVP during Rx. But relapse more
oBetter than simple behaviour/diet. Worse than complex
behav/hypnosis.
Treatment
o Simple Behavioural
• Night time Fluid Restriction
• Lifting
• Picking up asleep child and taking to BR before they wet
bed.
• Scheduled Awakening
• Star Charts & reward systems
• Retention Control training
• Daytime overload of bladder and attempt to delay
micturation.
Cochrane Review 2004
o17 studies > 700 kids [380 got behaviour training]
Results:
• Star charts, Lifting and Waking better than nothing
•Might be worth initiating 1st
•Drop out associated with frustration and family strife.
Treatment
o Complex behavioural
Dry Bed Training:
• Intensive 1st night  woken Q1h
• If bed wet  clean bed [cleanliness] & practice going to
BR
• Subsequent nights awoken once/night [getting earlier
and earlier]
Full spectrum Home Training:
o Alarm + cleanliness + retention control +
overlearning
Cochrane Review 2004
o18 trials >1000 kids
oResults:
oComplex training better than nothing
oNo better than alarm alone
Behavioural Therapy
o CPS Position:
• Insufficient evidence
• Labor intensive and can contribute to frustration
and conflict
• Might do more harm than good
• Shouldn’t be recommended without careful
consideration
Treatment
o Other modalities Include:
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•
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31 other drugs have been studied
Hypnosis
Psychotherapy
Accupuncture
Chiropractic adjustment.
o Not enough evidence to recommend.
Summary
o Distinguish NE from Diurnal and secondary
o Most important to have supportive
environment & minimise impact
o Conditioning using alarm most efficacious
o Special situations can use DDAVP
o Difficult circumstances  imipramine
o Judicious use of behavioural therapy
o Should be handled by paediatrician
o Persistence  urology referral
Feri-Feri
Management of primary nocturnal enuresis
Canadian Paediatric Society (CPS)
Paediatrics & Child Health 2005;10(10): 611-614
Practice Parameter for the Assessment and
Treatment of Children and Adolescents With
Enuresis
Journal of the American Academy of Child and Adolescent Psychiatry - Volume 43, Issue 12
(December 2004)
Parent Handout
http://www.caringforkids.cps.ca/growing&learni
ng/Bedwetting.htm