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Enuresis ( Bedwetting )

Enuresis refers to the involuntary loss of urine during sleep that occurs at least twice a week in children older than 5 yrs of age ( or the developmental equivalent ) for atleast 3 months ( NE- denoted nocturnal enuresis )

Monssymptomatic , Non-monosymptomatic , primary and secondary-Primary monosymptomatic nocturnal enuresis ( PMNE ) is the most commonly seen variant

How common –Widespread and common condition Prevalence of NE is generally quoted as
20 % at 5 yrs of age
5 % at age 10 yrs
0.1 to 1 % among teenagers / young adults Prevalence similar across cultures More common in boys with a ratio of 3 :1- this difference tends to reduce after 10 yrs of age NE – seems to be associated with psychological and behavioral comorbidities such as ADHD , ASD, anxiety , depression and constipation

Aetiology –Cause is not fully understood – a complex disorder Several disturbances and predisposing factors NE is generally associated with
◘ fragmented sleep
◘ lower proportions of motionless sleep
◘ higher night-time wakening Hereditary factors – clearly play a role
◘ if one of the parents or their immediate relatives has suffered from bed wetting the chance ↑↑ es to 44 % and if both parents have a +ve hx chance ↑↑es to 77 % NE may have an association with PLMS ( periodic limb movement disorder ) Three related mechanisms may play an important role




 Secondary ME is usually secondary to psychological stress or organic causes such as UTI , obstructive sleep hypoventilation , diabetes mellitus / insipidus and neurogenic bladder


Risk factors –Constipation and / or soiling developmental , attention or learning difficulties diabetes mellitus behavioral or emotional problems family problems or vulnerable child or young person or family obesity family history delay in obtaining bladder control sleep apnoea and upper airway obstructive symptoms

History-when did it start ? 
if in last few days or weeks ? consider an underlying systemic illness has the child been dry at night previously for 6 months ?
if so this suggests secondary NE and enquire possibility 
? any medical , emotional or physical triggers
If triggers identified- try and address those about the bedwetting itself
◘ how many nights a week
◘ how many times a night
◘ are the volumes large 
◘ what time of night
◘ does the child wake up after bedwetting is the toilet easily accessible at home

day time symptoms –daytime frequency
does the child pass urine more than 7 times / day daytime urgency daytime wetting passing urine infrequently
this means < 4 times/ day abdominal straining or poor urinary stream pain on passing urine

Day time toileting patterns –if daytime symptoms only occur in some situations toilet avoidance – e.g in school or other settings if the child or young person goes to the toilet more or less frequently than his / her peers

Impact of the illness –emotional and social well being guilt , shame , humiliation , victimization or loss of self esteem  sleep over , school trips how is the family coping cost

Examination –A physical exam is usually unremarkable An abdominal examination may reveal
○ faecal impaction
○ distended bladder Examination to r/o anatomical anomalies as
○ phallic or meatal defects in boys
○ labial adhesions or urethral anomalies in girls may be undertaken if suspected clinically Urinalysis only in certain situations – for e.g if

Urinalysis-bedwetting started in the last few days or weeks there are daytime symptoms there are any signs of ill health there is a history , symptoms or signs suggestive of UTI there is a history , symptoms or signs suggestive of diabetes mellitus

management –Management of enuresis can be complex Treatment of enuresis before age 5 is not recommended A suggestion ( via a questionnaire ) or history suggesting an underlying bladder dysfunction ( for e.g LUTS ) symptoms may suggest Non-MNE which should prompt a referral Treatment is based on aetiology Data from voiding diary filling is crucial and an important diagnostic tool Refer to the ERIC flowchart for management via https://www.eric.org.uk/flowchart-nighttime-wetting 


First line –Education Motivational therapy Behavioral advice
○ diet / fluid restriction at night
○ voiding before going to bed

Desmopressin reduces the amount of urine during the night
Well tolerated with no long term SEs Combination treatment can be used ( alarm + desmopressin ) in certain situations Alarm – requires motivated and supportive families ( burden of recurrent triggering ) Anticholinergics are used as add on for non-responders to desmopressin

Referral –severe daytime symptoms h/o recurrent UTIs known or suspected physical or neurological problems family problems or a vulnerable child or young person or family comorbidities or other factors as
○ constipation and / or soiling
○ developmental , attention or LD
○ diabetes mellitus
○ behavioural or emotional problems
○ family problems or a vulnerable child or young person or family

LINKS AND RESOURCES

ERIC is an absolutely great resource for matters related to constipation, enuresis and has sections for parents, professionals and a shop –https://www.eric.org.uk/flowchart-nighttime-wetting

Drydawn is another very useful resource and can be used in initial assessment http://www.drydawn.ie/

NICE guideline -bedwetting in under 19s https://www.nice.org.uk/guidance/cg111/resources/bedwetting-in-under-19s-35109384397765

Stopbedwetting Org is another great resource funded by Ferring Pharmaceuticals https://www.stopbedwetting.org/

Continence Foundation Australia has useful PILs  https://www.continence.org.au/pages/bedwetting.html

European Association of Urology guideline on paediatric urology : a large 159 page document 2018  https://uroweb.org/wp-content/uploads/EAU-Guidelines-on-Paediatric-Urology-2018-large-text.pdf

South African guideline on Enuresis via Science Direct – Open access  https://www.sciencedirect.com/science/article/pii/S1110570417300681

Supply for parents-from Drynites to purchase https://www.drynites.co.uk/en/products/drynites-pyjama-pants

References

  1. Recent advances in managing and understanding enuresis Charlotte Van Herzeele et al F1000 Research 2017,6 (F1000 Faculty Rev ):1881 Last updated Oct 2017
  2. Common urological problems in children : primary nocturnal enuresis Ivy HY Chan et al Hong Kong Med J 2019 ;25 ;305-11
  3. Bedwetting in under 19s NICE Clinical guideline October 2010
  4. Bedwetting ( enuresis ) CKS NHS January 2017
  5. Enuresis : practical guidelines for primary care Johan Vande Walle et al British journal of General Practice , July 2017
  6. Nocturnal Enuresis Marianela Gomez Rincon et al StatPearls July 2019
  7. Pictures snapshots from www.drydawn.com and www.eric.org.uk

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