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Review Article

 

ENURESIS: AND IT’S MANAGMENT

 N.A. Ramdinny-Purryag

Psychiatrist Jeen Pharmacy Mrurtious

 

 

Abstract

Enuresis refers to a repeated inability to control urination/bed wetting. It is most common in children. Nocturnal enuresis, or bed-wetting at night, is the most common type of elimination disorder. Daytime wetting is called diurnal enuresis. Some children experience either or a combination of both. this problem affects about 1-2 out of every 100 teens. At age 4½, 30% of children still wet the bed, 21% infrequently and 8% of these more frequently. At the age of 7½ years it was 2.6% wet their bed on two or more nights a week. Nocturnal enuresis found .52% in adults

Keywords:Enuresis

Introduction

While bedwetting is an extremely common condition, children are generally expected to no longer wet the bed (to be "dry") by a developmental age of five. Historically it has been common practice to only consider treating children for their bedwetting when they reach seven years.

However, in a change to current clinical practice, the National Institute for Health and Care Excellence (NICE) has not specified a minimum age limit in its new clinical guideline on the assessment and management of this condition. This means that healthcare professionals are now more likely to consider whether children under seven years may benefit from appropriate advice and treatments currently available on the NHS.Enuresis is a repetitive voiding of urine, either during the day or night, at inappropriate places. This state of affairs is normal in infancy.

Classification

(1)     Enuresis can be either of (1) primary type or (2) secondary type.

Primary type: where bladder control has never been achieved or,

Secondary type: where enuresis emerges after a period of bladder control (at least 1 year).

(2)Enuresis may also be classified as (1) Nocturnal only (2) Diurnal only or (3) Nocturnal and Diurnal

Nocturnal only: Passage of urine only during nighttime sleep

Diurnal type: Passage of urine during working hours

Nocturnal and Diurnal: a combination of the 2 subtypes above.

The diurnal only subtype may be referred to simply as urinary incontinence. Individuals with this subtype may further be divided into 2 groups: (1) Individuals with urge incontinence: individuals have sudden urge symtoms (2) Detrusor Instability: Individuals with “voiding postponement” consciously defer micturition urges until incontinence occurs.

Epidemiology

About 85% of children with enuresis have primary enuresis.The majority of children (about 80%) with enuresis have nocturnal bedwetting only. Non organic enuresis is more common in males (about 2 times).1Numbers show that diurnal enuresis is much less common. Overall, about 60% of those suffering are males. However, this too depends on age. From ages 4 to 6 years, the number of boys and girls is about equal. However, the ratio changes so that by 11 years of age, there are twice as many boys as girls.

Incidence varies with social class with more incidences among those with low socioeconomic status. Studies conducted in the United States show a varying prevalence with age: 33% of 5 years old, 25% of 7 years old, 15% of 9 years old, 8% of 11 years old, 4% of 13 years old and 3% of 15 to 17 years old. Most school based epidemiological studies on child and adolescent psychiatric disorders in India have focused on disorders of concern like learning disability, mental retardation and attention deficit hyperactive disorder with little or no reference to enuresis.2

Risk Factors

Nocturnal Enuresis

Environmental: Delayed or lax toilet training & psychosocial stressor/s. Latter include fights between parents, unfamiliar social situations and overwhelming family events such as the birth of a sibling.

Genetics Nocturnal Enuresis is a genetically heterogeneous disorder.  In 1995, Danish researchers announced that they had found a site on human chromosome 13 that is responsible, at least in part, for nocturnal enuresis. If both parents were enuretic, 77% of their children would be enuretic also; if only one parent was enuretic, then 44% of their offspring would be also.

Physiological Nocturnal enuresis has been associated with delays in the development of normal circadian rhythms of urine production. The body normally produces more ADH during sleep so that the need to urinate is lower at night. If ADH is not sufficiently produced at night, the making of urine may not be slowed down, leading to bladder overfilling. If a child does not sense the bladder overfilling, and is not awaken to urinate, wetting occurs.

Structural problems A blocked bladder or urethra may cause the bladder to overfill and leak. Nerve damage associated with the birth defect spina bifida can cause incontinence. An ectopic ureter can commonly cause incontinence. In these cases, the incontinence can appear as a constant dribbling of urine.

Obstructive sleep apnoea Nocturnal enuresis may be one sign of another condition called obstructive sleep apnoea, in which the child’s breathing is interrupted during sleep, often because of inflamed or enlarged tonsils or adenoids. Other symptoms of this condition include snoring, mouth breathing, frequent ear and sinus infections, sore throat, choking and daytime drowsiness. In some cases, successful treatment of this condition may also resolve the associated nighttime incontinence.

Diurnal Enuresis

Infrequent voiding When the child voluntarily holds urine for prolonged intervals, the bladder overfills and leaks urine. For example, a child may not want to use toilets at school or may not want to interrupt enjoyable activities, so that he or she ignores the body’s signal of a full bladder.

An overactive bladder This occurs when the bladder contracts strongly and the muscles surrounding theurethra may not be able to keep urine from passing. This often happens as a consequence of urinary tract infection and is more common in girls.

Other causes A small bladder capacity, constipation and food containing caffeine,chocolate or artificialcolouring.Sometimes, overly strenuous toilet training may make the child unable to relax the sphincter and pelvic floor to completely empty the bladder. Incomplete bladder emptying sets the stage for urinary tract infections.

Pathogenesis

The proposed condition PANDAS ( Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections) has been used to describe a set of children who have a rapid onset of OCD and/or tic disorders following a streptococcal infection, with a link to other symptoms such as enuresis.2

A broader classification of this hypothesis , PANS (Pediatric acute onset neuropsychiatric syndrome) has been proposed which states that some patients suffer from these symptoms in response to mycoplasma or lyme disease or even viruses rather than streptococcal.  This hypothesis describes children who have abrupt, dramatic onset of OCD or Anorexia Nervosa coincident with the presence of 2 or more neuropsychiatric symptoms. It is believed that these children experience a rise in dopamine levels as a result of cross-reactive anti-neuronal nqnantibodies. The rise in dopamine can cause such side effects as enuresis, bedwetting and urinary urgency.3

Diagnostic Features (DSM-V)

▪The essential feature is repeated voiding of urine during the day or at night into bed or clothes. Most often the voiding is involuntary, but occasionally it may be intentional.

▪The voiding of urine must occur at least twice a week for at least 3 consecutive months or cause clinically significant distress or impairment in social, academic or other important areas of functioning.

 The individual must have reached an age at which continence is expected (at least 5 years chronological age or for children with developmental delays, a mental age of at least 5 years).

 Urinary incontinence is not attributable to the physiological effects of a substance (eg diuretic, an antipsychotic medication) or another medical condition (diabetes, spina bifida, a seizure disorder).

Treatment

A.     Conservative Strategies

1.       Restriction of fluid intake after 8 pm in nocturnal enuresis

2.       Parents are encouraged to enforce frequent waking up of the child for trips to the bathroom during the night and to develop a cleanup routine for the child, with positive reinforcement for dry nights.

3.       Bladder training during daytime: Parents can be instructed to have their child drink more and more fluids during the day and delay urination for longer periods of time, attempting to strengthen bladder control.

4.       Avoiding caffeinated drinks

5.       Encouraging healthy urination such as relaxing bladder muscles & taking required time.

6.       Conditioning devices, which cause an alarm to sound as soon as the voided urine touches the bed sheet. It is important to check the child’s hearing before starting treatment. The alarm causes inhibition of further micturition and the child awakens. If properly used, it is an effective method of therapy. Bed wetting alarms have been around since 1938, when O.H Mowrer and W.M Mowrer first invented the bell and pad. This behavioural training is one of the safest and more effective treatments. By 12 weeks, the child will most likely have mastered his nighttime bladder control.

NICE recommends the following in its new guidelines regarding nocturnal enuresis

•Not to exclude under-7s from the management of bedwetting on the basis of age alone.

•Inform the child and their parents or carers that bedwetting is not the child's fault and so punitive measures should not be used.

•Encourage parents to reward their children for agreed behaviour rather than for dry nights, e.g. for drinking the recommended levels during the day, going to the toilet before sleep, taking medications, or for helping to change the sheets.

•Discuss with the child's parents or carers whether they need support, particularly if they are having difficulty coping with the bedwetting, or if they are expressing anger, negativity or blame towards the child.

•Address excessive or insufficient fluid intake or abnormal toileting patterns before starting other treatment for bedwetting in children.

•Refer children who have not responded to courses of treatment with an alarm and/or desmopressin (a medication that slows down urine production at night) to a relevant specialist, so that they can be assessed for factors that may be associated with a poor response, e.g. an overactive bladder, an underlying disease, or social and emotional factors.

B.     Pharmacotherapy

Drug treatment is usually not a preferred option for the treatment of enuresis.

The drug of choice in those who need pharmacotherapy has traditionally been a tricyclic antidepressant, usually imipramine (25-75 mg/dl). It probably acts by its anticholinergic effect as well as by decreasing the deep sleep (stage 4 NREM-sleep) period. However, there is a risk of sudden death in some children with the use of tricyclics; it should never be used for children under the age of 6 years.

Intranasal desmopressin has been found useful in some patients and it is a good alternative. There is difficulty in keeping the bed dry after the medication is stopped, with as high as an 80% relapse rate.

Oxybutynin, an anticholinergic may be prescribed to control bladder muscle spasms in case of an overactive bladder.

NICE GUIDELINES RECOMMEND THE FOLLOWING

(1)Alarms

An alarm is offered as initial treatment for children and young people whose bedwetting has not responded to advice on fluids, toileting, or an appropriate reward system unless:

(1)     The child, young person, parents, or carers do not want to try it or

(2)     The treating doctor thinks it is unsuitable for the child, young person, parents, or carers.

Alarms may not be suitable if the child or young person wets the bed infrequently (only once or twice a week), if the parents or carers are having emotional difficulty coping with the burden of bedwetting or are expressing anger, negativity, or blame towards the child or young person, or if the priority is for fast or short term improvement.

If alarm treatment is not successful,

Desmopressin (a synthetic analogue of antidiuretic hormone) is offered desmopressin  as well as use of the

alarm. Alternatively, if the parents, carers, child, or young person no longer want to use an alarm, offer

desmopressin alone.

Desmopressin is offered as first line of treatment if:

1-The child, young person, parents, or carers do not want to try an alarm.

2-The healthcare team decides that an alarm is not suitable

3-Fast acting, short term improvement is the priority.

4-If the bedwetting stopped when using an alarm but has started again after treatment ended, offer an alarm again. If bedwetting then recurs, offer desmopressin as well as using the alarm.

5-If alarm and/or treatment with desmopressin are not successful, refer for further review and assessment by a healthcare professional.

5-After such assessment consider offering an anticholinergic drug such as tolterodine or oxybutynin to take with desmopressin.Study findings have shown that starting with a low dose of 2.5mg tds, a positive result with fewer side effects is achieved.9

Side effects: blurred vision, dryness of eyes & mouth & throat, drowsiness, irregular heart beats, convulsions.

6- If no other treatment has been successful consider offering imipramine. Do not offer this in combination with an anticholinergic.

Until now, children have not been offered treatment until age 7 years. However, NICE guideline includes treatment options (such as advice, drugs, and alarms) for children aged 5-7 years. If a 4 month course with an enuretic alarm is unsuccessful, rather than using desmopressin, the alarm should be continued with relearning and consideration given to additional use of the dry bed training technique.4

References

1.        Non-Organic Enuresis. Ahuja –A short textbook of Psychiatry (7th Edition):169.

2.        Snider LA and Swedo SE. Pandas:current status and directions for research. Molecular Psychiatry 2004; 9:900-907.

3.        Swedo SE, Leckman JF, Rose NR. From Research Subgroup to Clinical Syndrome: Modifying the PANDAS Criteria to describe PANS. Pediatr Therapeut 2012; 2(2).

4.        Bath R1, Morton R, Uing A, Williams C. Nocturnal enuresis and the use of desmopressin: is it helpful? Child Care Health Dev 1996;22(2):73-84.

5.        Jonathan H C Evans. Evidence based management of nocturnal enuresis. BMJ 2001;323:1167–9.

6.        Herzeele V. Desmopressin improves sleep pattern and psychological functioning in patients with monosymptomatic nocturnal enuresis. European Society for Paediatric Urology Congress 2014, 7-10 May, Innsbruck, Austria.

7.        Fergusson et al. Nocturnal Enuresis in children. Behav Psychother 1986;78:884-90.

8.        Yeung CK et al. Nocturnal Enuresis in children. BJU Int 2006;97:1069-1073

9.        Bemelmans BL, Kiemeney LA, Debruyne FM. Low dose oxybutynin for the treatment of urge incontinence: good efficacy and few side effects. Eur Urol 2000; 37(6): 709-13.