Enuresis Flashcards
Prognosis of nocturnal enuresis
Commonly spontaneously remits, and does not require treatment if there is not significant distress or impairment due to symptoms
Caveats for using demopressin acetate (ddAVP) for treating nocturnal enuresis
Child must be older than age 7
Only necessary if the enuresis causes significant distress
May be advisable to delay until the child has motivation and capacity to adhere to the treatment program
Diurnal enuresis
Abnormal daytime micturition
Primary enuresis
Failure to establish bladder control by age 5
Secondary enuresis
Loss of continence after previously having achieved it for a period of at least 6 months.
Typically occurs between 5 and 8 years of age, but may occur at any time. Raises concern for a psychiatric or medical etiology, and especially for sexual abuse if the child is female.
Diagnosis of nocturnal enuresis
A voiding diary is very helpful.
A full history of psychosocial stressors should be taken, as should a full medical review of symptoms.
Medical conditions that may cause secondary enuresis
- Seizure disorders
- Diabetes
- Spina bifida
- Urinary tract infection
- Hypercalcemia
- Substance-induced
- Diuretics
- Atypical antipsychotics
- Lithium
Diagnostic criteria for enuresis
Inappropriate elimination of urine into bed or clothes
Either frequency of at least 2x/week for > 3 months OR clinically significant stress/impairment
Chronological age or developmental age > 5 years old
Not caused by a substance or medical condition
Specify if nocturnal, diurnal, or both.
If a child has developmental delay, __ will be delayed too
If a child has developmental delay, establishment of urinary continence will be delayed too
Daytime urinary incontinence may be due to. . .
. . . social anxiety surrounding public toilet usage
The evaluation of childhood enuresis should ALWAYS include. . .
. . . urinalysis
This screens for DKA, type I diabetes, diabetes insipidus, urinary tract infection, and dilutional hyponatremia
Is enuresis an indication for VCUG and renal ultrasound?
No, not on its own
This is more for recurrent pediatric UTIs (or pediatric UTI in a male), multiple urinary complaints, or other features suggestive of structural abnormality
Holding and encopresis
When children (especially those with intellectual disability or developmental delay) induce constipation via voluntary holding, then have uncontrollable overflow stool
If suspected, an abdominal x-ray should be ordered to assess stool burden.
Treatment of nocturnal enuresis
Family psychoeducation is the most important element. Education should stress that the behavior is NOT voluntary and that punishment is not only ineffective, but counterproductive.
Behavioral modification using bell and pad training for 6-16 weeks is effective. Has a 75% success rate and a low rate of recidivism. Dry-bed training (awakening in the night to use the bathroom at set intervals) is also an option. Overlearning involves increasing bladder capacity by purposefully loading the child with fluids before bed.
ddAVP before bed is an option for kids > age 7. Imipiramine has been used in the past with less success (it also requires EKG monitoring in high doses and has a risk of overdose), but is now fallen from popularity.
