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Nocturnal Enuresis

Nocturnal Enuresis. Dr Adnan Masood. What is it?. Enuresis- “involuntary discharge of urine by day or night in a child aged five or over, in the absence of congenital or acquired defects of the nervous system or urinary tract” Primary NE- when bladder control never achieved

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Nocturnal Enuresis

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  1. Nocturnal Enuresis Dr Adnan Masood

  2. What is it? • Enuresis- “involuntary discharge of urine by day or night in a child aged five or over, in the absence of congenital or acquired defects of the nervous system or urinary tract” • Primary NE- when bladder control never achieved • Secondary NE Bladder control achieved for six months and lost

  3. Causes • Genetic • Stressful life events • Diuretic drinks • Constipation • UTi • Organic pathology- rare, consider if daytime wetting

  4. How common? • 15% - 5 year olds • 5% - 10 year olds • 2% - 15 year olds • 1% - Adults • Twice as common in boys • Less than half patients consult doctor

  5. Making a diagnosis • History • Examination- Normal in Nocturnal enuresis • Ix minimum urine dipstick culture • If Hx suggests Consider USS Kidneys and urinary tract or direct referral. • Consider organic diagnosis • UTI/acute illness • Chronic constipation • DM/renal failure • Congenital abnormality PUV • Neurological disorders

  6. Complications and prognosis • Prognosis- Spontaneous remission 15% per year • Relapse rate- after all forms of treatment 10-20% • Complications: • Child Older child more disabling and distressing

  7. Treatment(1) • Various modalities/settings: Providing information and Reassurance is key in Primary care • Enuresis resource and information centre (www.eric.org.uk) Info and equipment • Consider referral to local enuresis clinic/adviser • Refer to appropriate hospital specialist if organic cause suspected

  8. Treatment(2) • BMJ Nov 2001 (Evidence based management of enuresis) Good R/V • Prodigy Guidelines (www.prodigy.nhs.uk) Detailed guidelines. • Two main treatment types • Alarms, dry bed training and star charts • Drug treatment

  9. Alarms, Dry bed training and star charts • Children given alarms 13 times more likely to become dry(95% CI 5.6-31) • Dry bed training involves waking up child to go to toilet at shorter intervals progressively until waking him/herself. As effective with alarm as alarm alone. • Little evidence on Star Charts

  10. Drugs • Desmopressin- 4.5 times more likely to become dry. After treatment stopped mean No of wet nights is no different to Placebo group • TCA- Imipramine 4.2 times more likely to stay dry cf Placebo. No reliable data on stopping treatment • Imipramine versus Desmopressin- One RCT 36 children Effects of two drugs did not differ significantly during treatment or follow up.

  11. Combination Therapy • One trial (Acta Padiatrica 1997) involving 76 children showed 76% with Desmopressin and alarm became dry cf 46% using alarm alone. Relapse rate similar 15% and 19%

  12. Conclusion • Patients with primary NE no daytime wetting no apparent psychological problems and supportive parents have a good prognosis with either alarm or desmopressin or combination of the two. • Any alarm features in the history should prompt Ix and appropriate referral • Reassurance and information needs to be provided.

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