RISK FACTORS: Emotional and psychological problems in children, An increased incidence of family and social problems (death in the family, temporary separation of mother, moving, accidents or surgery), Family history
GENERAL MEASURES :
. Pharmacotherapy, psychotherapy and behavioral modifications
. First address any obvious correctable cause (eg, diabetes mellitus, bladder outlet obstruction)
. Psychotherapy requires participation of child along with the entire family
. Behavioral modifi cations. These include:
. Self monitoring and record keeping is primary technique to improve enuresis
. Motivation and responsibility training. Child made responsible for changing/laundering bed linen.
. Calendar with star rewards for dry nights and some reward system
. Efficacy of 25% with 5% relapse rate
. Penalties for wet beds is counter-productive
. Bladder training. Exercises to increase bladder capacity. May include biofeedback. Effectiveness in nocturnal enuresis is variable.
. Enuresis alarms - 70% success with 30% relapse. Alarms appear more effective than desmopressin or
tricyclics by the end of treatment, and subsequently in most studies.
. Acupuncture (traditional and laser) may be beneficial in the treatment of NE by increasing nocturnal bladder
capacity. A promising alternative to conventional therapies for monosymptomatic NE.
SURGICAL MEASURES : Only necessary if enuresis is secondary to other surgically correctable cause (eg, tethered cord, ectopic ureter, benign prostatitic hypertrophy)
DIET :
β’ Restricting liquids after 6 PM may help
β’ Avoid caffeinated beverages entirely due to diuretic effect
β’ Avoid foods that appear to cause urinary problems (eg, spicy foods, certain fruits)
PATIENT EDUCATION : Explain to parents that most cases of childhood enuresis resolve spontaneously
DRUG(S) OF CHOICE :
. Oxybutynin (Ditropan, Ditropan XL, Oxytrol patch)
- anticholinergic: increases functional bladder capacity and aids in timed voiding
. Ditropan - adults and peds > 5 years - 5 mg po tidqid; peds 1-5 years - 0.02 mg/kg/dose bid-qid (syrup
5 mg/5 mL)
. Ditropan XL - adults 5 mg po qd; increase to 30 mg/d po (5 and 10 mg/tab)
. Oxytrol patch, apply one patch every 3-4 days (3.9 mg/patch)
. Periodic drug holidays recommended
. Ditropan 5 mg single night time dose - success rate of 30-50% with 50% relapse with stopping drug. Best
in children with frequency, urgency, concomitant day time wetting, and urodynamic evidence of uninhibited
detrusor contractions (success rate of 85-91%).
. Imipramine (Tofranil) - tricyclic antidepressant with anticholinergic effects
. Dose - adults 25-75 mg po qhs; peds: > 6 y: 10-25 mg po hs
. Increase by 10-25 mg at 1-2 wk intervals, treat for 2-3 mo, then taper, success rate of 25-30% when used >
3 months
. Desmopressin (DDAVP) - synthetic analogue of vasopressin, a naturally occurring human ADH decreases
nocturnal urine output. Intranasally 10-40 mcg or 0.2-0.6mg orally.
. Peds > 6 years 20 mcg intranasally hs. Success rate 10-60%. Safe even when used for more than 12 months. Desmopressin reduces the number of nights of primary nocturnal enuresis by at least 1 per week,
and increases the likelihood of ΒgcureΒh (defi ned as 14 consecutive dry nights) while treatment is continued.
The dosage of DDAVP tablets must be determined for each individual and adjusted according to response. The recommended starting dose is 0.2mg po qhs. If there is no response at this dosage, the dose may be titrated up to 0.6mg po qhs to achieve the desired response.
. Tolterodine (Detrol, Detrol LA) - anticholinergic
. Detrol 1-2 mg po bid
. Detrol LA 2-4 mg/d; no extensive experience in children
PATIENT MONITORING Follow until enuresis
resolved or to monitor therapy
POSSIBLE COMPLICATIONS :
β’ Urinary tract infection
β’ Perineal excoriation
β’ Psychologic problems (especially in children)
EXPECTED COURSE/PROGNOSIS :
β’ In children, nocturnal enuresis is generally self limiting
β’ 1% will persist as adult nocturnal enuresis; requires detailed evaluation for organic causes