enuresis

Enuresis

Based on lecture by Sandra Sexson, M.D.

Definition: involuntary or inappropriate passage of urine in a child beyond the gage he should be toilet trained.

"primary" = never dry for any 3-6 month period; probably a developmental issue.

"secondary" = relapses; usually self-limiting; often associated with stress.

3 million children in U.S. have primary nocturnal enuresis

male: female = 2:1

15% of 5-6 year olds

3% of adolescents

Consider medical causes of enuresis (but "don't go overboard" in your evaluation):

Organic causes

Diabetes (either insipidus or juvenile onset) - maybe first symptom.

Urinary tract infection, especially in girls if relapse in bed-wetting

Check urinalysis +/- urine culture

Neurological problems such as spinal bifida <= relatively rare

Maturational delay

Tends to be familial; fathers who were bed-wetters more likely to have bed-wetting offspring. May also be true for mothers.

Psychological delays (especially of secondary enuresis)

Stress may be causative, but bed-wetting more often a cause of than a symptom of psychological distress

Night terrors, sleep walking - associated with waking up from stage IV sleep

Spontaneous resolution peaks at ages 6-7, and at age 11-12.

Management of Primary Nocturnal Enuresis

Transmit optimism
Reassurance and simple suggestions for young child; education should be first thing you do:
e.g., bladder-training, encouraging children to hold their urine during the day for as long as they can; probably has more to do with muscular control of bladder, not actual size.
Put child on toilet before going to bed
Restrict fluids immediately prior to going to bed.
Other possibilities: consider these interventions when the enuresis is really disruptive to the family or causing great problems for the child:
Medication: imipramine (a tricyclic antidepressant) in low doses 25-50 mg po qhs

Conditioning devices, e.g., a bell and pad; when moisture hits the pad, the bell rings.

Encopresis = inappropriate passing of feces at developmentally inappropriate age (> 5 usually).

95% psychological
1.5 - 2%, probably higher because of family shame
male: female = 5-6: 1
most common age = 4-9 years old
may cause great psychological distress, as you can imagine (child maybe called "stinky kid" by peers)
children with this disorder may also go for weeks without having a bowel movement.
Gastrocolic reflex will diminish over time if you voluntarily ignore the urge to defecate.
In severe cases, may create an effective denervated colon because of huge mass of hardened feces that distends the colon and around which fresh feces must pass.

Treatment:

Use laxatives and enemas in combination.

Get KUB radiograph before initiating to insure colon isn't obstructed by huge mass of hardened feces.

May require manual disimpaction.

Keep stool movable
Attempt bowel movement 2 times / day - have child sit on toilet after breakfast and dinner.

Keep child's feet on something firm, so may need small toilet.

May need to sit for as long as half an hour, so may need some other activity to make it a more pleasant experience.