Interesting Case Rounds Nadim Lalani R 5 08

Interesting Case Rounds Nadim Lalani R 5 08. 21. 08

Which of the following are/were “Famous Bedwetters”?

“Fergie Wets Pants!” “I was late. . . I didn’t go to the restroom before I went onstage. It was horrible. But, whatever. It happened. . . everyone knows I wet my pants on-stage and had a crystal-meth addiction. That sucks. You have to laugh. ”

Objectives o Management of primary nocturnal enuresis • Case • Background • Treatment • • Alarms Pharmacotherapy Behavioural therapy Other o NOT discussing DIURNAL or SECONDARY

Case o 11 yo Boy brought to you by parents because of bedwetting. o History? Primary vs Secondary Nocturnal vs diurnal Fam hx [enuresis, DM, DI, kidney, neuro, Sickle] UTI? Sz? Polyuria/Polydypsia? Constipation? encop? Sleep? [terrors, OSA] Psychosocial. Developmental. Sexual ab? Parental response. • Meds [SSRI] • • •

Case o Physical? • • General [growth chart] Abdo [distended bladder, stool in rectum] GU [ectopic ureter, labial adhesions, Sexual ab] Neuro exam[ Sacral dimples or tufts of hair] o Diagnostics? • Urinalysis. First void SG • Unless secondary or treatment failure [see algorithm]

Case conclusion o Child had primary NE • Parents working with GP • Tried various methods [albeit suboptimally] o Child had normal urinalysis o Had ++ hx behavioural problems/anxiety/depression/hydrophobia o Was on Citalopram o Refered to Community pediatrician

Background: o Definition: Involuntary discharge of urine at night. Beyond age of bladder control. > Twice per week for 3 months Uncomplicated [85%] vs Complicated* [10%] o Epidemiology: • Boys >> girls [2: 1] • 15% of 5 yo [8% of 8 yo] 1% 15 yo • 5% are due to organic pathology * Have other symptoms [const/encop]

Pathophysiology o Often no clear etiology o Causes: • Maturational delay of voiding coordination • Sleep arousal dysfunction: [kids unable to wake up when they senses that the bladder is full] • Small functional bladder capacity: • habit polydipsia : [i. e. the child sips drinks all night long]. • Secondary nocturnal enuresis : • related to stressors at home/school • DM/UTI/Neuro dis/Bladder dysfxn/ Meds [SSRI, diuretix]

Pathophysiology o Genetics: • Risk: 43% [one parent with NE] 77% [both parents with NE] • 75% of kids with NE have a first-degree relative who had enuresis • Linkage studies have shown associated genetic loci on chromosomes 8 q, 12 q, 13 q, and 22 q 11

General Measures o Clarify the goal of getting up at night and using the toilet. o Assure the child’s access to the toilet. o Avoid caffeine-containing foods and excessive fluids before bedtime [<2 oz after 6 pm [<75 lb], 3 oz for 75– 100 lb, & 4 oz for >100 lb]. o Have the child empty the bladder at bedtime. o Take the child out of diapers. o Include the child in morning cleanup in a nonpunitive manner. o Preserve the child’s self-esteem. o Best for those < 6 yo

Treatment o Alarms • • • Invented in 1907. Many different kinds. “mini alarms” [wear device] Alarm/light/buzzer goes off when urine present Least effective <5 yo. Most after 7 -8 yo More effective than drugs Trial minimum 4 months • Continue until 14 consecutive dry nights • Overlearn by drinking 2 cups water 7 dry nights • Relapse back to alarm for 14 dry nights

Cochrane review 2005 o 56 studies. Over 3200 children o. RCT’s & quasi-RCT’s involving alarms [2400 pts] o. Excluded diurnal Results: o. Alarm 60% effective at stopping bedwetting o 50% relapse. Less relapse with overlearning and dry bed training. o. No difference in alarm types [but kids prefer wearable ones] o. DDAVP faster than alarm but not sustainable o. TCA no different, but also not sustainable

Alarms o Overall cure rate of 50% o Requires buy in from whole family as it’s disruptive o Impractical for ‘sleepovers’ and camp o No need to go high-end, kids like mini o Don’t buy second-hand [don’t work well after 2 -3 pts]

Treatment o Pharmacotherapy : DDAVP • Studied since 1970 s • Enuretic kids have decreased nighttime ADH secretion produce more urine. • Side effects water intoxication • Expensive • IN preparation pulled by FDA/health Canada • HYponatremia • 5 cases /10 million doses IN vs 1/10 million PO

Cochrane review in 2002 47 studies >2200 kids used DDAVP Results: o. Compared with no treatment : • 1. 3 fewer wet nights/week • 20% reduction in bedwetting at end of treatment o DDAVP no different to TCA [TCA more side effects] o DDAVP + alarm better than DDAVP during Rx, but same relapse rate

DDAVP o Do not use IN preparation o Can use 200 -600 mcg tablets before bedtime o Avoid water after 6 pm o CPS: • Useful only for sleep overs or camp

Pharmacotherapy o TCA • • Imipramine best studied Mechanism unclear. Anticholnergic? Side effects [mood/weight/OD/Cardiac/Sz] CPS Position Statement: • Short-term • Distressed, Older kids • Reliable parents

Cochrane review 2003 o 58 studies that used TCA > 3000 kids Results: o. Compared with no treatment: • 1 free night/week • 20% dry during Rx, but relapsed o Not enough evidence to compare other TCA/doses o. Equivalent to Alarm during therapy, but relapse more than alarm after. o. Equivalent to DDAVP during Rx. But relapse more o. Better than simple behaviour/diet. Worse than complex behav/hypnosis.

Treatment o Simple Behavioural • Night time Fluid Restriction • Lifting • Picking up asleep child and taking to BR before they wet bed. • Scheduled Awakening • Star Charts & reward systems • Retention Control training • Daytime overload of bladder and attempt to delay micturation.

Cochrane Review 2004 o 17 studies > 700 kids [380 got behaviour training] Results: • Star charts, Lifting and Waking better than nothing • Might be worth initiating 1 st • Drop out associated with frustration and family strife.

Treatment o Complex behavioural Dry Bed Training: • Intensive 1 st night woken Q 1 h • If bed wet clean bed [cleanliness] & practice going to BR • Subsequent nights awoken once/night [getting earlier and earlier] Full spectrum Home Training: o Alarm + cleanliness + retention control + overlearning

Cochrane Review 2004 o 18 trials >1000 kids o. Results: o. Complex training better than nothing o. No better than alarm alone

Behavioural Therapy o CPS Position: • Insufficient evidence • Labor intensive and can contribute to frustration and conflict • Might do more harm than good • Shouldn’t be recommended without careful consideration

Treatment o Other modalities Include: • • • 31 other drugs have been studied Hypnosis Psychotherapy Accupuncture Chiropractic adjustment. o Not enough evidence to recommend.

Summary o Distinguish NE from Diurnal and secondary o Most important to have supportive environment & minimise impact o Conditioning using alarm most efficacious o Special situations can use DDAVP o Difficult circumstances imipramine o Judicious use of behavioural therapy o Should be handled by paediatrician o Persistence urology referral

Feri-Feri

Management of primary nocturnal enuresis Canadian Paediatric Society (CPS) Paediatrics & Child Health 2005; 10(10): 611 -614 Practice Parameter for the Assessment and Treatment of Children and Adolescents With Enuresis Journal of the American Academy of Child and Adolescent Psychiatry - Volume 43, Issue 12 (December 2004)

Parent Handout http: //www. caringforkids. cps. ca/growing&learn ing/Bedwetting. htm