Enuresis

Enuresis

1. primary nocturnal enuresis

2. daytime enuresis

   • =lack of bladder control during day in a child old enough to be continent (3-5 years)
   • nocturnal enuresis also present
   • causes
     • lack of attention to bladder sensation
       • manifestation of psychogenic or developmental prob
       • may be in normal kids too busy to respond to sensation of full bladder
     • detrusor instability
       • =sudden urgent urge to void induced by sudden bladder contractions
     • neuropathic bladder
       • bladder enlarged & fails to empty properly, irreg thick wall
       • assoc w/ spina bifida
     • UTI
       • rarely in absence of other sx
     • constipation
     • ectopic ureter
       • causes constant dribbling, child always damp
       • girls dry @ night but wet on getting up
         • ectopic ureter opening into vagina
   • O/E
     • neuropathic bladder
       • distended bladder
       • abnormal perineal sensation
       • abnormal anal tone
       • abnormal leg reflexes
       • abnormal gait
       • sensory loss in S2, S3 &S4 dermatomes
       • spinal lesion
   • Ix
     • urine sample
       • microscopy
       • culture
       • sensitivity
     • if indicated
       • ultrasound
         • bladder pathology
           • w/ incomplete bladder emptying
           • w/ thickening of bladder wall
       • urodynamic studies
       • X ray of spine
         • vertebral anomaly
       • MRI
         • confirm or exclude non-spinal bony defect
           • e.g. tethering of cord
   • Mx
     • if neuro cause excluded
       • star charts
       • bladder training
       • pelvic floor exercises
     • treat constipation
     • portable alarm w/ pad in pants
       • for lack of attention to bladder sensation
     • anticholinergics
       • to damp bladder contractions
       • e.g. oxybutynin
       • if other measures fail

3. secondary (onset) enuresis

   • loss of previously achieved urinary continence
   • causes
     • emotional upset
       • commonest cause
     • UTI
     • polyuria
       • from osmotic diuresis in diabetes mellitus
       • from renal concentrating disorder e.g. sickle cell disease or chronic renal failure
   • Ix
     • urine sample: look for
       • infection
       • glycosuria
       • proteinuria
     • assessment of renal concentrating ability
       • measure osmolality of early morning urine sample
       • formal water deprivation test
         • to exclude urinary concentrating defect
         • rarely needed
     • ultrasound of renal tract