Background
-Enuresis=intermittent urinary incontinence during sleep in a child who is at least 5 years of age (i.e. 5 years or older).
-Approximately 5% to 10% of all seven-year-olds have enuresis, and an estimated 5 to 7 million children in the United States have enuresis.
Diagnosis
-H&P and urinalysis will be done as the initial evaluation.
–Will r/o associated conditions such as constipation, obstructive sleep apnea (OSA), Overactive bladder or dysfunctional voiding, ADHD, diabetes mellitus, diabetes insipidus, chronic kidney disease, and psychiatric disorders.
-UA to r/o CKD.
Treatment
-Patient likely has primary monosymptomatic enuresis (i.e., the only symptom is nocturnal bed-wetting in a child who has never been dry)
-Child and parents counseled on effective behavioral modifications.
–Bed alarm therapy and desmopressin discussed with parents today. Will hold off on desmopressin at this time.
-Will refer to a pediatric urologist in the future if the patient doesn’t respond to alarm therapy or desmopressin enuresis in addition to effective behavioral modifications or if secondary causes of enuresis like urinary tract malformations, recurrent UTIs or neurologic disorders are uncovered.
The pathophysiology of primary nocturnal enuresis involves the inability to awaken from sleep in response to a full bladder, coupled with excessive nighttime urine production or a decreased functional capacity of the bladder.
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First-line treatments for enuresis include bed alarm therapy and desmopressin.
Desmopressin = an analog of ADH. Works just like ADH.
Desmopressin has a success rate of approximately 70%, which is similar to alarm therapy, but the risk of recurrence after discontinuation is higher with desmopressin.
Treating a patient with Desmopressin:
If you start a patient on Desmopressin, “Follow-up should occur at 2 to 4 weeks to assess response and any adverse effects. If no response is achieved at the starting dose of 0.2 mg, it may need to be titrated up to 0.6 mg to achieve dry nights. Desmopressin should be withheld periodically for a short time every three months to assess if nighttime continence has been achieved.2,6 It can also be used on an as-needed basis for events such as sleepovers or camps after an effective dosage is found.” AAFP
Print approach to enuresis patient from AAFP article.
Also, print history questions to ask.
Patient education:
1) How bed-wetting alarms work.
Resources:
http://www.aafp.org/afp/2014/1015/p560.html
http://www.aafp.org/afp/2008/0815/p489.html