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childhood enuresis

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childhood enuresis

  1. 1. CHILDHOOD ENURESIS Presented by :- Dr. Kumar Keshav Chandra
  2. 2. HEADINGS • Anatomy of bladder • Physiology of micturition • Bladder innervation • Micturition reflex • Voiding and its control • Disorder of micturition • Nocturnal enuresis
  3. 3. URINARY BLADDER ANATOMY • Urinary bladder functions as a storage organ that can empty to completion at appropriate time and place. • The bladder is the most anterior element of the pelvic viscera. • Situated in the pelvic cavity when empty, but expands superiorly into the abdominal cavity when full. • The urinary bladder is abdominal at birth, positioned at the extraperitoneal area of the lower abdominal wall. • Around the 5th or 6th year of age the bladder gradually descends into the area of the true pelvis.
  4. 4. URINARY BLADDER ANATOMY It has 4 parts 1. Apex 2.Base 3.Superior surface 4.Inferolateral surfaces
  6. 6. PHYSIOLOGICAL ANATOMY OF URINARY BLADDER • Urinary bladder is a hollow organ, having parts namely: • BODY – formed by detrusor muscle • NECK - has trigone in its posterior aspect • Emptying of bladder is mainly guarded by Internal And External Sphincter • Internal Sphincter – completely involuntary. ( smooth muscle) • External Sphincter- voluntary. ( skeletal muscle)
  7. 7. INNERVATION OF URINARY BLADDER • Urinary bladder and Internal sphincter are supplied by sympathetic and parasympathetic nerve fibers. • Sympathetic supply : L1, L2 ( Hypogastric nerve) • Parasympathetic supply : S2,S3,S4 ( Nervi erigentes / pelvic nerve) • External sphincter is supplied by somatic nerve fibres. (through onuf’s nucleus S2,3,4. Pudendal nerve) , having voluntary control of urination. • Pelvic nerve ( nervi erigentes) also has sensory fibers, which carry impulse from the stretch receptors present on the wall of urinary bladder and urethra.
  8. 8. • Stretch receptor on bladder—sensation carried to spinal cord by sensory fibers of pelvic nerve—sense of distension carried in post column and sense of pain through lateral spinothalamic tract—reaches to brain stem (pontine centre) and suprapontine centre(para central lobule, basal ganglia, thalamus) • Output from supra pontine centre to pontine centre is inhibitory most of the time. • This supra pontine output becomes facilitatory only when it is socially acceptable to void.
  10. 10. Sympathetic supply stimulation of hypogastric nerve causes,relaxation of detrusor muscle and constriction of internal sphincter results in filling of bladder (Nerve of filling) • Parasympathetic supply stimulation of pelvic nerve causes contraction of detrusor muscle and relaxation of internal sphincter it results in emptying of bladder. (nerve of micturition).
  11. 11. TYPES OF NERVES NERVE FIBRES ACTION COMMENTS SYMPATHETIC HYPOGASTRIC NERVES(L1,L2,L3) INFERIOR MESNTERIC GANGLION motor to internal urethral sphincter, inhibitory to detrusor Help in filling of bladder and prevent reflux of semen into the bladder during ejaculation PARASYMPATHETIC PELVIC NERVES (S2,S3,S4) motor to detrusor inhibitory to internal urethral sphincter •Muscarinic receptors •emptying of urinary bladder SOMATIC PUDENDAL NERVES (S2,S3,S4) Voluntary control of External urethral sphincter This maintains the tonic contractions of the skeletal muscle fibers of the external sphincter, so that this sphincter is contracted always. During micturition this nerve is inhibited, causing relaxation of the external sphincter and voiding of urine. SENSORY HYPOGASTRIC, PELVIC AND PUDENDAL NERVES Cortical sensation
  13. 13. • FILLING • The walls of the ureters contain smooth muscle having regular peristaltic contractions occurring one to five times per minute move the urine from the renal pelvis to the bladder, where it enters in spurts synchronous with each peristaltic wave. When the volume of urine in bladder reaches threshold level to initiate Micturition reflex (this threshold level is adjusted by higher centers of micturition ) Bladder wall stretches Stretch receptors on the bladder wall are activated…Sensory signal is given to spinal centers through sensory fibres of parasympathetic (pelvic nerve) Reflex arc is produced in spinal cord…
  14. 14. continued Motor signal is given to urinary bladder through motor fibres of parasympathetic nerve ( pelvic nerve) DETRUSOR muscle contracts and INTERNAL SPHINCTER relaxes and urine passes down into proximal urethra.. Again afferent impulse from urethra is given to spinal cord… Afferent impulse reaches the higher centers in brain If the signal from higher center is TO MICTURATE impulse created from spinal center BLOCK PUDENDAL NERVE and sympathetic efferents to external sphinctor are inhibited…So, External sphincter relaxes and micturition occurs…
  15. 15. continued • If the signal from higher center is NOT TO MICTURATE, sympathetic efferents are stimulated • As a result, DETRUSOR EXPANDS and INTERNAL SPHINCTER constricts… External sphincter remain constricted… So, Urine continues to accumulate in bladder..
  16. 16. CENTERS FOR MICTURITION SPINAL CENTRES : • Located in sacral and lumbar segments in form of sympathetic and parasympathetic control. • Controlled by higher center of brain. • HIGHER CENTERS : • Facilitatory center : Pontine micturition centre(barrington nucleus), acting as a coordination center. Posterior hypothalamus. • Inhibitory center : cortical center(paracentral lobule). These are inhibitory to pontine center. • Controls pontine center till a suitable socially acceptable situation for micturition is available.
  17. 17. NORMAL VOIDING AND BLADDER CONTROL Fetal voiding occurs by reflex bladder contraction in concert with simultaneous contraction of the bladder and relaxation of the sphincter. The infant has coordinated reflex voiding as often as 15-20 times/day. . Bladder vol. of new born 20-30 ml. • Over time, bladder capacity increases • In children up to the age of 14 yr, the mean bladder capacity in milliliters = [AGE (in yr) +2] × 30. • = AGE (in yr) × 30 + 30. • At 2-4 yr, the child is developmentally ready to begin toilet training. • Females typically acquire bladder control before males, and bowel control typically is achieved before bladder control
  18. 18. To achieve conscious bladder control, several conditions must be present:  Awareness of bladder filling  cortical inhibition (suprapontine modulation) of reflex bladder contractions  ability to consciously tighten the external sphincter to prevent incontinence  normal bladder growth  and motivation by the child to stay dry.  The transitional phase of voiding refers to the period when children are acquiring bladder control.
  19. 19. MATURATION OF BLADDER CONTROL FETUS/ AT BIRTH Spinal cord reflex Spontaneous / reflex micturition 1-2 YEARS bladder capacity + Neural maturation of frontal and parietal lobe Sensation of bladder filling present but voiding is reflex 3-4 YEARS Voluntary control of EUS when awake(day time continence) Can delay micturition 5 YEARS Cortical inhibitory control achieved Dry by night >6 yrs Ability to initiate voiding even when bladder has not given a “full” signal Voiding under socially acceptable circumstances
  20. 20. • So fully mature bladder control have:- Generous bladder capacity Voluntary control of EUS Ability of cerebral cortex to initiate and inhibit a detrusor contraction for any bladder capacity, which enables voiding under socially acceptable conditions.
  21. 21. The sequence of maturational events for fecal and urinary continence Night-time fecal continence Daytime fecal continence Daytime urine continence Night-time urine continence. Majority of children are dry by day by the age of 2½ years and at night by 3- 4 years.
  22. 22. DISORDERS OF MICTURITION The International Children’s Continence Society (ICCS) has recommended the use of standard nomenclature when describing lower urinary tract malfunctions in children above 5-year-old which are as follows:- • Decreased daytime voiding frequency: 3 or fewer voidings/d • Increased daytime voiding frequency: 8 or more voidings /d • Polyuria: 24-hour urine output of more than 2 l/m2 BSA. • Incontinence: Uncontrollable leakage of urine  Continuous: Continuous leakage of urine, not in discrete portions, which indicates malformation or iatrogenic damage  Intermittent: Leakage of urine in discrete portions during the day and/or night.  Nocturnal incontinence is synonymous with enuresis  Urge incontinence: Incontinence in patients experiencing urgency, e.g. incontinence in children with overactive bladder  Voiding postponement: Incontinence in the presence of habitual holding maneuvers
  23. 23. . Enuresis: Intermittent incontinence of urine while sleeping (nocturnal incontinence) • Monosymptomatic: Enuresis without any (other) lower urinary tract symptoms.  Non-monosymptomatic: Enuresis with lower urinary tract symptoms , such as daytime incontinence, urgency and holding maneuvers. • Primary: Enuresis in a child, who has never been dry • Secondary: Enuresis in a child who has previously been dry for at least 6 months . Factor associated includes Nocturnal polyuria, detrusor instability, and an abnormally deep sleep pattern Overactive bladder: The condition in patients experiencing urgency symptoms Underactive bladder: The condition in patients with low voiding frequency; need to increase intra-abdominal pressure to void (replaces the term underactive bladder or lazy bladder)
  24. 24. Dysfunctional voiding: The habitual contraction of the urethral sphincter during voiding, as observed by uroflow measurements. Maximum voided volume: The largest voided volume, as documented in a bladder diary(diary maintained for 3 day)It replaces the term functional bladder capacity Expected bladder capacity: Age related expected maximum voided volume, as determined by the formula, [30 + (age in years × 30)] in ml.
  25. 25. Cystometric definitions • Detrusor overactivity: The observation during cystometry of involuntary detrusor contractions during the filling phase. • Detrusor-sphincter dyssynergia: The cystometric observation of a detrusor voiding contraction concurrent with an involuntary contraction of the urethra. • Detrusor underactivity: The cystometric observation of a contraction of decreased strength and/or duration, resulting in prolonged bladder emptying and/or a failure to achieve complete bladder emptying • Residual urine: Urine left in the bladder after voiding. Residual urine in excess of 5 to 20 ml indicates incomplete bladder emptying. A postvoid residual of more than 5 ml in the neonate and greater than 10% of the expected capacity in the older child is considered abnormal.
  26. 26. Nocturnal Enuresis • It is defined as normal, nearly complete, involuntary evacuation of the bladder at a wrong place and time at least twice a month( for more than 3 consecutive month )after the 5th year of life. • Overall, 75% of children with enuresis are wet only at night, and 25% are incontinent day and night. • Bladder control is usually attained between the ages of one and five years.  More than 85 percent children will have complete diurnal and nocturnal control by five years of age. The remaining 15 percent of children gain continence at a rate of approximately 15 percent per year and by adolescence 0.5-1 percent children continue to have enuresis.  Up to the eleventh year, enuresis is twice as common in boys as it is in girls; thereafter the incidence is similar or slightly higher in girls.
  27. 27. Etiology Most of the children with primary nocturnal enuresis are functional. Only 2-3% 0f nocturnal enuresis have true organic cause. There is no single definite underlying cause for enuresis, and the condition may be multifactorial: 1. Maturational Delay- This is the most likely cause of nocturnal enuresis, since spontaneous cure rates increase with age and the sequence to dryness mimics the pattern seen in normal children. • Delayed maturation of the cortical mechanisms that allow voluntary control of the micturition reflex. • Boys take longer to reach specific milestones and have a greater incidence of enuresis. • 2. Genetics:- controlling gene have been localized to chromosomes 12 and 13(ENUR1). If one parent was enuretic, each child has a 44% risk of enuresis; if both parents were enuretic, each child has a 77% likelihood of enuresis. Mode of inheritance is AD with reduced penetrance .
  28. 28. • 3. Antidiuretic hormone:- ADH has a circadian rhythm, with increased secretion occurring during the night and peak secretion between 4 and 8 am. A lack of this circadian rhythm or impaired response of the kidneys to ADH may be a possible etiology for nocturnal enuresis. Reduced ADH production at night, resulting in an increased urine output (nocturnal polyuria). • 4. Defective sleep arousal:- All children are most difficult to arouse in the first third of the night and easiest to awaken in the last third, but enuretic children are more difficult to arouse than those with normal bladder control • 5. Bladder Capacity:-The balance between bladder capacity and nocturnal urine production may be the ultimate determinant of whether or not an enuretic episode will occur. • The functional capacity, i.e. the volume of urine that the bladder can hold when awake or asleep, may be reduced in children with enuresis. • This is determined as the largest volume voided after measuring each void for 3 consecutive days and is compared to the estimated bladder capacity calculated using the age based formula.
  29. 29. 6. Organic factors, such as urinary tract infection, obstructive uropathy may lead to incomplete bladder emptying. 7. Obstructive sleep apnea may be an additional risk factor in obese children with primary monosymptomatic nocturnal enuresis. 8. Co morbid conditions:- Constipation and neuropsychiatric disorders such as attention deficit hyperactivity disorder are common in children with enuresis.
  30. 30. Clinical Manifestation and Diagnosis • A careful history should be obtained, especially with respect to fluid intake at night and the pattern of nocturnal enuresis. • Children with diabetes insipidus ,diabetes mellitus , and chronic renal disease can have a high obligatory urinary output and a compensatory polydipsia. • The family should be asked whether the child snores loudly at night. • Many children with enuresis have sleepwalk or talk in their sleep. • A complete physical examination should include palpation of the abdomen and possibly a rectal examination after voiding to assess the possibility of a chronically distended bladder and constipation.
  31. 31. • The child with nocturnal enuresis should be examined carefully for neurologic and spinal abnormalities. • There is an increased incidence of bacteriuria in enuretic females, and, if found, it should be investigated and treated. • A urinalysis to rule out infection, proteinuria and glucosuria is warranted in all children. • A renal USG is reasonable in an older child with enuresis or in children who do not respond appropriately to therapy. • If there are no daytime symptoms, the physical examination and urinalysis are normal, and the urine culture is negative, further evaluation for urinary tract pathology generally is not warranted
  32. 32. TREATMENT  No single therapeutic plan is ideal for all patients.  Assessing the level of motivation of the patient and his parents prior to offering the choice of treatment is important.  The best approach to treatment is to reassure the child and parents that the condition is self-limited and to avoid punitive measures that can affect the child's psychological development adversely.  The decision about when to start treatment should be guided by the degree of concern and motivation on the part of the child rather than the parents.  Active treatment should be avoided in children younger than 6 yr of age.
  33. 33. 1. General measures:- There is little objective evidence that withholding fluids in the evening, random awakening of the child to void or punitive measures result in significant cessation of enuresis. • Fluid intake should be restricted to 60 ml after 6 or 7 PM. Adequate fluid intake during the day as 40 percent in the morning, 40 percent in the afternoon and 20 percent in the evening is recommended. • Caffeinated drinks like tea, coffee and sodas should be avoided in the evening • The parents should be certain that the child voids at bedtime.
  34. 34. 2. Motivational therapy :-The success of any form of therapy depends largely on the child being motivated to work towards sleeping dry. • Every attempt is made to remove any feeling of guilt. • The child should be encouraged for total involvement in the therapy with maintenance of a dry night diary. • Dry nights merit praise and encouraging words from the parents. • 25 % of children may be cured with appropriate motivational therapy alone. .
  35. 35. 3.Conditioning therapy(Alarm) • Involves use of a loud auditory or vibratory alarm attached to a moisture sensor in the underwear or a mat under bedsheet. The alarm activates when voiding occurs and is intended to awaken children and alert them to void and conditioned response to awakening to the sensation of full bladder. • The child should awaken to the alarm, void in the toilet and reattach the alarm . • The alarm should be used consistently every night. • In case of response, alarm therapy is continued until at least 14 consecutive dry nights are achieved. • This form of therapy has a reported success of 30–60%, although the relapse rate is significant. • The alarm is best used after 7 yrs of age and its use continued for six months for better long-term success.
  36. 36. 4. Pharmacotherapy:- • Pharmacologic therapy is intended to treat the symptom of enuresis and thus is regarded as second line and is not curative. Direct comparison with alarm therapy favor the alarm because of lower relapse rates, although initial response rates are equivalent.  DESMOPRESSIN:- synthetic analog of VASOPRESSIN that reduces urine production overnight. • FDA-approved in children and is available as a tablet, with a dosage of 0.2-0.6 mg 2 hr before bedtime. • In the past a nasal spray was used, but some children experienced hyponatremia and convulsions with this formulation, and the nasal spray is no longer recommended for nocturnal enuresis.
  37. 37. • Hyponatremia has not been reported in children using the oral tablets. • Fluid restriction at night is important, and the drug should not be used if the child has a systemic illness with vomiting or diarrhea or if the child has polydipsia. • Desmopressin acetate is effective in as many as 40% of children and is most effective in those approaching puberty. • If effective, it should be used for 3-6 month, and then an attempt should be made to taper the dosage. • TAB MINIRIN/ TAB D-VOID (0.1 mg/0.2mg)
  38. 38. Anticholinergic drug For therapy-resistant enuresis or children with symptoms of an overactive bladder, anticholinergic therapy is indicated. Oxybutynin 5 mg or tolterodine 2 mg at bedtime often is prescribed. If the medication is ineffective, the dose may be doubled. The clinician should monitor for constipation as a potential side effect. TAB CYSTRAN/ NOCTURINE/OXYSPAS (5mg/10 mg)- oxybutynin TAB TEROL/ DETRUSITOL (1/2mg)– tolteradine.
  39. 39. Tricyclic antidepressants • A third-line treatment is imipramine, which is a TCA. • This medication has mild anticholinergic and α-adrenergic effects, reduces the urine output slightly, and also might alter the sleep pattern. • The dosage of imipramine is 25 mg in children age 6-8 yr, 50 mg in children age 9-12 yr, and 75 mg inteenagers. • Reported success rates are 30–60%. • Side effects include anxiety, insomnia, and dry mouth, and heart rhythm may be affected. • If there is any history of palpitations or syncope in the child, or sudden cardiac death or unstable arrhythmia in the family, long QT syndrome in the patient needs to be excluded • Tab ANTIDEP/IMIPRAMINE(25/50mg).
  40. 40. SUMMARY OF TRAETMENT • DDAVP has better short-term results but the alarm device has better long-term outcome. • If long-term efficacy, cost and safety are considered, enuresis alarms are superior. • In unsuccessful cases, combining therapies often is effective. • Alarm therapy plus desmopressin is more successful than either alone. • The combination of oxybutynin chloride and desmopressin is more successful than either alone. • Desmopressin and imipramine also may be combined.
  41. 41. The three system model, i.e.  Desmopressin for low vasopressin release,  Oxybutynin along with bladder training for instability and the  Alarm to enhance arousability from sleep, is usually satisfactory. • A combination of one of these with motivational therapy is ideal. Reassurance of the child for direct involvement in the therapy improves the outcome. • Children who fail both the first line therapies further evaluation to rule out non-monosymptomatic enuresis, ensuring correct technique of administration of therapies prescribed, and exclusion of constipation and psychiatric disorders.