This document discusses enuresis, or involuntary voiding of urine during sleep beyond the age of 5. It defines primary and secondary enuresis and describes the typical achievement of bladder control by age. Treatment options discussed include behavioral interventions, alarm therapy, pharmacotherapy using drugs like DDAVP and antidepressants, and rarely surgery. The overall approach emphasizes a multifaceted treatment tailored to each child, with the goal of solving the problem through a positive attitude and commitment from the child, parents, and pediatrician.

1. Enuresis
CSN Vittal

2. Enuresis
Definition :
Involuntary voiding of urine at least two
nights per month beyond the age of 5
years by which bladder control is
normally obtained and without any
congenital or acquired defects of the
urinary tract.

3. Enuresis
Achievement of bladder control
 85% by 5 yrs
 Remaining 15% at a rate of 15% per year
 Only 0.5 to 1% - no control at adolescence

4. Types of Enuresis
Primary
Child who never
gained nocturnal
urinary control
Accounts of 85%
of cases
Secondary
At least a 6 –
month period of
dryness has
preceeded the
onset of wetting

5. Enuresis
Presentation
 Type I : Monosymptomatic
 Type II : Diurnal enuresis without daytime frequency
 Type III : Nocturnal enuresis with daytime frequency
 Type IV : Nocturnal enuresis with daytime frequency
and voiding dysfunction

6. Types of Enuresis
Uncomplicated Complicated
OnsetOnset Primary Secondary
DaytimeDaytime
symptomssymptoms
Absent Present
StreamStream Normal Abnormal
Physical Exam.Physical Exam. Normal Abnormal
UrinalysisUrinalysis Normal Abnormal

7. Therapeutic Responses
Initial success:
14 consecutive dry nights have been achieved with treatment
Lack of success:
Failure to meet the above criteria
Relapse:
When 2 or more wet nights within two weeks of initial success and the
interval between the initial success and relapse measured
Continued success:
There is no relapse after 6 months of initial success
Complete success:
There has been no relapse in 2 years after an initial success

8. Development of Urinary Control
1. Nocturnal bowel control
2. Day time bowel control
3. Day time voiding control
4. Night time voiding control

9. Genetics
1. Familial pattern
2. Risk of enuresis 7.5 when father was
enuretic than when mother was.
3. 75% if both parents were enuretic
4. 45% in families with one parent enuretic
5. 15% when neither parent was enuretic
6. Primary – aut. Dominant with
penetrance above 90% with disease
locus in chr 13q

10. Evaluation
1. Complete history
• Primary or sec.
• Nocturnal or diurnal
• Does encopresis associated
• Associated urinary tract symptoms like dysuria, polyuria,
pollakiuria, hematuria, pyuria, etc.
2. Developmental history
• Birth history
• Achievement of milestones
• Neurological deficits
• CNS disorders
3. Family history
• H/o. enuresis in parents
• Traumatic incidents
• Parental harmony

11. Physical Examination
1. Visualization of urinary system
2. Abdomen exam – for renal / bladder mass
3. Genitals – hypospadiasis
4. Neurological
1. Peripherl reflexes
2. Perianal sensations
3. Tone
4. Gait
5. Lower back
1. Tuft of hair
2. Vertebral anomaly

12. Types of Nocturnal Enuresis
Polysymptomatic
Daytime enuresis,
encopresis, urgency,
dribbling
PE, neurological
abnormalities +
+ve urinalysis, c/s, USG
Need contrast studies,
urodynamic assessment
Monosymptomatic
Solely nocturnal
Normal physical
exam. &
urethrogram
No further
investigations

13. General Tratement
1. Avoid excessive fluids
2. Empty bladder at bed time
3. Told to wake up at night and use
toilet to remain dry
4. Improve access to toilet
5. Include the child in morning
cleaning up of urine-soiled cloths

14. Behavioural Intervention
Active participation &
commitment of
• parents
• the child &
• the pediatrician

15. Motivation Therapy (for > 7 yrs. Old)
1. Convince parents that the child wants to
be dry
2. Child is encouraged to assume
responsibility for his enuresis and
actively participate in treatment
3. Move from blame for wet nights to
praise for dry nights.
4. A dry morning should receive positive
recognition and should receive lavish
words of praise from everyone in family.
5. A major breakthrough may warrant
material reward.

16. Alarm Therapy
1. Alarm triggered when the diaper gets
wet to awaken the child from sleep and
stop micturition.
2. By repetitive inhibition of micturition a
conditioning process occurs ultimately.
3. With 3 mo. of treatment – 92% cured
4. Relapse rate is 30%
5. Response to retreatment is good
6. Adjuvant pharmacotherapy helps

17. Wet Alarm Therapy

18. Multidimentional behavioural Therapy
1. Full spectrum home training
2. Scharf’s Comprehensive
Treatment Program

19. Bladder Stretching
1. Increased oral fluids, lengthening
of period between daytime voiding
2. Holding back urination until the
point of incontinences – can help
increase anatomical and functional
bladder capacity

20. Pharmacotherapy
1. DDAVP (1-deamino-8 Arginine
Vasopressin) for > 4 yrs old.
• Reduces nocturnal urine output to a volume
lower than functional bladder capacity
• Useful in those who do not manifest diurnal
rhythm of vasopressin
• Dose: 20 micrograms (one spray) in each
nostril
• Max. up to 80 micrograms
Adverse Effects
Hyponatremia, disorientationm seizures,
coma

21. Pharmacotherapy
2. Anticholinergics
• Oxybutenin chloride
Acts by increasing bladder capacity and
reducing frequency of detrusor
contractions.
Adverse Effects:
Dryness of mouth, blurred vision, facial
flushing.
Dose: For > 7 yrs : 5 mg 2-3 times a day

22. Pharmacotherapy
3. Tricyclic antidepressants
• Imipramine
Alteration of sleep mechanisms and rousal pattern
Cholinergic properties
Adverse Effects:
Anxiety, insomnia, dry mouth, nausea, personality changes.
Cardiac arrhythmias, hypotension, respiratory complications,
convulsions
Dose: 25 mg for 6-8 yrs old
50-75 mg for older children
Administered at 6 pm.
Treatment for 3 – 6 months, then tapered off
Antidote: Physostigmine

23. Surgical Therapy
Cystoplasty
In select cases

24. Conclusion
Enuresis is basically a symptom and not a disease state
Intervention is justified for psychological benefit of child and
family
Problem of enuresis should be solved with 5 “P” regimen
• Praise
• Patience
• Perseverance
• Passion
• Positive attitude