children with “diurnal enuresis”: how do we help them? dr jonathan evans consultant paediatric...

Children with “Diurnal Enuresis”: How do we help them?

Dr Jonathan EvansConsultant Paediatric Nephrologist

Nottingham Children’s Hospital

• Normal & abnormal bladder function

• Classification & causes of urinary incontinence

• Assessment • Management

Diurnal Enuresis is…..

A. Not urinary incontinenceB. Non Organic wettingC. Less of a problem than incontinenceD. Useful terminology to help guide

managementE. A patronising term used by health care

professionals who have failed to make a proper diagnosis

Urinary Incontinence

EXCLUDINGBedwetting

Plumbing Problems

Neurogenic Bladder

The Master control – inhibits voiding (conscious or subconscious) until it choses

Co-ordinates micturition - inhibited by cortex

Storage/Filling – under SYMPATHETIC control: •β/ β3+ suppresses detrusor & parasymp/muscarinic/cholinergic•α+ stimulates internal sphincter

Voiding/Micturition – by SYMPATHETIC inhibition – •α- relaxes internal sphincter•release of parasymp/muscarinic/cholinergic stimulation detrusor contraction

Normal bladder function in children

• in utero cyclical emptying

• 1st yr cyclical, small bladder

• 2nd/3rd yr when bladder is FULL...– recognise need to pee!– defer micturition briefly

voluntary micturition when full bladder

• 4th/5th yr from any fullness…. – Can defer or initiate micturition, but usually void at strong desire

• Adult? Planned micturition

… DRY byday / night

Normal Bladder Function 5yr+Storage• Detrusor relaxation + urethral closure maintained by

INVOLUNTARY control of detrusor and bladder neck/internal sphincter smooth muscle

• Micturition reflex can be supressed by CNS control (central inhibition)

• Expected Bladder Capacity = 30(Age+1yr) in mls!• Store urine for several hours at low pressure• Able to store urine overnight

Normal Bladder Function 5yr+Voiding• Co-ordinated detrusor contraction and urethral relaxation no

abdominal straining, completely empty bladder

• good, continuous urinary stream (“bell shaped curve”)

• Small post micturition dribble is common!

• micturition reflex at FBC can be deferred or initiated voluntarily

• pee 4-7 times per day and occasionally at night

What is abnormal bladder function?Depends on developmental age..

Storage• Urgency• Frequency or • Nocturia• Holding manoeuvres• Incontinence

– Intermittent– Night or Day

• Urge• Stress• Unaware • Giggle• Post micturition

– Continuous

Voiding• Hesitancy• Straining• Poor stream• Intermittent/variable

stream• Explosive stream• Incomplete emptying• (other LUTS such as dysuria,

haematuria!)

Causes of Abnormal Bladder FunctionInput•Genetics•Uropathy•Neurogenic•CNS disorder•Development (ADHD, ASD)•Psychosocial•Infection•Constipation

OutcomeL.U.T.S associated with•Overactive Bladder•Underactive Bladder•Dysfunctional Voiding•Dysfunctional Elimination•Giggle Micturition•Other!

e.g SI with multiple causes including anatomical & neurogenic

AssessmentHistory– Voiding, Storage, Bowels, Co-morbidities,

Psycho-social, Developmental, Attitudes, Values & Behaviours

Examination– General + Abdomen, Bladder, Ext

Genitalia?, Spine, Reflexes, BPBasic Investigations– Urinalysis, Freq/Vol chart, Stool Chart,

Intermediate Investigations– Bladder Scan, Uroflow, Renal tract USS

Invasive Investigations– MCUG, Urodynamics, MRI Spine..

All

Few

Frequency Volume Charts Avoid over

interpretation! Need 2-3 days to be

representative Freq = 4-7/d EBC= 30 x (Age+1) MVV = 75% EBC Ignore first morning

wee If you don’t drink

you wont pee much!

normal over

activ

e

dysfunctionalvoiding

Abdominal straining - Underactive bladder

Outflow obstruction

Data Analyser

Fluid

Pressure in Bladder(Measured)

Intra abdominalPressure

(Measured)

Pressure in Bladder(Calculated)

Other Measurements

•Fill volume•Urine flow rate•Pelvic Floor EMG

Time - minutes

84 ml 151 ml

Patterns of daytime incontinenceSymptom Functional Disturbance Pathology

Urge incontinence Overactive bladder Detrusor overactivity – functional or urological /neurogenic

Giggle wetting NormalOABGiggle micturition Dysfunctional voidingUnderactive bladder

Depends on associated symptoms

Post micturation dribble Normal or Vaginal reflux of urine

Normal, Vaginal reflux of urine

Stress (e.g with cough, sneeze, exertion)

Dysfunctional voiding, Underactive bladder, OAB

Dysfunctional voiding, Underactive bladder, OAB +/- Neurogenic, Urological

Continuous dribble Ectopic ureter Ectopic ureter

Unaware Anything but Normal or OAB commonest!

Anything includingUrological / neurogenic

What is the evidence for widely used interventions?

• Fluids - more or less?

• Constipation - cause or effect?

• UTI - pathogenic or benign?

• Toileting - timed, prompted or hold on?

• Pelvic Floor - hold on or let go?

• Drugs - how effective?

• Neuromodulation - any evidence??

Treatment of Overactive Bladder• Drink enough to avoid dehydration• Caffeine avoidance• Treat/prevent constipation• Treat/prevent symptomatic UTIs• Regular or timed voiding– Reminder alarm

• Anticholinergics• β3 agonist? (Mirabegron)• Neuromodulation (sacral/tibial nerve)? • Botulinum Toxin • Bladder Augmentation

All

Few

Mirabegron (Betmiga)• A β3 agonist – suppresses detrusor and

augments the sympathetic inhibition of cholinergic receptors

• Efficacy similar to anticholinergics• NICE TA290 (2013) - an option for adults in

whom antimuscarinic drugs are ineffective, or have unacceptable side effects

• Anecdotal use in children…

Neuromodulation (sacral)Percutaneous - Tibial = NICE approved (adult)- Sacral = FDA approved

Transcutaneous - Evidence less robust!- sacral = TENS machine

Treatment of Voiding Dysfunction• Drink enough to avoid dehydration• Caffeine avoidance• Treat/prevent constipation• Treat/prevent symptomatic UTIs• Treat OAB (e.g anticholinergics)

PLUS• Regular or timed voiding, relaxed voiding, double

voiding• Biofeedback• Alfa Blocker (e.g Doxazocin)• Botulinum Toxin to ext sphincter?• Intermittent self cathetersisation (ISC)

Biofeedback-transcutaneous electrodes measure pelvic floor/sphincter and abdominal muscle activity

-Converts to visual / auditory signal

-Computer game controlled by pelvic floor & abdominal muscles!

• Pediatric Animation Mode. There are five different characters that the patient can choose from

• Top screen (Channel 1) monitors the patients pelvic floor.

• Bottom screen • (Channel 2) monitors

the patients abdominal muscles.

Accumulating evidence of effectiveness in adults (and children) with voiding dysfunction but very varied models of biofeedback

α Blockers • Inhibit smooth muscle in internal urinary

sphincter and prostatic urethra• Good evidence in benign prostatic

hypertrophy!• Case series, Anecdote and expert opinion says

it is helpful as part of a multicomponent bladder rehabilitation package!

• Doxazocin vs (“me to”-ocins)!• For expert use!

Treatment of Giggle Incontinence

• Treat underlying bladder dysfunction• Timed voiding• Pelvic floor training (awareness)• Trial of anticholinergics• Biofeedback• MethylphenidateEvidence is limited to case series, expert opinion

and anecdote!

Children with “Diurnal Enuresis”: How do we help them?CQC Domain To Help Children with URINARY INCONTINENCE

Safe Understand bladder dysfunctionUndertake a careful evaluationWork within your competenciesRecognise warning signs (both medical & social)

Effective Offer the correct treatments based on your evaluationRefer to specialist (MDT) for complex investigation & management

Caring Empathy & Support, avoid being dismissive

Responsive Listen to child and parent - adapt management to account for patient choice , ability and beliefs

Well Lead Advocate, Support staff, Manage expectations, Know the services that are available…