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