Bed wetting- a neglected topic: Case based discussion

120 µg

Dr Tarannum Khondaker Rasha

Associate Professor
Bangladesh Shishu Hospital &
Institute
 Introduction

Nocturnal enuresis is defined as wetting at night, in a child over five years,

in the absence of neurological or structural problems affecting the bladder.

If untreated, bedwetting can persist into adulthood .The duration of bedwetting

negatively correlated with quality of life and self-esteem.

Effective treatment can alleviate this burden, allowing the child to enjoy normal
social and emotional development.

Kenna NL, Evans JHC. Drug Treatment of Nocturnal Enuresis. Paediatric and Perinatal Drug Therapy. 2000; 4(1):12-18
Jain S, Bhatt GC. Advances in the management of primary mono symptomatic nocturnal enuresis in children. Paediatrics and International Child Health, 36:1, 7-14
 Classification of Nocturnal Enuresis

Nocturnal
Enuresis

Primary Nocturnal
Secondary Nocturnal
Enuresis (PNE): The child
Enuresis (SNE):
has never achieved
Bedwetting occurs after the
sustained dryness at night
child has been dry for more
for a period of at least 6
than 6 months
months

Mono- symptomatic Non-mono- symptomatic

Without LUTS or day time With LUTS or day time
symptoms urinary symptoms

Neveus T et al. The standardization of terminology of lower urinary tract function in children and adolescents: report from the Standardisation
Committee of the International Children's Continence Society. J Urol. 2006 ;176(1):314-24.
 Epidemiology

More common in boys than girls ( Approx 1.4).

Prevalence in 7-year-olds of 5–10%.Declining to 1– 2% in young

adults.
Spontaneous resolution rate of 15%.Children with frequent NE
have much lower resolution rate.

NMNE is more common (approximately 75%) than MN.

Yeung CK, Sreedhar B, Sihoe JD, Sit FK, Lau J. Differences in characteristics of nocturnal enuresis between children
and adolescents: a critical appraisal from a large epidemiological study. BJU international. 2006;97(5):1069-73.
Nocturnal Enuresis – heterogeneous pathophysiology
Approach to a Child with Bed wetting
 Case history
Factor Variable

When did bed wetting start Days or weeks

Previously been dry at night for 6 month
Bed wetting pattern
Day time symptoms and toilet pattern
Yes/no
Nights /week. Times/night, time of bed wetting,
awakening after bed wetting, volume of urine
Frequency, urgency, leaking, dysuria, passing
urine< 4 times /day, poor stream, abdominal
straining . Urine in special situation, urine avoiding
in school, frequent or less urine than other peers.

Fluid intake during day and night Volume of fluid intake

Comorbidities Bowel problem, developmental and behavioural
problem, family problem, diabetes mellites.

Reddy NM et al. Nocturnal Enuresis in India: Are We Diagnosing and Managing Correctly? Indian Journal of Nephrology. 2017
 Physical Assessment

Examination of the abdomen

 Check for distended bladder and
faecal impaction
 Rectum
 Genitalia (identify signs suggestive
of sexual abuse which may be the
cause of secondary/persistent
enuresis)
Neurological assessment
Spine
Growth
Reddy NM et al. Nocturnal Enuresis in India: Are We Diagnosing and Managing Correctly? Indian Journal of Nephrology. 2017; DOI:
10.4103/ijn.IJN_288_16
 Voiding and Bowel diary

Bed wetting diary for 7 consecutive night to assess nocturnal polyuria

 Voiding and Bowel diary

Day time diary for 3-4 days to calculate MVV

 Assessment of Bladder Capacity and Nocturnal
polyuria
Reduced UB capacity:
Nocturnal polyuria (NP):
➢ Nocturnal urine volume on a night ➢The observed maximal voided
with enuresis exceeding 130% of EBC volume (MVV) is compared with age-
of the child. expected bladder capacity (EBC).
➢Nocturnal urine volume =
difference in diaper weight before and ➢ EBC = (Age in years) x 2 + 30 mL.
after sleep + first morning void.
➢Reduced MVV is defined as MVV
➢Alternative definition: Nocturnal <65% of EBC.
urine volume exceeding 20 x((age in
years) + 9)
Walla JV et al. Practical consensus guidelines for the management of enuresis. Eur J Pediatr.2012;171:971–983
 Investigation

 Urine analysis and culture : to exclude infection

 USG of KUB : Assess post void residue, cystitis, structural
abnormality.
 Urodynamic study : evaluation of NMNE
 Secondary enuresis -
 Eelevated Serum Glucose.
 Blood Urea Nitrogen and Creatinine.
 Urological Evaluation
 Other Investigations :
 Serum ADH level : may reduce in PNE .

A current study in Bangladesh revealed Serum ADH level was significantly lower in children with primary
Noctunal enuresis .

Serum antidiuretic hormone level in nocturnal enuretic school children in a tertiary care hospital.
Jannatul Ferdaus, Zahid Hasan Khan and Anwer Hossain Khan et al
 Primary Nocturnal Enuresis -
Management

Non Pharmacological
Pharmacological therapy
therapy

- Motivational therapies - Desmopressin

- Dietary and fluid - Oxybutynin

adjustment - Imipramine
- Alarm treatment
 Motivational therapy
 Combination of providing reassurance, emotional support, eliminating
guilt, and rewarding the child for dry nights.
 Avoidance of dairy products, fruits juices, and fluids 2 hours before
bedtime, voiding just before bed.
Motivational therapy completely resolves enuresis in up to 25% of
 The cases,
risk of
andsecondary
the number ofinjury to the
wet nights child's
reduces self-esteem
in up to is minimized by
70% of children
discouraging ridicule from siblings and by avoiding a critical
demoralizing approach.
• pharmacological Management of
• Enuresis: Alarm Therapy

Reddy NM et al. Nocturnal Enuresis in India: Are We Diagnosing and Managing Correctly? Indian Journal of
Nephrology. 2017; DOI: 10.4103/ijn.IJN_288_16
 Treatment of enuresis using voiding diary

Reddy NM et al. Nocturnal Enuresis in India: Are We Diagnosing and Managing Correctly? Indian Journal of Nephrology. 2017; DOI: 10.4103/ijn.IJN_288_16
CASE BASED APPROACH
 Case Scenario 1
Case 1
A seven year old boy presented with
 Occasional bed wetting ( 2-3 times /week) since mother noticed.
 He often voids in deep sleep and cannot arouse.
 He does not have any day time symptoms of urgency,
frequency or lower urinary tract symptoms.
 His bowel habit is normal.
 His elder brother had H/O bed wetting in younger age.
 Case 1

Type of Enuresis :

• Primary Monosymptomatic Nocturnal enuresis

Case Study -1 ………………
 Urinalysis : No features of
infection, no glycosuria.
 Ultrasonography of KUB
revealed normal with no
significant post void residue.
 Voiding diary revealed
Nocturnal polyuria.
Treatment
a. Motivational therapy
b.Desmopressin
Outcome at follow up
Patients bed wetting dramatically
improves .
 Desmopressin

 Desmopressin( DDVAP) is a synthetic

vasopressin analog.

 It temporarily resolve symptoms.

 The response rate to desmopressin

therapy is 60%–70%.

Reddy NM et al. Nocturnal Enuresis in India: Are We Diagnosing and Managing Correctly? Indian Journal of Nephrology. 2017; DOI:
10.4103/ijn.IJN_288_16
 Role of AVP in Enuresis and Rationale of Desmopressin

Since lower nocturnal vasopressin levels have been demonstrated in a large

percentage of patients , children with NP are most likely to benefit from
desmopressin.

Kamperis P et al. Optimizing response to desmopressin in patients with monosymptomatic nocturnal enuresis. Pediatr Nephrol. 2016; 32(2):217-226
 Formulation of Desmopressin
There are various formulation of Desmopressin .
Intravenous, oral, intranasal and oral lyophilisate Only Desmopressin
available in BD

Dose : Tablet 0.2 mg – 0.6 mg

Melt Dose – 120-360 ug

60 & 120
µg
The oral lyophilizate (melt )formulation of
desmopressin is preferred to the tablet and nasal
spray in children.

Oral lyophilisate should be administered one

hour before bedtime & at least 2 hours after the Kamperis P et al. to desmopressin in patients with
evening meal. monosymptomatic nocturnal enuresis. Pediatr
Nephrol. 2016; 32(2):217-226
Desmopressin Therapy Algorithm

Walle JV et al. Practical consensus guidelines for the management of enuresis. Eur J
Withdrawal schedule

Structural withdrawal involved keeping dosage constant with increasing

treatment intervals to alternate evening, twice weekly and once weekly
 Effect of constipation on desmopressin

The presence of constipation negatively affects the response to

desmopressin , especially in patients with severe enuresis and in
patients prescribed with low dose of desmopressin

Ma Y et al. Constipation in nocturnal enuresis may interfere desmopressin management success. J Pediatr Urol. 2019
Apr;15(2):177.e1-177.e6
 Case Scenario 2
• A 9 year old boy presented with occasional bed
wetting.
• Aggressive behavior.
• Poor school performance.
• His urinalysis reveled normal.
• Ultrasonography of KUB revealed no significant post
void residue.
• His voiding diary reflects low MVV at night.
• Responded well with motivational therapy,
psychotherapy and enuresis alarm.
 Enuresis alarm

Enuresis alarm consists of

a sensor device attached
to the child’s underwear or
to a mat under the
bed‑sheet and an alarm
placed on the bedside or
attached to the child’s
collar

Limited acceptability and it requires significant parental involvement and sleep disturbance,
which could be stressful for child and family.

Reddy NM et al. Nocturnal Enuresis in India: Are We Diagnosing and Managing Correctly? Indian Journal of Nephrology. 2017; DOI:10.4103/ijn.IJN_288_16
Recommendations
 Resistance to therapy
 NMNE diagnosis missed
 Abnormal Renal/Bladder Ultrasound
 Concomitant constipation
 Dysfunctional voiding
 Variation in desmopressin pharmacokinetics – availability
 Insufficient desmopressin dosing
 Comorbid psychiatric and other conditions
Challenges in Management of non
monosymptomatic enuresis ….
 Case Scenario 3

• A 9 years old girl presented with bed wetting

started since early infancy .
• Day time frequency , urgency occasional
urine
leak.
• Abnormal weight gain day by day.
• Psychological assessment near normal.
• Not maintaining voiding diary.
• Sonography showed normal findings.
• Uroflowmetry revealed Tower shaped curve suggestive
over active bladder

• Treatment and Response

Anticholinergic drug along with motivational therapy .
Added enuresis alarm as response was not optimum.
As patient responded partially desmopressin also added.
• After six month of follow up patient responded well.
Association between obesity and nocturnal
enuresis
Rates of severe enuresis in patients with
normal weight, overweight, and obesity Obesity is
were 63.9%, 77.5%, and 78.6%, associated with
respectively
severe enuresis
The odds of presenting with and low efficacy
severe enuresis were 1.99 times higher in of behavioral
children who are obese or overweight
compared to children with normal weight
therapy in
(OR: 1.994) children with
nocturnal
The complete response of the normal
group was higher than those of the
enuresis
overweight and obese groups (26.8% vs.
14.0% & 26.8% vs. 0.0%)

Ma Y et al. Association between enuresis and obesity in children with primary monosymptomatic nocturnal
enuresis. Int Braz J Urol. 2019 May 30;45. doi: 10.1590/S1677-5538.IBJU.2018.0603
 Pharmacological Therapy : Anticholinergics

• Act mainly by suppressing detrusor overactivity

• Treat children with daytime urgency or frequency as well as

night-time enuresis.
• Treat PMNE only where primary treatment has failed

• Oxybutynin and tolterodine are commonly used.

• Newer Agent : Mirabegron

Side effects include flushing, blurred vision, constipation, tremor, decreased

salivation and decreased ability to sweat
Jain S, Bhatt GC. Advances in the management of primary monosymptomatic nocturnal enuresis in children. Paediatrics and
International Child Health, 36:1, 7-14
Pharmacological Therapy of Enuresis: Imipramine
• Oldest agent.
• Weak peripheral anti-cholinergic effect and smooth muscle
relaxation. WHO & NICE has now endorsed that
• Reduces detrusor activity cannot
Imipramine be recommended
and increases for
bladder capacity
treatment of PNE
• Initial success rate ranges 10-75%
• Long term cure rates lower- High relapse
• 17.3 adverse events per 100 children with imipramine as against
7.1 per 100 children with desmopressin
• Major drawbacks- insomnia, anxiety, dry mouth, nausea. Overdose can
have serious and potentially lethal effects, including ventricular
dysrhythmias, seizures and coma

Jain S, Bhatt GC.. Paediatrics and International Child Health, 36:1, 7-14
A recent study done in Bangladesh revealed Mirabegron is
effective in treating enuresis due to overactive bladder in
children.
Effect of Mirabegron on nocturnal enuresis due to overactive bladder in a tertiary care hospital
• Asma Labony, Mohammed Anwar Hossain Khan et al
Key Message

• Obtaining an accurate patient history is essential.

• Voiding diary can guide the treatment policy.

• Optimum and rational use of pharmacological

therapy and follow the response is crucial.

• Maintaining adherence to therapy may improve the

outcome.