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Enuresis final
This document discusses various types of urinary incontinence and enuresis (bedwetting) in children. It begins by defining nocturnal and diurnal enuresis, as well as other types of incontinence like stress incontinence. It then provides details on evaluating and examining children with these issues, including taking a history, questionnaires, physical exam, and basic investigations. Treatment approaches are discussed, emphasizing non-pharmacological interventions like counseling, education on toileting habits, and behavioral techniques using bedwetting alarms. Medications are also summarized, along with their advantages and disadvantages.
Enuresis final
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- 3. Hello AHMAD ELSABA FAMILYMEDICINE SPECIALIST TECHNICAL SUPERVISOR IN ONIAZAH PUPLIC HEALTH SECTOR
- 6. Voiding of urine Notpreceeded by dryness (for 6m) Voiding of urine Preceeded by dryness (for 6m) Primary Secondary
- 7. Types of Incontinence Urgemicturation Frequency < 7 times / day Small volume voided Infrequent micturition (< 5 times / day) Postponement Straining to initiate and during micturition Interrupted stream of urine Wetting during coughing, sneezing Small volumes Wetting during laughing Large volumes + complete emptying Interrupted stream Emptying of bladder possible only by straining Urge incontinence Stress incontinence Voiding Postponement Giggle Incontinence Detrusor underactivity Dysfunctional voiding
- 11. • Frequent enuresis, definedby two or more wet nights per week, affected only 2.6% of them (boys 3.6%, girls 1.6%)
- 12. * marked geneticComponent: 1-monosymptomatic enuresis 2-urge incontninenced * Genetic+environmental: secondary enuresis * Environmental: voiding postponement
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- 15. 1. PRESENTING SYMPTOMS Generalintroduction: Time of wetting: Start with the most important symptom, i.e., night or daytime problems 2. NOCTURNAL WETTING • Frequency of wetting. • Amount of wetting. • Depth of sleep. • Dry intervals. • Impact and distress. • Social consequences. 3. Daytime wetting & micturition problems during the day : • Frequency of wetting. • Amount of wetting. • Timing during the day. • Frequency of micturition. • Voiding postponement. • Holding manoeuvres. • Urge symptoms. 4. TREATMENT TRIALS • Previous therapy. 5. ENCOPRESIS • Soiling. • Toilet habits. • Dry intervals during the day. • Problems with micturition. • Urinary tract infections. • Medical complications. • Eating and drinking habits. HITORY TAKING
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- 24. • Each childshould be examined physically at least once at the beginning of treatment. • It is essential that organic causes of incontinence are ruled out. • A full paediatric and neuorological exam is recommended. • Children with daytime incontinence may require several examinations in the course of treatment, especially if UTI’s and other complications occur. • For most children with enuresis, especially with monosymptomatic enuresis, one exam will suffice. Physical Examination
- 25. At leastone urinalysis (with a urine stick) is recommended to be sure that no signs of bacteriuria and manifest UTI are present. This is especially important in daytime urinary incontinence. it is usually negative in children with monosymptomatic enuresis. Investigations
- 26. The psychiatric historyis divided into : • presenting symptom(s), • family history. 1- PRESENTING SYMPTOMS • Please describe the problem as much detailed as possible. • How often does it occur? • In which situations (at home, at school , with friends)? • Has the child been seen or treated for the problem? • What are your main worries? • What do you expect from this consultation? THE CHILD PSYCHIATRIC Assessment
- 27. Externalising problems: • Isyour child restless, constantly too active? • Is easily distracted? • For how long can concentrate? • Does your child seem to act impulsively without thinking? • How does your child respond to rules? • Is your child sad, unhappy or withdrawn? • Has your child lost interest in play, seeing other children? • Does your child find it difficult to get an activity going? • Are there problems with sleeping or eating? • Is your child afraid of certain objects, situations or animals (phobias)? Internalising problems:
- 28. Parents: • Age, occupation(educational achievemnt), illnesses. Marital relationship? • Did you wet the bed as a child? • How would you describe your relationship to your child? Siblings: • Age. Biological siblings? School-grade, illnesses and wetting problems. • How do your children relate to each other? • Are there especially close bonds or rivalries? Other relatives: • Did other relatives wet the bed as children? • Other illnesses, especially psychiatric or kidney? FAMILY HISTORY
- 30. Treatment of enuresisand urinary incontinence is based on simple effective steps that can be delivered in many primary care settings. Several meta-analyses have shown conclusively that overall Non-pharmacological interventions are more effective than medication.
- 31. • A childshould be at least 5 years of age (the age required to diagnose enuresis and urinary incontinence), younger children do not require treatment • concurrent disorders, encopresis and constipation should be treated first because some children will stop wetting once these problems solved. • Daytime incontinence should be treated first, as many children will stop wetting at night once the daytime problems have been treated • Primary and secondary enuresis are treated in the same way General principles
- 32. • Counselling, supportand provision of information • Enhancing motivation and alleviating guilt feelings • A baseline period is then recommended with a simple observation and recording of wet and dry nights over a period of 4 weeks. Children are asked to draw a symbol for wet and dry nights (clouds and suns, stars, etc.) in a chart and bring it to the next consultation. • Educating about drinking and toileting habits: • Discontinuing all ineffective measures such as punishing the child & ineffective medication. The initial treatment steps are simple, non- specific aspects of “good practice
- 34. Treatment Advantage Disadvantage Bed-wettingalarm Effective, low relapse rate Takes weeks for results; can be disruptive to family Desmopressin (DDAVP) Rapidly effective, few side effects High-relapse rate with discontinuation Imipramine (Tofranil) Inexpensive, works quickly High-relapse rate with discontinuation; side effects, including cardiotoxicity at high doses
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