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ENURESIS PowerPoint Presentation

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Description : Check out this medical presentation on Pediatrics, which is titled "ENURESIS", to know about Enuresis, a repeated inability to control urination in children and older people.

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Published on : Aug 02, 2021 | Views : 2513 | Downloads : 13

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DEPRESSION IN CHILDREN AND ADOLESCENTS DEVELOPMENTAL DISORDERS ENURESIS Adapted by Julie Chilton Chapter C.4 Companion PowerPoint Presentation Alexander von Gotard
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The “IACAPAP Textbook of Child and Adolescent Mental Health” is available at the IACAPAP website http://iacapap.org/iacapap-textbook-of-child-and-adolescent-mental-health Please note that this book and its companion powerpoint are: · Free and no registration is required to read or download it · This is an open-access publication under the Creative Commons Attribution Non- commercial License. According to this, use, distribution and reproduction in any medium are allowed without prior permission provided the original work is properly cited and the use is non-commercial.
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Enuresis Outline Definition and classification Epidemiology Clinical presentations Etiology and risk factors Comorbidity Diagnosis Treatment
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Enuresis The Basics Very common Occurs worldwide at same rate 7 year olds 10% at night 2-3% during the day Adolescents 1-2% at night <1% during the day Vast majority are functional 20-40% comorbid disorders Most treated with counseling and CBT
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Enuresis Definition
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Enuresis Outline
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Enuresis Approximate Normal Values in Childhood Micturition frequency: 5-7 times per day Voided volumes: (age + one) multiplied by 30 ml
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Enuresis Epidemiology of Enuresis 2-3 times more common than daytime urinary incontinence 1.5 to 2 times more common in boys Prevalence decreases with age 20% of 4 year olds 10% of 7 year olds 1-2% of adolescents 0.3-1.7% of adults Primary more common than secondary Monosymptomatic twice as common as non-monosymptomatic Daytime urinary incontinence 1.5 x more common in girls Urge incontinence is most common Voiding postponement second most common
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Enuresis Worldwide Prevalence 4% Chinese children and adolescents 6-16 years old 8% Taiwanese children aged 6-11 years 15% Turkish children aged 5-7 years 15% children and adolescents in Saudi Arabia 17% of 7 year olds in Sudan 21% Ethiopian children and adolescents aged 6-15 years (including daytime incontinence)
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Enuresis Clinical Presentations: Monosymptomatic Enuresis Deep sleep and difficult arousal Increased urine volume at night Large wetted volumes Normal bladder function during the day
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Enuresis Clinical Presentation: Non-Monosymptomatic Enuresis Similar nighttime symptoms of monosymptomatic enuresis Daytime urinary incontinence (except wetting) May also have UTIs, constipation and encopresis
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Enuresis Clinical Presentation: Secondary Enuresis Comorbid behavioral and emotional disorders Stressful life events can cause relapse Separation or divorce of parents Birth of sibling Otherwise, no difference from primary enuresis
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Enuresis Clinical Presentation: Urge Incontinence High micturition frequency More than 7 x a day Short intervals in between Urge symptoms Incontinence with small micturition volumes Holding maneuvers Vulvovaginitis, perigenital dermatitis Urinary tract infections
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Enuresis Clinical Presentation: Voiding Postponement Low micturition frequency: < 5 times a day Postponement in certain situations Holding maneuvers till wetting unavoidable Stool retention, constipation, encopresis Repeated straining Intermittent and fractioned flow Incomplete bladder emptying with residual urine and UTIs Vesico-ureteral reflux
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Enuresis Etiology and Risk Factors Monosymptomatic enuresis: marked genetic component Urge incontinence: marked genetic component Secondary enuresis: genetic and environmental Voiding postponement: mostly environmental
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Enuresis Etiology and Risk Factors: Enuresis Genetically determined maturational disorder of the central nervous system 70-80% have affected relatives Concordance rates: monozygotic > dizygotic twins Most autosomal dominant inheritance Loci on chromosomes 12, 13, 22 Neurological soft signs Longer to complete motor tasks Sleep architecture not affected Mean latency = 3 hours
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Enuresis Main Mechanisms for Development Increased urine volume in some Circadian variation of antidiuretic hormone Impaired arousal Inhibition deficit of pontine micturition centre of brainstem Type of toilet training has no effect Psychosocial factors bigger role in secondary enuresis
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Enuresis Etiology and Risk Factors: Urinary Incontinence OR > 3 if mother affected OR > 10 if father affected Positive linkage to chromosome 17 Urge incontinence: spontaneous contractions of detrusor Giggle incontinence has genetic factor Voiding postponement due to acquired habit or oppositionality
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Enuresis Comorbidity: Enuresis Psychological disorders 2-5 x greater in children with elimination disorders Especially with secondary enuresis and non-monosymptomatic enuresis Most common comorbidity: ADHD Rates slightly higher with daytime incontinence Also common: Separation anxiety Social anxiety Specific phobia Generalized anxiety Depression ODD Conduct disorders ADHD
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Enuresis Diagnosis Standard: History 48 hour frequency/volume chart Questionnaires Pediatric physical exam Urinalysis Child psychiatric screening/assessment Sonography (if available) If indicated: Urine bacteriology Uroflowmetry and pelvic floor EMG Radiological exams Invasive urodynamics Cystoscopy
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Enuresis General Principles of Treatment Overall: non-pharmacological interventions>medication Treat only after age 5 Treatment should be symptom oriented Primary psychotherapy is not effective Treat comorbidities separately Treat encopresis and constipation first Treat daytime incontinence first Treat primary and secondary enuresis in same way
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Enuresis Initial Treatment Steps Counseling, support, information Enhance motivation Alleviate guilt Education: drinking and toileting Discontinue all ineffective measures Punishment Fluid restrictions Waking and lifting Ineffective medication Alternative medicines Record wet and dry nights for 4 weeks
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Enuresis Alarm Treatment
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Enuresis Medication Indications Unwillingness for alarm treatment Lack of motivation Overwhelmed family Short-term dryness required quickly 2 medication choices: Desmopressin (preferred) Tricyclic antidepressants
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Enuresis Medication: Desmopressin (DDAVP) Synthetic antidiuretic hormone Effective in 70% of cases Relapse common after discontinuation Tablet form in evening 0.2mg-0.4mg titrated over 4 weeks Stop after 12 weeks; may repeat Monitor for hyponatremia Otherwise well tolerated
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Enuresis Treatment: Urinary Incontinence Urge toilet (no holding) Wet/dry chart Go to toilet in any situation Works in 1/3 Other 2/3: oxybutine 0.3-0.6 mg/kg per day in 3 doses Max daily: 15 mg Dose dependent, reversible side effects Flushing, blurred vision, tachycardia, hyperactivity, dry mouth, residual urine, constipation
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Enuresis Course Excellent long-term outcome 13% spontaneous remission rate per year 60-80% become dry with alarm treatment; 50% dry long-term 1-2% adolescents have long-term enuresis Adult prevalence <2% Urge incontinence has best prognosis
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Enuresis Further Resources http://i-c-c-s.org/ https://www.nice.org.uk/guidance/cg111
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Enuresis Thank You!