Chapter 2 Index

A. Evaluation by system:

1. General

2. HEENT

3. Cardiopulmonary

4. GI

5. GU
--UTIs and Vesicoureteral Reflux
--Practice Parameter for UTI under age 2 years

Nocturnal Enuresis

Incidence: 10-15% of 6 year olds; 1% adults

Definition: Bed-wetting in girls older than 5 years, boys older than 6 years.

Etiology: thought to be due to lower ADH secretion in enuretics - not true. Might be true at the ADH receptor level (Arch Dis Child 1995;73:508-11).  No clear-cut behavioral problems associated with enuresis.  Bladder capacity is normal in enuretics (Scand J Urol 1994;156:1-48).

Sex Predilection: males > females 3:1

Classification:

1. Primary - 80%: child has never been continent at night
2. Secondary - 20%: child had formerly been dry at some point

Natural History of Enuresis: Self-limited: ceases without treatment in 15% of cases/year

Medical Workup of Enuresis:
Physical exam; urine culture if accompanied by daytime enuresis.

There is no indication for ultrasound or other imaging.           

Treatment of Enuresis: 80% of physicians use alarms; 52% use meds despite info below:

1. Behavior modification: chart system with positive reward systems - this should always accompany other forms of treatment.  Not enough by itself.

2. Restrict fluids after supper; have parents awaken and go to bathroom before going to bed.  Study indicating wet nights associated with low SG of urine.

3. Alarms - clearly superior to medications. Mechanism of Action of Alarms: alarm awakens child, which causes contraction of the bladder sphincter.  Eventually child contracts sphincter without the help of the alarm.  Usual time for cure: about 6-8 weeks. Most pediatricians use alarms more than meds because 56% dry after 12 mos vs meds: 16% dry after 12 months. (J Urol 95;154:755-8)

Types of Alarms:

• Nytone: Example of a type of alarm that has a buzzer on the wrist, and connects to the child’s underpants.  Buzzes when pants wet. (Phone: 801-973-4090; fax: 801-973-0176)
• Wet Stop: Buzzer on the collar, sensor on plastic card that fits in pocket of underwear.
• Sears mattress alarm: Covers entire mattress and buzzes when wet.  Problem is that it takes larger volume to set it off.  More expensive as well.
• Potty Pager: Different mechanism: Vibration occurs when wet; it cycles on and off so child cannot be lulled back to sleep.  Cost $50.00 (phone: 1-800-497-6573).  It works.

4. Medications: use of DDAVP is based on hypothesis that ADH secretion is low at night in enuretics: Arch Dis Ch 1995;73:508-11.

Only possible indication for medications:  Sleepovers, camp, etc. (Editorial: Pediatrics: 467;1993; Peds 1993;92:420-5)

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Department of Pediatrics  |  Medical College of Georgia
Please email comments, suggestions or questions to:
John T.  Benjamin M.D.,  jbenj@mcg.edu

February 27, 2004