Children with “Diurnal Enuresis”: How do we help them? Dr Jonathan Evans Consultant Paediatric Nephrologist Nottingham Children’s Hospital • Normal & abnormal bladder function • Classification & causes.
Download ReportTranscript Children with “Diurnal Enuresis”: How do we help them? Dr Jonathan Evans Consultant Paediatric Nephrologist Nottingham Children’s Hospital • Normal & abnormal bladder function • Classification & causes.
Children with “Diurnal Enuresis”: How do we help them? Dr Jonathan Evans Consultant Paediatric Nephrologist Nottingham Children’s Hospital • Normal & abnormal bladder function • Classification & causes of urinary incontinence • Assessment • Management Diurnal Enuresis is….. A. B. C. D. Not urinary incontinence Non Organic wetting Less of a problem than incontinence Useful terminology to help guide management E. A patronising term used by health care professionals who have failed to make a proper diagnosis 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/cholin ergic 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 … DRY by day / night from any fullness…. – Can defer or initiate micturition, but usually void at strong desire • Adult? Planned micturition 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 Function Outcome Input L.U.T.S associated • Genetics with • Uropathy • Overactive Bladder • Neurogenic • Underactive • CNS disorder Bladder • Development • Dysfunctional (ADHD, ASD) Voiding • Psychosocial • Dysfunctional Elimination • Infection • Giggle • Constipation Micturition • Other! e.g SI with multiple causes including anatomical & neurogenic Assessment History – Voiding, Storage, Bowels, Co-morbidities, Psycho-social, Developmental, Attitudes, Values & Behaviours All Examination – General + Abdomen, Bladder, Ext Genitalia?, Spine, Reflexes, BP Basic Investigations – Urinalysis, Freq/Vol chart, Stool Chart, Intermediate Investigations – Bladder Scan, Uroflow, Renal tract USS Invasive Investigations – MCUG, Urodynamics, MRI Spine.. 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! Abdominal straining - Underactive bladder overactive normal dysfunctional voiding Outflow obstruction Fluid Data Analyser Pressure in Bladder (Measured) Pressure in Bladder (Calculated) 84 ml Other Measurements •Fill volume •Urine flow rate •Pelvic Floor EMG Intra abdominal Pressure (Measured) Time - minutes 151 ml Patterns of daytime incontinence Symptom Functional Disturbance Pathology Urge incontinence Overactive bladder Detrusor overactivity – functional or urological /neurogenic Giggle wetting Normal OAB Giggle micturition Dysfunctional voiding Underactive 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 including Urological / 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 All – Reminder alarm • • • • • Anticholinergics β3 agonist? (Mirabegron) Neuromodulation (sacral/tibial nerve)? Botulinum Toxin Bladder Augmentation 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 • Methylphenidate Evidence 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 dysfunction Undertake a careful evaluation Work within your competencies Recognise warning signs (both medical & social) Effective Offer the correct treatments based on your evaluation Refer 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…