very summarized but informative.

1. Assignment
Systemic pediatric
Enuresis
Mustafe Aadan A/lahi
3/25/2018

2. Enuresis
Introduction
Is a repeated inability to control urine. This uncontrolled voiding can happen at night or at day. It
typified as being primary enuresis in which the baby does not experience period of dryness or
secondary enuresis in which the child experiences a period of dryness. If there is physical
disorder, it shouldn’t be labeled as enuresis.
Pathogenesis
Nocturnal enuresis that occurs at children who are physically and emotional normal are not
clearly understood. But most cases of bedwetting is related to decreased physical development,
increased urine production at night, inability to recognize filled bladder during sleeping and
anxiety. Possibility of genetic influence is understood. In the developmental milestone, the child
starts to develop the ability to relax the external sphincter by two years of age. By fourth year, a
child with normal functioning bladder should have complete control to voiding. Negligence from
the parents to train their children does have also contribute to this problem.
Diagnosis
1. History
History is very important for the establishment of the causation as well as recognizing the
enuresis as primary or secondary. The history should cover:
 Family history of the same problem
 Toilet training history
 Nutritional history
 Fluid intake history (E.g. if the baby is given much fluid just before bedtime)
 Sleeping pattern history
 Daytime voiding pattern
 Number of episodes of bedwetting
 Timing of bedwetting
2. Physical examination
 Vital sign especially the blood pressure
 Inspection of:
 External genitalia
 Lumbosacral spine
 Palpation of the:
 Abdomen to look for hard stool
 Lumbosacral spine
 ;lower neurological examination
 Assessment of anal wink (for neurological examination)

3. DSM-5 diagnostic criteria for enuresis
A. Repeated voiding of urine into bed or clothes:
a. Involuntary or intentional
B. Clinically significant criteria (1 of the following)
a. Twice weekly for at least 3 consecutive weeks
b. Significant distress
c. Impaired functioning
C. Developmental age 5 years or older
D. Secondary cause not present:
a. Medication (e.g. diuretics, lithium)
b. Diabetes mellitus
c. Spina bifida
d. Seizure disorder
Management
The most problem to have enuresis (once excluded structural or neurological origin) is that it
causes embarrassment and anxiety to the child and work burden (in our country) and frustration
to the parents. So the initial focus is to obliterate this by giving psychological support to the
children and sharing with the parents the pandemicity of this problem. Parents are encouraged to
share what they think is causing it (although mostly irrational) to establish trust and simplicity.
Parents should also be ensured if they think the presence of congenital abnormalities. Initial
management is also include; proper hydration of the child throughout the day so that he/she may
not over-drink just before bedtime. The child should also void completely right before leaving
the house for school or where-ever else as well as before going to bed. The child should also be
allowed to visit the toilet during his/her learning time in the school as per required.
The next step is to use alarming therapy. Depending on the choice of the parents and the child,
the family can get a wearable one in which the alarm is attached to the child and is triggered after
sensing wetness or the one which is attached to the wall (also triggered by wetness). The
alarming therapy goes on for 3 months and if the child does not get dryness after 90 days, it will
be doomed as a failure therapy.

4. The next step is the use of medication. In this category desmopressin is the drug of choice for its
efficacy and low side effects. But the child should not be given water 2 hours before bed. It’s
recommended a cup of water within in the drug and no more to prevent dilutional hyponatremia,
because the mechanism of the action of the drug is to increase the reabsorption of the water.
Anti-cholinergic drugs such as oxybutynin and tolterodine are also used but mostly if there is
neurogenic bladder disorder and over-reactive bladder. Anti-cholinergic drugs can be combined
with vasopressin-related drugs for increased efficacy. The anti-depressant drug imipramine are
longer used for enuresis.
Sources:
1. https://emedicine.medscape.com/article/1014762
2. https://en.wikipedia.org/wiki/Enuresis
3. https://online.epocrates.com/diseases/69036/Enuresis/Diagnostic-Criteria