Source: Manual of Ambulatory Pediatrics 2010
SOAP Note – Enuresis
ENURESIS
The involuntary or intentional passage of urine, usually occurring at night (nocturnal enuresis) in a child over 5 years of age into bed or clothes. It is subdivided into two classifications—primary and secondary. Primary enuresis occurs in a child who has never been dry at night for a period of more than 1 week and accounts for 80% of cases. Secondary enuresis occurs in a child who has been dry at night for a prolonged period and subsequently loses bladder control. Diurnal enuresis is enuresis occurring during the day.
The diagnosis is made when at least two events a month occur in a child under 5 years of age and at least one event a month for older children.
I. Etiology
A. Primary nocturnal enuresis
1. Immature development of bladder with resultant small capacity
2. Immature arousal mechanism for non-REM sleep
3. Psychological problems, such as regression after the birth of a sibling
4. Neurologic causes: Myelomeningocele, mental retardation
5. Urologic lesions or anomalies
6. Diabetes mellitus or diabetes insipidus (nocturnal polyuria)
B. Secondary nocturnal enuresis
1. Psychological problems or stress
2. Developmental delays
3. Urinary tract infection (UTI)
4. Diabetes mellitus
5. Diabetes insipidus
II. Incidence
A. Approximately
1. 10% to 15% of 6-year-olds
2. 5% of 10-year-olds
3. 3% of 12-year-olds
4. 1% of 15-year-olds
B. Enuresis is more common in boys than in girls.
C. There is a familial tendency toward enuresis. It is more prevalent in large families and in lower socioeconomic groups.
III. Subjective data
A. Primary: Bed-wetting one or more times a night at least once a week without having achieved bladder control at night
B. Secondary: Bed-wetting one or more times a night at least once a week after having achieved bladder control at night
Note: As part of the history obtained at the well child visit, every child should be asked if he or she has any urinary symptoms or ever wets his or her pants or the bed.
C. Pertinent subjective data to obtain
1. Has child ever been dry? If so, when did onset of wetting occur?
2. How frequently does child wet the bed?
3. When does wetting occur, late evening or early morning?
4. What do parents do about bed-wetting? How do they feel about it? Do they see it as a problem?
5. Is there a history of bed-wetting in the family: siblings or parents?
6. How does the child feel about wetting the bed?
7. Is there a family history of diabetes mellitus?
8. Has child awakened with sore muscles or bitten tongue, suggesting nocturnal seizures?
9. Does child have a full stream when voiding?
10. What is the daytime voiding pattern: frequency, volume of urination, dribbling, diurnal enuresis? (Frequent, small-volume voidings, dribbling, and diurnal enuresis suggest primary enuresis.)
11. Has the child complained of frequency, urgency, pain, or burning on urination?
12. Has the child been dry when sleeping away from home?
13. Determine whether there are any psychosocial problems (indicative of secondary enuresis):
a. New baby in the family
b. Death of a family member
c. Illness or hospitalization of the child or a family member
d. Divorce or separation of parents
e. School problems
f. Loss of a pet
14. Obtain accurate history of hours of sleep and child’s bedtime routine.
a. Does he or she have regular sleep habits and sufficient sleep?
b. Does he or she have a large amount of fluid at bedtime?
c. Does he or she void before going to bed?
IV. Objective data
A. Physical examination is generally within normal limits. Significant neurologic deficits would present with history or findings in addition to nocturnal enuresis and would probably already have been identified.
1. Complete physical and neurologic examination
a. Check for constant dribbling.
b. Check urinary stream.
c. Check genitalia for external anomalies.
d. Check rectal sphincter tone.
e. Check skin for café-au-lait spots.
f. Check spine for bony defects, masses, hairy tufts.
g. Check abdomen for masses or enlarged kidneys.
h. Check gait.
2. Measure height, weight, blood pressure to rule out chronic occult urinary tract disease.
B. Laboratory tests: Urinalysis and culture of clean-voided specimen
V. Assessment: Differential diagnosis
A. Urinary tract infection: Positive urine culture
B. Diabetes mellitus: Urine positive for glycosuria and acetonuria
C. Diabetes insipidus: Specific gravity under 1.006
D. Glomerulonephritis, pyelonephritis, cystitis, urethritis
1. Urine positive for proteinuria
2. Microscopic examination positive for erythrocytes and leukocytes
VI. Plan
A. Before any treatment for enuresis is attempted, the child must want to be dry, and the parents must be willing to participate in the treatment.
B. A voiding volume of under 200 to 300 mL will not be sufficient for child to remain dry at night.
C. Management should not be attempted until psychosocial issues and pressures within the family have been ruled out or issues have been resolved.
D. Do not attempt management when any stress is anticipated, such as a family move or birth of a sibling.
E. Primary enuresis. The following are three commonly used, acceptable methods of management:
1. Bladder-stretching exercises
a. Have mother measure volume of urine several times.
b. Once daily, have child hold urine as long as possible after the desire to void is felt.
c. Encourage increased fluid intake, particularly during the time child is holding urine.
d. Measure voiding volume after child has achieved maximum ability to control the desire to urinate.
e. Once child has increased bladder capacity, have him or her practice starting and stopping urine stream.
f. “Gold Star Chart.” Make a chart to record bladder capacity and for dry nights.
2. Pharmacologic therapy
a. Imipramine (Tofranil): The drug most frequently used. It has an atropine-like effect on the bladder, increasing the capacity by increasing sphincter tone and decreasing the tone of the muscle that causes bladder contraction. Imipramine is an antidepressant and may interfere with natural sleep pattern and depth. Do not use in children under 6 years of age.
(1) Initially 15 to 25 mg at bedtime, increased to a maximum dosage of 50 mg in children under 12 years of age and 75 mg in children over 12 years of age
(2) Continue treatment for 6 to 8 weeks, and taper dosage over 4 to 6 weeks to avoid relapse.
(3) If child wets during the early night hours, give 25 mg of imipramine at 4 PM, and repeat dose at bedtime.
(4) Discontinue use if no improvement noted after 3 weeks.
b. DDAVP (Desmopressin Acetate): An antidiuretic hormone that decreases urine production. It is used intranasally in children age 6 and older. Can be ordered in tablet form as well.
(1) Initially 20 g intranasally at bedtime. Administer one spray (10 g) per nostril.
(2) Subsequent dosage: If no clinical response, increase by 10 g (one spray) at bedtime every two weeks, to a maximum dose of 40 g.
(3) When response is achieved, maintain at dosage for 2 weeks, then titrate down by 10 g at bedtime to lowest effective dose (minimum dose 10 g).
3. Behavioral treatment
a. Pad and bell technique
(1) Studies report an initial success rate of 75%. The alarm system is a pad of two conductive layers with an insulating cloth in between. The child sleeps on the pad. When the child wets and soaks through the insulating cloth, an electrical circuit is completed, causing the bell to ring.
(2) When the bell rings, awakening the child, he or she should go to the bathroom to finish voiding.
(3) Child or parent then changes the bed and resets the alarm.
(4) Treatment with this method may take 5 to 12 weeks.
(5) If there is no improvement after 10 weeks, stop treatment. Another trial may be undertaken in 3 months.
(6) There is a relapse rate of 20% to 40% with this method. If relapse occurs after cessation of treatment, retreatment with the pad and bell is successful in most instances.
b. Sleep Dry Alarm or Wet Stop
(1) Moisture sensor is attached by Velcro patch sewn on underpants. Alarm unit attaches to pajama top with Velcro.
(2) At onset of voiding, alarm goes off to awaken child.
(3) Sleep Dry Alarm program includes instructions and motivational materials (charts, stars).
(4) Treatment may take 3–4 months.
F. Secondary enuresis. Therapy must be specific to the etiology.
1. Psychosocial problems or stressful situations
a. Counseling
(1) Explanation of enuresis to parents and child
(2) Discontinuance of pressure and punishment
(3) Development of a plan with child and parents that will work for them
(4) Contact school principal or nurse regarding school problems.
b. Imipramine: See above for dosage.
2. Developmental lag
a. Behavioral conditioning
b. Gold star chart
3. UTI (see Urinary Tract Infection, p. 404)
4. Diabetes mellitus. Refer to physician.
5. Diabetes insipidus. Refer to physician.
VII. Education
A. Do not attempt management unless child is willing and is over 8 years of age.
B. Primary enuresis is a self-limited problem. Reassure parents that it is a developmental issue. The child is not lazy or refractory.
C. Avoid punishment, embarrassment, or shaming the child.
D. Do not be too aggressive in approach.
E. Avoid causing anxiety in other family members or child.
F. Involve child in treatment plan.
G. Bladder stretching
1. When increasing fluid intake, child may have more frequent enuresis and may have daytime accidents.
2. It may take several months for child to achieve a voiding volume of 240 to 300 mL.
3. Generally, when voiding volume of 300 mL is achieved, child will be able to sleep through the night without voiding. Some children, however, need a greater volume before becoming dry at night.
H. Do not diaper child.
I. If child is willing, restrict fluids after dinner.
J. Have child void before going to bed.
K. If child has no difficulty going back to sleep, it is sometimes helpful for parents to get child up to void before they go to bed.
L. Make a chart or calendar on which to record bladder capacity and wet and dry nights. Encourage child to keep the chart. Use gold stars for dry nights.
M. Imipramine
1. Most common side effects seen in enuretic children on imipramine are irritability, sleep disorders, fatigue, gastrointestinal disturbances, and nervousness. Other reported reactions include constipation, convulsions, anxiety, emotional instability, syncope, and collapse.
2. Keep imipramine out of reach of small children.
3. Success rate is 20%.
4. Recidivism does occur.
N. DDAVP
1. An antidiuretic hormone
2. Decreases urine production by increasing urine concentration
3. Nasal spray bottle accurately delivers 50 doses of 10 g each. Discard remaining medication after 50 doses.
4. Most common side effects are nasal congestion, rhinitis, flushing, and mild abdominal cramps. Symptoms abate with decreased dosage.
5. Restrict nighttime fluid intake to decrease potential occurrence of fluid overload.
6. Approximately 50% of children improve. However, relapse rate is about 60%.
O. Pad and bell technique
1. Do not use alarm system that has an electric shock; use only the type that has a bell.
2. Check batteries on apparatus frequently; electrolysis of urine may result from weak batteries, producing topical burns and preventing alarm bell from ringing.
P. Wet Stop and Sleep Dry have moisture sensors in underpants which, when activated by even a few drops of urine, trigger alarms. Child is awakened before bed is wet and voiding is completed. Also, the alarms are located near the child’s head so that he or she responds to it more readily.
Q. Alarms have the highest cure rate—about 70%—but are expensive and require a high level of motivation.
R. Bedwetting Store (for alarms, waterproof bedding, books, and supplies); catalog available. PO Box 337, Olney, MD 20830-0337 or http://www.bedwettingstore.com
S. Wet Stop Alarm available from Palco Labs, 1595 Soquel Drive, Santa Cruz, CA 95065 or http://www.Wet-stop.com
T. Sleep Dry Alarm: Follow instructions with program. Available through Star-Child/Labs, PO Box 404, Aptos, CA 95001-0404.
VIII. Follow-up
A. Primary enuresis
1. Serum electrolytes after 1 week of therapy with DDAVP
2. Telephone contact in 2 weeks. Have child or parent call back to report progress.
3. Return visit in 1 month. Have child bring in chart.
4. Continue follow-up at 2to 4-week intervals for encouragement.
5. Follow-up may alternate between telephone calls and office visits.
B. Secondary enuresis
1. Counseling contract should be individualized. Initially, follow-up should be at least every 10 to 14 days. Encourage child or parent to call and report successes.
2. Return visits at least monthly while on imipramine
3. With behavioral conditioning and gold star chart, follow recommendations above.
4. UTI (see Urinary Tract Infection, p. 404)
IX. Complications: A management plan that is too vigorous or stressful may result in psychological problems or increase stress for the family.
X. Consultation/referral
A. Diurnal enuresis, dribbling
B. Identification of significant psychological problems or child abuse
C. UTI
D. Genitourinary abnormality
E. Failure to improve with adequate trial of bladder retention or behavioral conditioning
F. Diabetes insipidus, diabetes mellitus