Enuresis

Hey you guys, in this lesson we are going to talk about the diagnosis Enuresis.

Enuresis is the inability to control the bladder, day or night, by the time it is developmentally expected. For the most part we expect kids to have developed this bladder control by the age of 5. So before this age, even if the parents are super frustrated by these accidents, it’s not considered abnormal.

The diagnostic criteria for this is having these accidents 2x week for 3 months in a row.

Enuresis can be classed as diurnal (so just happening during the day), nocturnal (just happening at night) or mixed.

It is also important to make the distinction between primary enuresis and secondary. Primary is when kids have never been able to achieve dryness, Whereas secondary means that they have had dryness and control of voiding but now they don’t. Developmentally we would call this a regresion. And with secondary enuresis we really need to really focus on looking for a cause. So, let’s take a look at the possible causes

So, I’ve got two categories here, common causes and then causes that are super important to rule out.

On the common side, there is slow development, anxiety and stress about toileting or even with other things in life. For example, it’s not uncommon to see kids who are diagnosed with cancer develop secondary enuresis as a result of the stress and drastic change to routine.

Then you have family history as a possible contributing factor, overactive bladder and idiopathic. Idiopathic just means that no obvious cause can be found.

Important medical causes to rule out are spina bifida, or really anything that would cause a neurogenic bladder. Neurogenic bladder just means that some kind of brain, spinal cord or nerve damage has caused a lack of control over the bladder.

New onset diabetes mellitus often causes excessive increased urine output which can cause enuresis. As does diabetes insipidus.

And two of the most common causes of secondary enuresis are UTI and constipation.

For your assessment you really want to get a very thorough history of what’s been going on. A really important part of this is asking about toilet training o you can work out if it’s a primary or secondary enuresis.

The child’s daily routine can give really important clues for this topic. So get details about their hydration status, what they are eating and what their routine is like at home and at school.

Then you want to look for signs of possible contributing factors. Are they constipated? Are there signs of infection or new onset diabetes? Do they have any signs of a neurogenic bladder, like a change in gait or paralysis?

The first step of management is to simply try behavioural modifications. Patients are encouraged to void ever 1.5-2 hours during the day. They should avoid caffeinated and surgery drinks after 4pm. They should urinate immediately before bed and parents may even do a purposeful wake up to empty the bladder in the middle of the night.

If this isn’t effective, a bed alarm may be used to try and wake the patient up when they begin void.

Medications are only used if these two attempts don’t work. Desmopressin acetate or DDAVP is first-line. It works by increasing water reabsorption and decreasing urine production over night. Anticholinergics like, oxybutynin may be used to stop bladder contractions which may help prevent urination during the night.

Emotional support is super important. It can be very distressing for parents and kids. Kids should be involved in all of the management planning so they can feel empowered. Parents need to know that enuresis is not a symptom of bad parenting and it’s also not an act of willful rebellion or misbehaviour on the kids part.

Your priority nursing concepts for a pediatric patient with enuresis are elimination, human development, and coping.
Ok let's go over your key points for this lesson. Enuresis is when a kid isn’t able to control their bladder after the expected developmental age, which is 5 years. It can be classified as primary or secondary and it can affect kids during the day or the night or both.

There are a lot of different variables and diagnosis to consider when we think about what's causing this problem, but the most important ones to rule out are new onset diabetes, UTI constipation and neurogenic bladder.

In your assessment you want to focus on finding out information about their voiding history and also just about their life and their routine.

The first step in management is to modify behaviours. The most important changes are to ensure routine toileting throughout the day and also right before bed And to also avoid caffeine and sugary drinks after 4 p.m.

Medications that can be used or desmopressin acetate and oxybutynin but these are only going to be used after behavioral modifications and a bed alarm have failed.

That's it for our lesson on enuresis. Make sure you check out all the resources attached to this lesson. Now, go out and be your best self today. Happy Nursing!