The behaviour therapeutic falls in management of enuresis, The pharmacological drug of choice for this case in
Enuresis Defined as normal, complete evacuation of the bladder at a wrong place and time at least twice a month after 5 year of age. More than 85% children attain complete diurnal and nocturnal control by 5 years of age. Enuresis is primary when the child has never been dry and secondary when bed wetting stas after a minimum period of six months of dryness at night. It is said to be monosymptomatic if not accompanied by any lower urinary tract infection and nocturnal if it occurs during sleep. It has to be differentiated from continuous or intermittent incontinence or dribbling.The bed is usually soaking wet in enuresis, compared to incontinence in which there is loss of urine without normal emptying of bladder. ETIOLOGY:- 1. Maturation delay is most likely cause. 2. Anxiety producing episodes during the 2 nd to 5 th years, the time for development of nocturnal bladder control, are associated with increased risk of enuresis. 3. Lack of circadian rhythm of ADH or impaired response of kidneys to ADH. 4. Secondary enuresis can be precipitated by acute stressful condition or traumatic experience. Bladder irritability due to urinary tract infection or severe constipation with the full rectum impinging on the bladder can cause enuresis. 5. Conditions causing polyuria, spina bifida, ectopic ureter and giggle and stress incontinence are other causes. Treatment:- General advice given to all enurectic children but active treatment need not begin before 6 years of age. Caffeinated drinks like tea , coffee, sodas should be avoided in evening. Adequate fluid intake during day as 40% in morning, 40% in afternoon and 20% in evening is recommended. First line of treatment is usually non pharmacological, comprising motivational therapy and use of alarm devices. Motivational therapy:- Successful in curing enuresis upto 25%. The child is reassured and provided emotional suppo.Every attempt is made to remove any feeling of guilt. The child is encouraged to assume active responsibility, including keeping a dry night diary, voiding urine before going to bed, and changing wet clothes and bedding. Dry nights should be credited with praise.punishments and angry parenteral response should be avoided. Child is encouraged both to void frequently enough to avoid urgency and daytime incontinence and to have daily bowel movement. Alarm therapy: Involves the use of device to elicit a conditioned response of awakening to the sensation of full bladder. Best used afteemr seven years if age. Successful in two third cases without much recurrence. The alarm device consists of a small sensor attached to child&;s underwear or a mat under the bed sheet and an alarm attached to the childs collar or at bedside. When the child stas wetting, sensors are activated thus causing the alarm to ring. Pharmacotherapy:- Used if enuresis persists despite alarm therapy, regular voiding habits, exclusion or treatment of constipation, exclusion of post voidal residual urine. Imipramine works by aleing the arousal sleep mechanism. It gives satisfactory initial response at dise of 1-2.5 mg/ kg/ day. Relapse rate after discontinuation of therapy seen. Cardiac arrythmia is a serious adverse effect. Anticholinergic drugs reduce uninhibited bladder contractions and are useful in children who have significant daytime urge incontinence besides nocturnal enuresis. Usual dose is 5 mg for oxybutynin, 2 mg for tolterodine. Desmopressin works by reducing volume of urine. Reference: GHAI Essential pediatrics, 8th edition
Phenytoin
Diazepalm
Imipramine
Alprax
Growth and development