The age, typically achieve urinary continence in children varies, but> 90% of children are dry during the day at an age of 5 years. Reaching the nocturnal continence takes longer. Nocturnal enuresis relates to 30% of children at 4 years, 10% of 7 years, 3% at 12 years and 1% at 18 years. About 0.5% of adults continue to have episodes of nocturnal incontinence. Nocturnal enuresis is more common in boys and if there is a family history (1).
Urinary incontinence is defined as involuntary loss of urine ? 2 times per month during the day or night. Enuresis diurnal (incontinence during the day) is not detected usually before the age of 5 or 6 years. Nocturnal enuresis (Nocturnal incontinence or bedwetting) is not detected usually before the age of 7 years. Before that date, nocturnal enuresis is typically referred to as bedwetting. These ages are meant for children who develop regular and can children who are impaired in their development, not be applied. Both enuresis diurnal and nocturnal enuresis are no symptoms and diagnoses and thus need a clarification of the underlying causes. The age, typically achieve urinary continence in children varies, but> 90% of children are dry during the day at an age of 5 years. Reaching the nocturnal continence takes longer. Nocturnal enuresis relates to 30% of children at 4 years, 10% of 7 years, 3% at 12 years and 1% at 18 years. About 0.5% of adults continue to have episodes of nocturnal incontinence. Nocturnal enuresis is more common in boys and if there is a family history (1). In primary enuresis children have never reached a urinary continence, if sustained for ? 6 months. In secondary enuresis children experience after a period of at least 6 months without incontinence an episode of urinary incontinence. An organic cause is closer to the secondary enuresis. Even if there is no organic cause, are an appropriate treatment and counseling of the parents because of the physical and psychological effects of enuresis essential (2). Notes 1. Horowitz M, Misseri R: Diurnal and nocturnal enuresis. In Clinical Pediatric Urology, ed 5, published by Docimo S, D Canning, Khoury A. London, Martin Dunitz Ltd, 2007 S .. 819-840. 2. Austin PF, Vricella GJ: Functional disorders of the lower urinary tract in children. in Campbell-Walsh Urology, ed. 11, edited by wine A, Kavoussi L, Partin A, Peters C. Philadelphia, Elsevier, 2016, pp 3297-3316. Pathophysiology bladder function has a storage phase and an emptying phase. Abnormalities in one of the two phases may cause primary or secondary enuresis. In the storage phase, the bladder acts as a reservoir for urine. The storage capacity depends on the size and ability to learn the bladder. The storage capacity is better when the children grow older. The ability to learn can be reduced by repeated infections or obstruction, resulting in bladder muscle hypertrophy result. In the emptying phase goes bladder contraction with an opening of the bladder neck and the external urethral sphincter associated. If there is a dysfunction in the coordination or in the sequence of urination, enuresis may occur. There are several reasons for the dysfunction. One example is a bladder irritation that leads to irregular contractions of the bladder and an asynchronous emptying sequence, enuresis requires. Bladder irritation may result from a urinary tract infection or something else that presses on the bladder (z. B. an extended rectum by constipation). Etiology urinary incontinence in children has different causes and treatments than the urinary incontinence in adults. Although enuresis diurnal and cause some anomalies both nocturnal enuresis, the etiology may vary – depending on whether the enuresis occurs during the day or night or whether it is primary or secondary. Most primary Enuresen occur at night and have no underlying organic disorder. Nocturnal enuresis may be symptomatic mono (only occurs during sleep on), or complex, z. As when other abnormalities are present, such as enuresis diurnal and / or discomfort during urination. Nocturnal enuresis Organic diseases account for approximately 30% of cases and are more frequent than in the mono-symptomatic enuresis in the complex enuresis. The remaining majority of cases is of unknown origin, but it is believed to be caused by a combination of factors, including the following, include: delay the ripening process is not yet complete, process dry down Functional small bladder capacity (the bladder is not really small however, contracted before it is completely filled) Increased nocturnal urine volume difficulty waking from sleep when the bladder signals are Family history (if one parent had nocturnal enuresis, there is a 30% chance that their children will also suffer , increased to 70% if both parents were affected) Among the factors that contribute to organic causes of nocturnal enuresis include:. conditions that increase the urine volume (such as diabetes mellitus, diabetes s insipidus, chronic renal failure, excessive water absorption, sickle cell anemia, sickle cell trait, and sometimes [hyposthenuria]) conditions that increase the irritability of the bladder (z. As urinary tract infection, pressure on the bladder through the rectum and the sigmoid [constipation caused by]) Structural abnormalities (eg. B. ureter, both to diurnal enuresis, can be used as nocturnal enuresis also lead to) abnormal sphincter deficiency (z. B. Spina bifida, which can nocturnal lead to both enuresis diurna, as well as enuresis) Some factors that may be involved in nocturnal enuresis cause suspicious findings diagnostic approach constipation irregular, hard, small chairs (like pebbles) Enkoprese abdominal discomfort history with a Ernä currency that acts clogging (eg. As much milk and dairy products, low in fruits and vegetables) Clinical evaluation (including defecation diary) Sometimes radiograph of the abdomen Increased urine output due to any cause (eg., Diabetes mellitus, diabetes insipidus, excessive water intake, sickle cell anemia or signs of it) The after fault varying For diabetes mellitus: serum glucose for diabetes insipidus: osmolality in serum and blood for sickle cell anemia screening of sickle cell delay ripening No enuresis diurna common in boys and deep sleeping children Maybe a family history Clinical evaluation sleep history of snoring with breathing pauses audible Excessive of loud snorers daytime sleepiness Enlarged tonsils polysomnography Dysraphism the spine (eg. B. Spina bifida, ligated spine, unknown defects), which leads to urinary retention obvious vertebral body defects protruding Hirnhautausbuchtung, lumbosacral pits or tufts of hair, lower limb weakness, decreased sensation in the lower extremities absence of the Achilles tendon reflex, the Kremasterreflexes and low rectal tone Lumbosacral radiograph for hidden diseases: spinal MRI stress problems at school, social isolation or difficulties, stress in the family (. eg divorce, separation) Clinical evaluation (including voiding diary) urinary tract infection Dysuria, hematuria, urinary frequency, urgency, fever abdominal pain urinalysis urine culture for patients with pyelonephritis: Common ultrasonography and voiding cystourethrogram enuresis diurna causes are irritable bladder Relative weakness of detrusor muscle (the continence difficult) constipation, urethrovaginaler reflux or vaginal discharge: Girls during a false position urination taking (eg. As both legs pressed tightly together have) or excess skin folds, can have a backflow of urine have in the vagina, which then trickles on standing. Structural abnormalities (eg. As ectopic ureter) abnormal sphincter deficiency (z. B. spina bifida, unset spine) Some organic causes of diurnal enuresis cause suspicious findings diagnostic approach constipation irregular, hard, small chairs (like pebbles) Sometimes encopresis, abdominal discomfort history of a diet that works clogging (eg. as much milk and dairy products, some fruits and vegetables) Clinical evaluation (including defecation diary) Sometimes X-rays of the abdomen Voiding dysfunction as a result of a lack of coordination of the detrusor and sphincter muscles; without neurological cause Often encopresis, vesicoureteral reflux and urinary tract infections may enuresis during the day and urodynamic during night studies showing a dyssynergy the bladder muscles urine flow tests Sometimes voiding cystourethrogram (VCUG) incontinence when they laugh or giggle emptying during laughter, almost exclusively in girls at other times normal urination Clinical evaluation Increased urine output due to any cause (eg., diabetes mellitus, diabetes insipidus, excessive water intake, sickle cell anemia or signs of it) Varies disorder Diabetes mellitus: serum glucose in diabetes insipidus: osmolality in serum and blood In sickle cell anemia screening of sickle cell Miktionsverzögerung with overflow incontinence in children who wait too long to go to the bathroom frequently in children of preschool age, engrossed playing Matching history voiding diary neurogenic bladder due to a dysraphism the spine (eg. B. Spina bifida Tethered Cord, hidden defects), or a nervous system disorder obvious vertebral body defects protruding Hirnhautauswölbung, lumbosacral pits or tufts of hair, lower limb weakness, decreased sensation in the lower extremities Lumbosacral radiograph case of hidden disorders: spinal MRI sonography of the kidney and bladder urodynamic studies Overactive bladder urination (important for diagnosis); often frequency and nocturia Sometimes position of emptying (z. B. squats or Vincent-Knicks sign) history consistent with symptoms or overactive bladder into account the Miktionstagebuchs, urodynamic studies, urine flow tests Sexual abuse insomnia, difficulty (in school z. B. crime, poor grades) Seductive behavior, depression, unusual interest in or avoidance of all sexual issues, for the age inappropriate knowledge about sexual matters expert judgment sexual abuse stress * school problems, social isolation or difficulties, stress i n family (eg. As divorce, separation) Clinical evaluation Structural anomaly (eg. As ectopic ureter, posterior urethral valves) in children who have never during the day continents were enuresis diurnal and nocturnal in girls history with normal emptying, but stänidig wet underwear, vaginal discharge possible history of urinary tract infections or other Harnwegsanomalien sonography renal nuclear medicine examination of the kidneys or iv Urography CT of the abdomen and pelvis, MRI urography UTI dysuria, hematuria, urinary frequency, urgency, fever abdominal pain urinalysis urine culture for patients with pyelonephritis: ultrasound and VCUG vaginal reflux (backflow urethrovaginal or vaginal discharge) for any reason (including labial adhesions) of rain in standing after urination Clinical investigation, including information on the correct posture urination to avoid retention of urine in the vagina (eg. as sit on the toilet or backward with his knees wide apart) * Stress is a cause especially in acute incontinence VCUG = voiding cystourethrogram; VUR vesicoureteral reflux = Clarification The clarification should always be a test for constipation include (this may diurna enuresis and nocturnal enuresis favor). The history of the history of current disease inquires after the onset of symptoms (ie, primary versus secondary enuresis), after the time of symptoms (eg. As in the night, during the day, just after discharging) if the symptoms are continuous (ie, and constant trickle) or occur sporadically. Keeping a Miktionstagebuchs can be helpful. It should record the timing, frequency and amount emptied. Important associated symptoms are polydipsia, dysuria, urgency, frequency, dribbling and effort. The position during the emptying and the strength of the urine stream is recording. To prevent leakage, some children with enuresis take up a special body posture as crossed legs or squatting posture (if pressed by hand or the heel against the perineum). In some children, this postponement may increase their risk for urinary tract infections. Similar to the voiding diary, a stool diary may help to diagnose constipation. A review of organ systems should look for symptoms that suggest a cause such. B. Frequency and characteristics of the chair (constipation), fever, abdominal pain, dysuria and haematuria (urinary tract infection), perianal itch and vaginitis (maggots), polyuria and polydipsia (diabetes insipidus or diabetes mellitus), snoring or pauses in breathing during sleep (sleep apnea) , Children should also be examined for the possibility of sexual abuse, which is indeed a rare cause, but is too important to be overlooked. The history should identify possible known causes, including perinatal injury or birth defects (eg. As spina bifida), neurological disease, kidney disease and past urinary tract infections. Any current or previous treatments for enuresis and how they have been taken should be recorded, as well as all Medikamte that are taken at the time. The development process should be noted and possible developmental delays or other developmental disorders associated with micturition disorders (eg. As / hyperactivity disorder attention deficit) reveal that can contribute to enuresis. A family history should ask the family to Enuresisvorfällen and urological disorders. to ask about social circumstances, can identify existing stressors such. As school problems, problems with friends or at home. Although enuresis is not a psychological disorder, brief episodes of enuresis can occur after stress. Doctors should also after impact of enuresis ask the child, because even this treatment bestimmt.Körperliche investigation The investigation will begin with a review of vital signs such as fever (urinary tract infection), signs of weight loss (diabetes) and hypertension (kidney disease). An examination of the head and neck should pay attention to enlarged tonsils, mouth breathing or poor growth (sleep apnea). The examination of the abdomen palpated possible lesions due to chair or a full bladder. In girls, a genital examination for labial adhesions, scars or injuries should pay that may be sexual abuse suspect. An ectopic ureteral orifice is often hard to see, but should be investigated. In boys Meatusreizungen or possible lesions on the glans or around the rectum should be reviewed. In children of both sexes perianal scratches can indicate a pinworm infestation. The spine should be examined for all midline defects (z. B. deep sacral dimple, sacred tuft of hair). A complete neurological evaluation is important and should target the power, the feel and the tendon reflexes of the lower extremities, their feeling and tendon reflexes, examine sacral reflexes (z. B. rectal tone) and to identify the cremasteric possible dysraphism the spine in boys , A rectal examination may be useful to a blockage or a decreased rectal tone to erkennen.Warnhinweise Worrying findings are signs or concerns of sexual abuse Excessive thirst, polyuria and weight loss Longer primary enuresis diurnal (over the age of 6 years out) all neurological symptoms , especially in the lower extremities Physical signs of neurological impairment interpretation of the findings Usually the primary enuresis is nocturnal in children with an otherwise unremarkable history and examination only an indication of a delay in the maturation. A small percentage of children have a treatable disorder, sometimes, findings possible causes close (see table: Some factors that may be involved in nocturnal enuresis). For children who are tested for nocturnal enuresis, it is important to determine whether evidence of enuresis exist diurna such. As urinary urgency, frequency, hinauszögernde postures and enuresis. Children with these symptoms have a complex enuresis and treatment should be aimed primarily at controlling the symptoms a day. When enuresis diurna impaired bladder emptying by intermittent enuresis is suggested that precede a strong urge to urinate, frequent interruptions while playing or a combination thereof. Enuresis after urination (by incomplete emptying of the bladder) may also be a part of the history. Enuresis caused by a urinary tract infection is probably an acute episode of a chronic rather than intermittent problem and may by typical symptoms (eg. As urgency, frequency, painful urination) are accompanied. However, other causes of enuresis can lead to secondary urinary tract infection. Constipation should in the absence of other findings in children who have hard stools and difficulty with bowel movements (and sometimes palpable chair in the abdominal examination) are considered. Sleep apnea should be considered in conjunction with excessive daytime sleepiness and sleep disorders. the parents of snoring or breathing pauses may be able to report during sleep. Rectal itching (especially at night), a reference to vaginitis, urethritis or pinworm infestation can be. Excessive thirst, daily and nocturnal enuresis and weight loss suggest a possible organic cause down (z. B. diabetes mellitus). Stress or sexual abuse can be difficult to prove, but should be considered werden.Tests The diagnosis can usually be made based on history and examination findings. Usually a urinalysis and bacterial culture of urine in children of both sexes are required. More testing is useful, especially when the medical history, physical examination, or both an organic cause to suggest (see table: Some factors that may be involved in nocturnal enuresis and see Table: Some organic causes of diurnal enuresis). An ultrasound of the kidneys and the bladder is often performed to check whether the Harnwegsanatomie is normal. Urine flow tests can show with a disorder of urination a staccato emptying in patients. Treatment The most important part of treatment is to inform the family about the cause and the clinical course of enuresis. This background knowledge will help to reduce the negative psychological effects of bed-wetting and to achieve a good compliance in treatment. The treatment of urinary incontinence should be directed to the cause that has been identified. However, often no cause is found. In such cases, the following measures may be useful. Nocturnal enuresis The most effective long-term strategy is a device with alarm sound when wetting of the substrate. Although somewhat expensive, can be the success rate of this measure up to 70% when the children are motivated and the family supports them. The nighttime use of the apparatus can be up to 4 months needed until symptoms of enuresis disappear completely. An alarm is triggered when the base is moist. Although the children initially continue bedwetting, they learn over time always better to associate the feeling of a full bladder with the alarm and then wake up more frequently in front of the alarm and thus prevent himself a bedwetting. The corresponding Wake Up Device are readily available (including online) and do not need a prescription. A Weckgerät should not in children with complex nocturnal enuresis, or in children with reduced bladder capacity (as determined by a voiding diary occupied) are used. These children should just as children are treated with enuresis diurna. It is important to avoid punitive methods because these undermine the success of treatment and only lead to low self-esteem. Drugs such as desmopressin (DDAVP) and imipramine (see table: drugs for enuresis in children *) can help to improve nocturnal enuresis. However, results are not maintained in most patients when the treatment is stopped. Parents and children should therefore be warned to avoid disappointment. DDAVP is strongly preferred imipramine, because with imipramine in rare cases, sudden death occur kann.Enuresis diurna It is important to treat a possible underlying constipation. Information from a voiding diary can help identify children with reduced functional bladder capacity, striking frequency and urgency with urination as well as children with rare urination. Among the general measures include exercises to control the urge to urinate: Children are instructed to go to the bathroom when they feel an urge. On the toilet should they hold their urine as long as possible and only when it no longer goes to urinate, then stop again, and then let go and urinate again. This exercise strengthens the sphincter and gives children the confidence that they can make it to the toilet before wetting it. Gradual extension of urination intervals (if detrusor instability or a dysfunctional emptying is suspected) changes in behavior through positive reinforcement and planned urination (micturition after time) (for example, delayed urination.): Children (by an alarm clock that is better than if the parents play this role) reminded to go to the bathroom. A use of proper evacuation methods to avoid urinary retention in the vagina: Girl with vaginal storage of urine can be advised, conversely, to sit on the toilet or keep your knees wide apart. These attitudes create a better expanses of the Introit and allows direct flow of urine into the toilet. In labial adhesions a conjugated estrogen or a cream containing 0.5% sodium triamcinolone may be used. Drug treatment (see table: drugs for enuresis in children *) is sometimes helpful, but is usually no treatment of choice. Anticholinergics (oxybutynin and tolterodine) can benefit with enuresis diurna that have a voiding dysfunction and for whom treatment with behavioral therapy or physiotherapy has no success patients. Medicines for nocturnal enuresis can be useful to reduce nocturnal enuresis, and they sometimes can guarantee nocturnal staying dry at nights. Medications for enuresis in children * Drug Dosage Some side effects voiding dysfunction in enuresis diurnal (overactive bladder) Oxybutynin For children> 5 years: 5 mg po 2 times daily, may be increased to 5 mg 3 times daily Slowed release. po 5 mg: for children> 6 years once a day, depending on the tolerance of increased to 5 mg a day every day to a maximum of 15 mg. Confusion, drowsiness, increased temperature, flushing, constipation, dry mouth tolterodine For children> 5 years; 1 mg p.o. 2 times a day for children who can swallow tablets: Nocturnal capsules with delayed release 2 mg to 4 mg once daily constipation, flushing, dry mouth enuresis desmopressin (DDAVP) for children ? 6 years: initially 0.2mg po once a day 1 hour before bedtime, as required intranasal desmopressin increased to a maximum of 0.6 mg once daily (DDAVP) is because of the risk of hyponatremia dilutionaler no longer recommended imipramine For ages 6-8 J., 25 mg p.o. once a day / evening for children> 8 years, 50 mg p.o. einmal täglich am Abend Selten Tod Mögliche Nervosität, Persönlichkeitsveränderungen, Schlafstörungen, Herzrhythmusstörungen * Diese Medikamente werden meist als Medikamente zweiter Wahl verwendet. Die Behandlung der zugrunde liegenden Erkrankung und eine Verhaltenstherapie sollten zuerst angewendet werden. Von plötzlichen Todesfällen unklarer Ätiologie wurde berichtet. Dieses Medikament wird nur noch selten verwendet. EKG sollte durchgeführt werden, um eine Verlängerung des QT-Intervalls und/oder des korrigierten QT-(QTc-)Intervalls zu identifizieren, die die Verwendung von Imipramin kontraindizieren. Zusammenfassung Primäre Harninkontinenz manifestiert sich häufig als näc