I. Scope of application of this guideline
This guideline only applies to children with monosymptomatic nocturnal enuresis. This guideline does not cover the treatment of nocturnal enuresis with a combination of lower urinary tract symptoms.
Etiology and pathogenesis
The cause of nocturnal enuresis is still unclear, and it is thought to be caused by a combination of factors.
1. Sleep-wake dysfunction: The most important pathogenesis of nocturnal enuresis is that the nerve impulses generated by the filling of the bladder cannot awaken the child after entering the sleep state, and the child urinates in the non-awake sleep state. The specific mechanism leading to the delayed development of the central nervous system involved in this process is unknown, but there are two possible factors: (1) insufficient nerve impulses generated by bladder filling to induce awakening; (2) too deep sleep and failure to awaken.
2. Nocturnal polyuria: Some children with enuresis. kidneys produce large amounts of urine at night, exceeding the maximum bladder capacity. It may be related to insufficient secretion of antidiuretic hormone by the pituitary gland at night.
3, abnormal bladder function: mainly the reduced bladder capacity caused by overexcitation of the nocturnal detrusor muscle, resulting in more urination and less urine volume each time.
4.Family inheritance: about 62% of children with enuresis have parents or other relatives who have a history of similar disease, indicating that the disease may have a genetic tendency.
5. Other: diabetes, depression and sleep apnea may also be associated with enuresis.
Diagnosis and evaluation
Children with monosymptomatic nocturnal enuresis have no symptoms other than enuresis, so history taking is extremely important in the diagnosis.
1.History taking (recommended)
a. Understand the general condition of the child, including health, development and whether there is a combination of mental illness.
b. What is the severity of bedwetting at night, including the time of occurrence and frequency.
c. Whether the bedwetting is combined with other symptoms, including daytime symptoms of urinary frequency, urgency, difficulty in urination or urinary incontinence.
d. Whether it is combined with nocturnal polyuria, how much water is consumed on weekdays and what are the drinking habits.
e. Whether it is combined with intestinal symptoms, such as constipation or fecal incontinence, etc.
f. Whether urine loss has an impact on the child’s psychology and daily behavior, and whether it affects socialization, learning and family relationships.
g. How the child sleeps at night, and whether there is severe snoring or apnea during sleep.
h. Ask the parents about the current measures to deal with the child’s nocturnal enuresis, including the method of waking the child to urinate at night (unawakened, regularly awakened or randomly awakened).
2. Physical examination and other tests
Recommended examination items: ① genitourinary system examination; ② urinary routine, urinary ultrasound and residual urine volume measurement.
3.Questionnaire (optional)
a. Clinical managemet took (CMT).
b. Urinary diary for at least 3 days.
IV. Treatment
Since children with monosymptomatic nocturnal enuresis generally have no organic pathology, treatment should begin with proper education and guidance. Some children’s symptoms can gradually disappear as they get older, so children before the age of 6 can generally be treated without medication or other special treatment.
(I) Education and guidance (recommended)
1. First of all, we should emphasize that bedwetting at night is not the child’s fault and avoid being blamed for it.
2.Ensure the normal daily fluid intake of the child, and reduce the amount of fluid 3~4 hours before bedtime.
3.Educate and supervise the child to develop good urination habits (4-7 times/d)
4. Parents are advised to use a calendar to record the occurrence and frequency of enuresis each night.
(B) The correct method of waking up at night (recommended)
1.Time to wake up: wake up the child when his bladder is full and he is about to urinate
2. Urination in the awake state: wake the child from sleep to urinate in the awake state.
(C) Urine loss alarm (optional)
For children whose education and guidance are ineffective and whose parents have a certain level of culture and education, we can consider using it.
Continuous use for 2 to 3 months can generally achieve satisfactory results. If the symptoms do not improve significantly after 2 to 3 months of continuous use, consider stopping the use or adding desmopressin acetate.
(iv) Desmopressin acetate (optional)
Desmopressin acetate is an antidiuretic hormone analogue and is currently the first-line drug used in the treatment of enuresis. It is especially suitable for children with enuresis who have nocturnal polyuria.
Currently, desmopressin acetate is commonly used in China as an oral tablet, which is administered 1 h before bedtime.
The commonly used dose is 0.2~0.4mg (regardless of age and gender). After treatment with desmopressin acetate, some children can have short-term symptomatic improvement, but the symptoms tend to recur after stopping the drug, so it is usually necessary to use the drug continuously for at least 3 months.
Desmopressin acetate has few adverse effects and is safe for long-term use, but it can cause water intoxication, hyponatremia and convulsions when taken after drinking large amounts of water. In order to ensure the safety of the drug, parents are recommended to control the fluid intake of the child from dinner to bedtime within 200
ml or less until the morning of the second day.
(E) Anticholinergic drugs (optional)
It is especially indicated for children with monosymptomatic enuresis who have combined nocturnal detrusor overactivity. The main adverse effects of this drug are dry mouth, constipation and difficulty in urination.
(vi) Tricyclic antidepressants (optional)
The adverse effects are more frequent and should be considered only after the child’s family cannot afford the enuresis alarm and desmopressin acetate or after treatment has failed.
(vii) Biofeedback therapy (optional)
It can be considered when educational guidance and medication are not effective. It requires good compliance and some understanding of the treatment and is suitable for older children.
Follow-up
There is no uniform standard, but according to clinical experience, outpatient follow-up can be performed every 3 to 6 months.
Prognosis
The majority of children can be cured after improving their habits, using an enuresis alarm or desmopressin acetate. In a small number of children who do not respond well to treatment, other treatment options may be tried, and the underlying cause may be further investigated.
Related terms and definitions
Nocturnal enuresis
enuresis: The age and frequency of enuresis are still controversial, both nationally and internationally, and among different disciplines. According to the definition developed by the International Childhood Urinary Control Association in 2006, nocturnal enuresis is defined as involuntary leakage of urine during sleep at least twice a week for ≥3 months in children >5 years of age without central nervous system pathology. In some pediatric guidelines its defined age is 3 years. Nocturnal incontinence (nocturnal
incontinence and other causes of nocturnal bedwetting are collectively referred to as nocturnal enuresis, which is subdivided into monosymptomatic nocturnal enuresis and compound nocturnal enuresis.
1.Monosymptomatic nocturnal enuresis
enuresis): There is only nocturnal enuresis without other combined lower urinary tract symptoms. According to the characteristics of enuresis, it can be further divided into primary and secondary enuresis.
2. primary enuresis: enuresis with symptoms persisting since childhood (asymptomatic period not exceeding 6 months).
Secondary enuresis: It refers to enuresis that has had an asymptomatic period of at least 6 months and then occurs again.
3.Composite nocturnal enuresis (nonmonosymptomatic nocturnal enuresis)
enuresis): It refers to the combination of lower urinary tract symptoms or bladder dysfunction in addition to nocturnal enuresis, including daytime urinary frequency, urgency, urinary incontinence, difficulty in urination or lower urinary tract pain, etc.