1

danarTi 1

enurezis marTva pirvelad

jandacvaSi

klinikuri praqtikis erovnuli rekomendacia

(gaidlaini)

damtkicebulia saqarTvelos Sromis, janmrTelobisa da socialuri dacvis ministris 2010 wlis 24 seqtembris

# 304/o brZanebiT

miRebulia “klinikuri praqtikis erovnuli rekomendaciebis (gaidlainebi) da daavadebaTa marTvis saxelmwifo

standartebis (protokolebi) SemuSavebis, Sefasebisa da danergvis erovnuli sabWos"

2009 wlis 30 dekembris #2 sxdomis gadawyvetilebis Sesabamisad

2

enurezis marTva pirvelad jandacvaSi

1. daavadebis ganmarteba, sinonimebi, klasifikacia da

terminologia

enurezis ganmarteba

Ramis enurezi aris ganmeorebadi, uneblie Sardva Zilis dros 5 wlisa da meti asakis bavSvebSi.1 nebismieri saxis uneblie Sardva Zilis dros xuTi wlisa da meti asakis bavSvebSi enurezad ganixileba. enurezi SeiZleba iyos pirveladi an meoreuli, monosimptomuri (gaurTulebeli) da aramonosimptomuri (Tan axlavs qveda saSarde gzebis dazianebis simptomebi). bavSvebi pirveladi enureziT monosimptomurni arian, ar aReniSnebaT qveda saSarde gzebis dazianebis niSnebi da anamnezSi Sardis buStis funqciis darRveva.1 mdgomareoba iTvleba pirveladad, rodesac simSralis periodi eqvs Tveze naklebia. mdgomareoba iTvleba meoreulad, rodesac simptomisgan Tavisufali periodi Seadgens 6 Tves an mets.

cxrili #1

enurezis saxeebi damaxasiaTebeli niSnebi

pirveladi enurezi (SemTxvevaTa 80 %)

enurezis aRmocenebamde simSralis periodi 6 Tveze naklebia.

meoreuli enurezi (SemTxvevaTa 20 %)

enurezis ganmeoreba, sul mcire, 6-Tviani simSralis periodis Semdeg.

Ramis enurezi

enurezi, romelic aRiniSneba Zilis dros.

dRis sisvele

Sardis Seukavebloba bavSvis sifxizlis periodSi.

monosimptomuri (gaurTulebeli) enurezi

enurezi qveda saSarde gzebis dazianebis simptomebisa da Sardis buStis disfunqciis gareSe.

aramonosimptomuri enurezi enurezi qveda saSarde gzebis dazianebis simptomebiT (mag: Sardvis sixSiris gazrda an Semcireba, dRis sisvele, Sardis Sekaveba, moSardvis imperatiuli survili, daWimuloba, Sardis susti an wyvetili nakadi, moSardvis Semdgomi wveTi, Semakavebeli manevrebi (fexis wverebze dgoma, fexebis gadajvaredineba, Cacucqeba da quslebis miWera Sorisze), arasruli daclis SegrZneba, diskomforti muclis qveda nawilis an genitaliebis areSi.

SeniSvna: RamiT mosaSardad erTxel gaRviZeba ar ganixileba normidan gadaxrad.

3

terminologia:

sisvele, Casveleba – uneblie Sardva.

simSrale – uneblie Sardvis ararseboba.

simSralis periodi – drois monakveTi, romlis ganmavlobaSi Ramis uneblie Sardva ar aRiniSneba.

sawyisi warmateba – simSrale 14 Tanmimdevruli Ramis ganmavlobaSi, 16-kviriani mkurnalobis periodSi.

warumatebloba – simSralis ararseboba 16-kviriani mkurnalobis periodSi.

nawilobrivi Sedegi – enurezis sixSiris Semcireba 50-90%-iT.

mkurnalobis araefeqturoba – enurezis sixSiris Semcireba 50%-ze naklebiT.

xangrZlivi warmateba – recidivis ararseboba 6 Tvis ganmavlobaSi.

2. epidemiologia

Ramis enurezi samjer ufro xSiria dRis sisvelesTan SedarebiT da vlindeba mcire asakis bavSvebis 6,7%-Si da mozrdili bavSvebis 2,8%-Si.3,4 is samjer ufro xSiria biWebSi5. meoreuli mizezebis sixSire naklebia 25%-ze.6,7 pirveladi enurezis SemTxvevebis 97-98% ganpirobebulia araorganuli paTologiiT. daaxloebiT 2% modis organul darRvevebze.

prognozi

pirveladi enurezis SemTxvevebis absoluturi umravlesoba TviTgankurnebadia pubertatuli asakis dadgomamde.

3. etiopaTogenezi

pirveladi enurezis etiologia jer kidev ganxilvis sagania da bolomde garkveuli ar aris.

pirveladi enurezi ganpirobebulia, erTi mxriv, Sardis buStis tevadobisa da meore mxriv, RamiT producirebuli Sardis moculobas Soris SeusabamobiT, agreTve bavSvis uunarobiT, gaiRviZos savse Sardis buStis sapasuxod.8

amrigad, enurezis paTofiziologia sami ZiriTadi faqtoriT aris warmodgenili: Ramis ganmavlobaSi gamomuSavebuli Sardis raodenobasa da Sardis buStis tevadobas Soris disbalansi, Sardis buStis swrafi avseba RamiT, gamoRviZebis problema (ix. cxrili #2).

4

cxrili #2

enurezTan asocirebuli da xelSemwyobi faqtorebi

faqtorebi aRweriloba

Sardis buStis funqcia8 Sardis buStis tevadobis Semcireba, RamiT Sardis Sekavebis unaris daqveiTeba.

detruzoris arastabiluroba8, 9

gamoRviZebis problema Sardis buStis gavsebisas da Seukavebeli SekumSva (mcire qvejgufSi).

genetikuri faqtorebi10,11 enurezis sixSiris mateba, rodesac anamnezSi erT an orive mSobels aReniSneboda enurezi. tyupebis SemTxvevaSi Cveulebriv orive maTgans aReniSneba enurezi. genetikuri gavlena enurezze heterogenuli da kompleqsuria.10 pasuxismgebeli genebi mdebareobs me-8, me-12, me-13 da 22 qromosomebSi10.

ganviTarebis Seferxeba2,8 cns-is, motoruli ganviTarebisa da metyvelebis Seferxeba

Ramis poliuria8 antidiurezuli hormonis gamomuSavebis Semcireba Ramis ganmavlobaSi iwvevs poliurias (antidiurezuli hormonis mimarT pirdapiri pasuxi).

fsiqologiuri faqtori2,8,12

iSviaTia pirveladi enurezis SemTxvevaSi. ufro xSiria meoreuli enurezis dros. ganixileba rogorc sapasuxo simptomi stresze an travmaze (mag: mSoblebis ganqorwineba, travma skolaSi, hospitalizacia, sqesobrivi Zaladoba, bavSvis ignorireba).

Zilis darRvevebi9 enurezi SesaZlebelia aRmocendes Zilis yvela fazaSi. enurezis mqone bavSvebSi SeiZleba Zalian Rrma Zili aRiniSnebodes.

mdgomareobebi/daavadebebi, romelTa arsebobisas enurezi erT-erTi gamovlenaa/simptomia (meoreuli enurezi):

Sardis buStis disfunqcia;

Tirkmlebis qronikuli ukmarisoba (bavSvebSi iSviaTia);

yabzoba;

uSaqro diabeti (bavSvebSi iSviaTia);

Saqriani diabeti;

hiperTireoidizmi;

obstruqciuli Zilis apnoe;

WiebiT invazia (Enterobius vermicularis); fsiqologiuri stresi;

krunCxviTi darRvevebi;

namglisebrujredovani daavadeba (bavSvebSi iSviaTia);

saSarde gzebis infeqcia (iSviaTia bavSvebSi)2,6.

5

4. enurezis garTulebebi

enurezis garTulebebia: bavSvis dabali TviTSefasebis SegrZneba, SiSi rom problema ar gaxdes cnobili sxvisTvis, Tavs “gansxvavebulad” grZnoben Tanatolebisgan (“nadiroba bizonebze”); akldebian/toveben socialur aqtivobas, romelic Ramis gaTevas iTvaliswinebs. bavSvebze yvelaze did uaryofiT gavlenas axdens is, rom iZulebulebi arian dauyovnebliv imoqmedon – daibanon da gamoicvalon tansacmeli.

ojaxis mxriv: umweobis, danaSaulis, SfoTvis SegrZneba, zewola ojaxis sxva wevrebisgan (“ratom ar mkurnalob”, ”eqimTan ratom ar migyavs”, ”Seni bralia” da a.S.), ramac SeiZleba ojaxis wevrebs Soris uTanxmoeba gamoiwvios.

mSoblebisTvis/momvlelebisTvis: zedmeti datvirTva (recxva da gasufTaveba, suni, damatebiTi finansuri danaxarjebi axali zewrebisTvis, leibebisTvis, sacvali, cxeli wyali da a.S.).

5. daavadebis diagnozi, klinikuri simptomebi

pirveladi enurezis mqone bavSvebSi mkurnalobis dawyebamde rekomendebulia anamnezis Sekreba, fizikuri gasinjva da Sardis saerTo analizi (ix. cxrili #3).

enurezis gamosavlenad rekomendebulia 5 wlisa da ufrosi asakis bavSvebis Sefaseba rutinuli vizitebis dros [D]. am vizitebis dros unda gamoikiTxon Tavad pacienti da mSoblebi.

6

cxrili #3

enurezis Sefaseba

anamnezi

(enurezisTvis specifikuri)

bavSvis asaki enurezis aRmocenebisas, enurezis xangrZlivoba da simZime, simSralis periodis xangrZlivoba (enurezis diagnozi ar ismeba 5 wlamde asakis bavSvebSi. sul mcire 6 Tviani simSralis periodis Semdeg recidivi mianiSnebs meoreul enurezze).

qveda saSarde gzebis dazianebis simptomebis arseboba*- (niqturiis garda yvela simptomi miuTiTebs aramonosimptomur da meoreul enurezze).

anamnezSi sxvadasxva daavadebebis arseboba- (mag.: Saqriani diabeti, Zilis apnoe) SeiZleba miuTiTebdes aramonosimptomur enurezze.6

fsiqologiuri anamnezi (fsiqologiuri darRvevebi aReniSneba meoreuli enurezis mqone pacientebis erT mesameds).8

enurezis ojaxuri anamnezi (xSiria, Tu anamnezSi erT an orive mSobels hqonda enurezi; tyupebis SemTxvevaSi, Cveulebriv, orive maTgans aReniSneba).2,10,12

miRebuli siTxis, moSardvisa da defekaciis Sesaxeb dRiuris warmoeba (sixSirisa da moculobis gansazRvra gvexmareba davadginoT Sekrulobis arseboba, enurezis simZime da mkurnalobis efeqturoba).2,8

warsulSi Catarebuli gamokvlevebisa da mkurnalobis Sesaxeb informacia.

sayuradRebo niSnebi: dizuria, tkivili an gamonadeni genitaliebis an swori nawlavis areSi, WinTvis grZnoba Sardvisas.

fizikuri gamokvleva2,6,8,17

yuris, cxvirisa da yelis daTvaliereba adenotonzilaruli hipertrofiis gamosavlenad.

muclis Rrus palpacia gadidebuli Sardis buStisa da Tirkmlebis aRmosaCenad.

Sorisis gamokvleva hipo-epispadiis, ureTris xvrelis stenozis, ureTris eqtopiisa da sasircxo bageebis adheziis dasadgenad. swori nawlavis gamokvleva perianaluri da perinealuri mgrZnobelobis, sfinqteris tonusisa da perianaluri eqskoriaciebis da vulvovaginitis dasadgenad.

mizanmimarTuli nevrologiuri gasinjva: siaruli, kunTTa tonusi, Zala da perinealuri mgrZnobeloba.

sayuradRebo niSnebi (saWiroa Semdgomi kvleva): adenotonzilaruli hipertrofia, xerxemlis

7

paTologia (deformacia, gava-kudusunis CaRrmaveba an Warbi Tmianoba, rac miuTiTebs nervuli Reros defeqtze/disrafizmze), paTologiuri myesTa refleqsebi qveda kidurebSi, gadidebuli Tirkmlebi an Sardis buSti, siarulis darRveva, seqsualuri Zaladobis niSnebi.

Sardis saerTo analizi, Sardis baqteriologiuri

gamokvleva6 ×

saSarde gzebis infeqciis, Saqriani da uSaqro diabetis dadgena.

sisxlis saerTo analizi, sisxlis

bioqimiuri kvleva6 ×

sisxlSi SardmJavas da Sratis kreatininis gansazRvra (Tirkmlebis qr. ukmarisoba), glukozis gansazRvra (Saqriani diabeti), hemoglobinis eleqtroforezi (namglisebrujredovani daavadeba), Tiroidmastimuli-rebeli hormoni (hiperTiroidizmi).

gamosaxulebiTi kvlevebi2,6,8 ×

Tikmlebisa da Sardis buStis ultrasonografia da cistoureTrografia - struqturul paTologiaze eWvis dros, mniSvnelovani dRis sisvelis an morecidive saSarde gzebis infeqcia vezikoureTruli refluqsis aRmosaCenad. Mmagnitur- rezonansuli kvleva lumbosakralur areSi zurgis tvinis disrafizmze eWvis dros an nevrologiuri gasinjviT miRebuli paTologiis dasadastureblad.

urodinamikurikvleva2,8 ×

narCeni Sardis moculobis gansazRvra da cistometria Sardis buStis disfunqciis Sesafaseblad.

* niqturia, Cacucqeba, moSardvis imperatiuli survili, dRis sisvele, Sekruloba.

× saWiroa mxolod meoreuli enurezis niSnebis arsebobis, sayuradRebo niSnebis aRmoCenisas (anamneziT an kvleviT) da im SemTxvevaSi, rodesac standartuli mkurnaloba araefeqturia.

enurezis mqone yvela pacienti unda iqnes gamokvleuli enkoprezisa da Sekrulobis dasadgenad. Sekrulobis dadasturebis SemTxvevaSi, saWiroa misi mkurnaloba enurezis mkurnalobis dawyebamde [C].

yabzobis diagnostireba advilia klinikuri suraTis mixedviT (nawlavTa moqmedeba kviraSi samze naklebia). es ukanaskneli SeiZleba enurezis gamomwvevi erT-erTi mizezi iyos (gadavsebulma nawlavebma SeiZleba gamoiwvios Sardis buStis gaRizianeba anatomiuri siaxlovis gamo). Sekruloba meoreuli enurezis dros SemTxvevaTa 50%-Si an ufro xSirad aRiniSneba, xolo pirveladi enurezis dros - 75%-Si. igi aseve dakavSirebulia dRis sisvelesTan.13 prospeqtuli jvaredini kvleviT gamovlinda, rom Sekruloba pirveladi Ramis enurezis mqone pacientebis mesamedze mets aReniSneba.

8

miuxedavad imisa, rom sisvele SeiZleba iyos Ramis epilefsiuri gulyris gamovlineba, ar arsebobs epilefsiasa da enurezs Soris kavSiris damadasturebeli mtkicebuleba. eleqtroencefalografia ar aris enurezis sadiagnozo rutinuli meTodi [B], garda im SemTxvevebisa, rodesac anamneziT vlindeba gulyrebi/epilefsia an enurezs Tan axlavs gulyrisTvis damaxasiaTebeli sxva simptomebi.

pirveladi monosimptomuri enurezis mqone bavSvebSi rekomendebulia Zilis apnoes simptomebis gamoricxva [C] (mtkicebulebis dabali donis miuxedavad). arsebobs Zilis apnoesa da Ramis enurezs Soris kavSiris damadasturebeli monacemebi [IV]. meoreuli enurezis SemTxvevaSi Zilis apnoe yovelTvis unda gamoiricxos [A].

6. mkurnaloba

pirveladi Ramis enurezis mkurnalobis pirveli etapia problemis Taobaze pacientisa da misi mSoblebis ganaTlebaa. maT unda icodnen, rom pirveladi Ramis enurezi, Cveulebriv, mkurnalobis gareSe ikurneba (wliuri maCvenebeli 15%).17 pirveli rigis mkurnaloba martiv qceviT Carevas gulisxmobs. gangaSis sistema da farmakoTerapia gamoiyeneba mozrdil bavSvebSi, romelTac fsiqo-socialuri problema da dabali TviTSefaseba aReniSnebaT. medikamenturi mkurnaloba iniSneba 7 wlisa da meti asakis bavSvebSi, rodesac arafarmakologiuri RonisZiebebi araefeqturia. erTi meTodis gamoyenebisas warumateblobis SemTxvevaSi, mimarTaven kombinirebul mkurnalobas (arafarmakologiuri da farmakologiuri an sxvadasxva medikamentebis kombinacia). mdgradi enurezis SemTxvevaSi saWiroa referali specialistTan (sqema 1.).

arafarmakologiuri mkurnaloba:

Tu pirveladi Ramis enurezi stresul zemoqmedebas ar axdens bavSvze, raime saxis mkurnaloba saWiro ara aris. Tumca, mSoblebs unda miewodos informacia bavSvis fizikuri da fsiqikuri janmrTelobis mdgomareobis Sesaxeb da mieces rCeva ar dasajon, Searcxvinon an daadanaSaulon bavSvi.2,19 Ramis pirveladi enurezis mkurnaloba unda gadaidos, sanam bavSvs Tavad ar eqneba survili an SesaZlebloba CaerTos mkurnalobis procesSi. mkurnaloba iSviaTadaa naCvenebi 7 wlamde asakis pacientebisaTvis. efeqtis misaRwevad zogjer ramdenime Tvea saWiro, amasTanave, bavSvs myari motivacia unda hqondes. mkurnaloba efeqturad iTvleba, Tu 16 kviris ganmvalobaSi bavSvs mSrali periodi eqneba 14 Ramis ganmavlobaSi Tanmimdevrulad, mkurnaloba araefeqturia, Tu enurezis sixSire Semcirda 50%-ze naklebad, 50-90%-iT Semcireba nawilobrivi Sedegis maCvenebelia.1

motivaciuri Terapia gulisxmobs emociur mxardaWeras, danaSaulis grZnobis ugulebelyofas, bavSvis waxalisebas saimisod, rom Tavad

9

ikisros pasuxismgebloba mkurnalobis procesze (miuxedavad imisa, rom paTologiis aRmoceneba bavSvze ar aris damokidebuli, mas [bavSvs] Tavisi funqcia aqvs mkurnalobis procesSi).20

qceviTi intervencia mSoblebis aqtiur CarTvas moiTxovs. es procesi xangrZlivia, Sromatevadi da zogjer uimedobis gancdas iwvevs.21,22 Tu waxalisebis meTodis gamoyenebiT efeqti ver iqna miRebuli, SeiZleba bavSvis TviTSefaseba zedmiwevniT daqveiTdes.19 amitom es meTodi SeiZleba gamoyenebuli iqnes sxva meTodebis CarTvamde an maTTan kombinaciaSi, miT umetes, rom mas gverdiTi movlenebi ar gaaCnia [D].

gangaSis sistemis gamoyeneba gulisxmobs sxvadasxva sasignalo mowyobilobis gamoyenebas, romelTa muSaobis principi efuZneba sensoris gaaqtivebas sisveleze. es meTodi efeqturia.2,19,24 gangaSi aiZulebs bavSvs gaiRviZos an Sewyvitos moSardva. pacientebis umetesobas 6-16 kviriani mkurnalobis kursi esaWiroeba. am meTodis gamoyenebisas enurezi ikurneba bavSvebis 2/3-Si, Tu amis Semdeg meTodis gamoyeneba grZeldeba - maTi naxevari rCeba mSrali.24 gangaSis yvela aparati erTnairad Rirebulia21. uaryofiTi mxarea Zilis darRveva (gaRviZeba). es meTodi efeqturia im SemTxvevaSi, rodesac mSoblebi aqtiurad TanamSromloben, ar aRiniSneba Tanmxlebi fsiqikuri da qceviTi problemebi, Sardis buSti mcire moculobisaa da loginis dasvelebis epizodebi xSiria (kviraSi 4 da meti Rame). gangaSis sistema gamoyenebuli unda iqnes mozrdili asakis, motivirebul bavSvebTan, romelTa mSoblebi CarTuli iqnebian mkurnalobis procesSi da romlebTanac qceviTi meTodebi araefeqturi aRmoCnda.

warmatebuli mkurnalobis albaToba izrdeba, rodesac gangaSis sistema kombinirebulia qceviT meTodebTan, saxeldobr:

recidivis risks amcirebs bavSvis waxaliseba, miiRos Warbi raodenobiT siTxe Sardis buStis moculobis gasazrdelad (rodesac simSrale miRweulia 14 Tanmimdevruli Ramis ganmavlobaSi).24

,,mSrali loginis“ treiningis damateba (bavSvis gaRviZeba gansazRvruli intervalebiT, sanam TviTon ar mieCveva gaRviZebas saWiroebis dros)17 75%-iT ufro efeqturia, vidre mxolod gangaSis sistemis gamoyeneba, amasTan, mcirdeba recidivis riski.36

gangaSis sistemis kombinacia gaRviZebis treiningTan (signalis sapasuxod bavSvis gaRviZebis qcevis waxaliseba-dajildoveba) efeqturia pacientebis 90%-ze metSi.8 .

maRviZara saaTis gamoyeneba martivi, iafi, usafrTxo da zomierad efeqturia gangaSis sistemasTan kombinaciaSi. bavSvi iRviZebs uneblie Sardvamde. maRviZara saaTi gamoiyeneba bavSvis gasaRviZeblad, raTa dacalos savse Sardis buSti sanam Seukavebloba ganviTardeba an daZinebidan 2-3 saaTSi. maRviZara saaTis gamoyeneba efeqturia SemTxvevaTa 62-77%-Si. Tumca,

10

mkurnalobis dasrulebidan 3 Tvis Semdeg recidivis riski igivea, rac gangaSis sistemis gamoyenebisas37.

“saxlis treiningi” moicavs qcevis iseT wamaxalisebel RonisZiebebs, rogoricaa bavSvis mier dasvrili zewris gamocvla, loginis dalageba, M ̀mSrali loginis” treiningi, Sardis buStisa da zedmeti siTxis miRebis treiningi. sistemurma mimoxilvam cxadhyo, rom mxolod am meTodebis gamoyeneba minimalur efeqts iZleva, magram, gangaSis sistemasTan kombinirebisas mcirdeba recidivis ganviTarebis sixSire23.

gangaSis sistema arCevis meTodia pirveladi Ramis enurezis dros, rodesac ojaxi motivirebulia da mzadaa TanamSromlobisTvis. [B]

gangaSis sistemiT mkurnaloba unda Seicvalos, Tu, misi gamoyenebis miuxedavad, bavSvi droulad ar iRviZebs [C].

11

sqema 1. enurezis Sefaseba da mkurnaloba

dRis Seukavebloba an aramonosimptomuri enurezi (disfunqciuri Sardva, sxva

ZiriTadi samedicino problema).

disfunqci-uri

Sardva

ZiriTadi daavadeba

Sardvis reJimi,

referali specia-

listTan.

gamomwvevi mizezis

mkurnaloba, saWiroebi-

sas referali specia-listTan

pirveladi Ramis enurezi

pacientisa da mSoblebis ganaTleba,

arafarmakologiuri meTodebi.

bavSvebi, romelTa asaki ≥7 wels da araefeqturia qceviTi da

gangaSis meTodebi.

motivirebuli, mozrdili

bavSvebi, loginis dasvelebis xSiri

epizodebiT.

farmakoTerapia: arCevis preparatia

desmopresini, gansakuTrebiT

iSviaTi Casvelebis dros.

oqsibutinini, kombinirebuli mkurnaloba, referali

specialistTan.

gangaSis sistema Warbi

raodenobiT siTxis miRebiT an mis gareSe.

anamnezi;

fizikuri gasinjva;

saSiSroebis niSnebis Sefaseba;

Sardis saerTo analizi (saWiroebisas – baqteriologiuri analizi).

12

farmakologiuri mkurnaloba

farmakologiuri mkurnaloba amcirebs enurezis sixSires an spontanur gankurnebamde, droebiT aqrobs simptomebs. gamoiyeneba antiqolinerguli saSualebebi (oqsibutinini, hiosciamini), tricikluri antidepresantebi (imipramini, dezipramini) da desmopresini. am saSualebebidan mxolod imipraminisa da desmopresinis gamoyenebaa nebadarTuli aSS sakvebisa da wamlis departamentis mier (FDA). tricikluri antidepresantebi kviraSi erTi RamiT amcireben sisvelis epizodebs. imipraminis dozaa 25 mg 6 welze meti asakis bavSvebSi (20-25 kg sxeulis masiT) da 50-75 mg 11 wlis da met asakSi. zogierTi rekomendaciis mixedviT, mkurnaloba unda SeizRudos 3 Tvemde.19 preparati iniSneba erTxel, daZinebamde erTi saaTiT adre. preparatis miRebidan 1-2 kviraSi efeqtis ararsebobis SemTxvevaSi doza unda gaizardis 50 mg-mde 7-12 wlis bavSvebSi da 75 mg-de mozrdilebSi20. bavSvebis umravlesobas imipraminis Sewyvetis Semdeg recidivi aReniSneba.26

mSoblebs unda miewodoT informacia potenciurad saSiSi, dozaze damokidebuli gverdiTi efeqtebis Sesaxeb26, rogoricaa: Zilianoba, leTargia, agzneba, depresia, Zilis darRvevebi da kuW-nawlavis traqtis gaRizianeba. iSviaTia krunCxvebi, ariTmiebi da sikvdili dozis gadaWarbebis SemTxvevaSi. mkurnalobis dawyebamde rekomendebulia ekg-is gadaReba2.

desmopresini, vazopresinis analogia, Sardis moculobas amcirebs distalur milakebSi reabsorbciis daqveiTebis xarjze. mkurnalobis efeqturoba 60-70%-Si vlindeba, Tumca 80%-s mkurnalobis Sewyvetis Semdeg recidivi uviTardeba2,8,30. desmopresini rekomendebulia im pacientebisaTvis, romelTa ojaxebsac ar SeuZliaT an ar surT aramedikamenturi mkurnalobis Catareba. preparati yvelaze efeqturia 8 wlisa da meti asakis bavSvebSi, romelTac aqvT monosimptomuri enurezi Ramis poliuriiT, Sardis buStis normaluri tevadobiTa da loginSi Casvelebis (uneblie Sardvis) naklebad xSiri epizodebiT31.

desmopresini gamoiyeneba tabletis (0,2 mg) an nazaluri spreis saxiT (10 mkg - erTi Sesxureba). moqmedebis xangrZlivoba 12 saaTia.2 mkurnaloba iwyeba erTi tabletiT an erTi SesxurebiT yovel saRamos. doza izrdeba yovelkvireulad. desmopresiniT mkurnaloba kombinirebulia siTxis miRebis SezRudvasTan (240 ml-ze naklebi RamiT, mkurnalobis fonze) da Zilis win moSardvasTan. intranazaluri da ekvivalenturi peroraluri doza Tanabrad efeqturia30. meore gzaa preparatis swrafi titracia simSralis periodis miRwevamde32.

desmopresini minimaluri efeqturi doziT unda iqnes gamoyenebuli. mkurnaloba igive doziT grZeldeba sul mcire 4-6 kvira, ris Semdegac safexurebrivad mcirdeba 6-7 Tvis manZilze. es amcirebs mkurnalobis Sewyvetis Semdeg recidivis ganviTarebis sixSires32. desmopresinisa da oqsibutininis kombinacia amcirebs dRis

13

Casvelebis sixSires. xolo desmopresinisa da gangaSis sistemis kombinacia zrdis mkurnalobis efeqturobas da amcirebs recidivis risks.

desmopresiniT gamowveuli gverdiTi efeqtebi SemTxvevaTa 5%-Si vlindeba. intranazalurma gamoyenebam SeiZleba gamoiwvios cxviridan sisxldena, yelis tkivili, xvela an Tavis tkivili. sistemuri reaqcia vlindeba gamonayariT, saxis SeSupebiT, enis an lorwovanis SesiebiT, anoreqsiiT, gulisreviT, muclis tkiviliT, mxedvelobis dabindviT da piris RruSi cudi gemos SegrZnebiT. amitom saWiroa sifrTxile preparatis dozis SerCevisas, siTxeebis SezRudva da hiponatremiis Sefaseba im SemTxvevaSi, Tu pacients gulisreva/Rebineba an Tavis tkivili aReniSneba.

antiqolinergiuli saSualebebi (oqsibutinini 2,5-5 mg samjer dReSi) amcireben Sardis buStis detrusoris tonuss, Sardvis sixSires, moSardvis imperatiul survils da zrdian Sardis buStis tevadobas. antiqolinergiuli mkurnaloba SeiZleba gamoyenebuli iqnes bavSvebSi pirveladi Ramis enurezisa da dRis sisvelis kombinaciis (Sardis buStis tevadobis Semcireba detrusoris hiperaqtivobis gamo), agreTve desmopresinis araefeqturobis dros.8,17,28 gverdiT movlenebs miekuTvneba: piris simSrale, mxedvelobis dabindva, Tavis tkivili, gulisreva, Rebineba, Tavbruxveva, taqikardia, kuW-nawlavis gaRizianeba. antiqolinerguli saSualebebis efeqturoba da usafrTxoeba klinikuri kvlevebiT Semdgom dadasturebas saWiroebs [C].

cxrili #4

enurezis mkurnaloba

mkurnalobis saxe Cveneba efeqturoba gverdiTi movlenebi

motivacia17,19,22

mcire asakis bavSvebi pirveladi Ramis enureziT; aucilebelia motivaciuri Terapia (waxaliseba, simSralis periodSi varskvlavebis an stikerebis gamoyeneba), dadanaSaulebis acileba, mxardaWera.

nawilobrivi efeqti 75 % ; recidivi 5 %;

frustracia; simSralis miuRwevloba waxalisebis sistemis gamoyenebisas aqveiTebs TviTSefasebas

Sardis buStis treiningi17,22

mcire asakis bavSvebi pirveladi Ramis enureziT; xangrZlivi periodis ganmavlobaSi uzrunvelyofs Sardis Sekavebas.

minimaluri gaumjobeseba

ara aqvs

14

mkurnalobis saxe Cveneba efeqturoba gverdiTi movlenebi

mSrali loginis treiningi17,23

mcire asakis bavSvebi pirveladi Ramis enureziT; gulisxmobs bavSvis gaRviZebas mosaSardavad garkveuli intervalebiT.

minimaluri gaumjobeseba

Zilis darRveva

enurezis gangaSis sistema2,17,19,24

mozrdili, motivirebuli bavSvebi pirveladi Ramis enureziT; bavSvis gaRviZeba sisveleze maRviZaras rxeviTi reaqciiT.

efeqturia pacientebis 2/3-Si, gangaSis sistemis gamoyenebisas simSrale grZeldeba 50 %-Si.

Zilis darRveva

imipramini (25-75 mg dRiuri doza)2,19,20,26,27

dezipramini (1-3 mg kg/wonaze)

bavSvebi pirveladi enureziT

efeqturia 40-60 %-Si; recidivi mkurnalobis Sewyvetis Semdeg

Zilianoba, krunCxvebi, ariTmia, leTargia, agzneba, depresia, Zilis darRveva, kuW/nawlavis gaRizianeba.

oqsibutinini 2,5-5 mg 3-jer dReSi8,17,28,29

bavSvebi dRis SeukaveblobiT, pirveladi Ramis enureziT

efeqturia 47-71%-Si, efeqturoba izrdeba desmopresinTan kombinaciiT

piris simSrale, mxedvelobis dabindva, Sekruloba, Zilianoba, taqikardia, gulisreva, Tavis tkivili, kuW-nawlavis gaRizianeba.

desmopresini (0,2-0,6 mg dRiurad) desmopresini intranazaluri 10-40 mkg dRiurad2,8,30-

35

bavSvebi piveladi Ramis enureziT

60-70%; 80% - Si recidivi mkurnalobis Sewyvetis Semdeg.

Tavis tkivili, epistaqsisi, yelis tkivili, muclis kolika, alergia, hiponatriemia, anoreqsia, gulisreva, mxedvelobis dabindva, cudi gemos SegrZneba pirSi.

desmopresiniT mkurnaloba alternatiuli meTodia [B]. desmopresinis intranazaluri gamoyenebisas mcirdeba sveli Rameebis sixSire, efeqti dozaze damokidebuli ar aris. Tu mizani sawyisi warmatebaa (14 Tanmimdevruli mSrali Rame), mniSvneloba ar aqvs dozebs (0,2-0,4-0,6 mg).

desmopresiniT mkurnaloba usafrTxoa, rogorc xanmokle, ise xangrZlivi droiT miRebisas. gverdiTi movlenebi iSviaTia da gansakuTrebiT naklebad vlindeba peroruli gamoyenebisas [Ia]. desmopresiniT mkurnalobisas, wyliT intoqsikaciis Tavidan asacileblad, rekomendebulia siTxis miRebis SezRudva 240 ml-mde (1 Wiqa) 8-saaTian Zilamde erTi saaTiT adre. intranazalurTan SedarebiT, ufro misaRebia desmopresinis peroruli forma, vinaidan usafrTxoa [A] da teqnikurad martivad Sesasrulebeli [D]. desmopresiniT mkurnalobis xangrZlivoba 1 Tveze naklebi periodiT ar aumjobesebs gamosavals.

15

mkurnalobis xangrZlivoba

im SemTxvevaSi, Tu mizani sruli gankurnebaa, preparatis miRebis Sewyveta unda daiwyos efeqtis miRwevidan 1 Tvis Semdeg[B]. xangrZlivi mkurnalobis dros, efeqturobis Sesafaseblad rekomendebulia mkurnalobis perioduli Sewyveta 1-2 kviriani intervalebiT [D].

recidivi xSiria, Tu desmopresinis miReba swrafad wydeba. rekomendebuli ar aris mkurnalobis Sewyveta efeqtis miRebisTanave [B]. mkurnalobis struqturirebuli Sewyvetis gegmis arseboba (safexurebrivi, wyvetili) recidivis gareSe gankurnebas ganapirobebs pacientebis 50%-Si, romelTac manamde, aseTi gegmis ararsebobisas, ganuviTardaT recidivi. mkurnalobis Sewyvetis momentis gansazRvrisaTvis rekomendebulia struqturirebuli Sewyvetis gegmis gamoyeneba (sruli dozebiT mkurnalobis dros) [B].

mkurnalobis sxvadasxva meTodebis kombinacia

desmopresinis kombinacia gangaSis sistemasTan ar iZleva mdgrad upiratesobas, Tumca sawyis etapze mSrali Rameebis raodenoba metia.

specifikuri SemTxvevebis garda, rodesac didi mniSvneloba aqvs mkurnalobis sawyis etapzeve simSralis periodis miRwevas, ar aris rekomendebuli rutinulad desmopresinisa da gangaSis sistemis kombinacia [A]. bavSvebSi, romelTac uneblie Sardva Ramis ganmavlobaSi erTze ufro xSirad aReniSnebaT, SeiZleba desmopresinis gamoyeneba Sardvis sixSiris Sesamcireblad, raTa gangaSis sistema asatani gaxdes pacientisTvis [D]. desmopresinisa da antiqolinergiuli preparatebis kombinacia SeiZleba ufro efeqturi iyos, vidre mxolod desmopresinis gamoyeneba, gansakuTrebiT im SemTxvevebSi, rodesac manamde Catarebuli mkurnaloba uSedego iyo [IV].

cxrili #5

sxvadasxva meTodis gamoyenebis upiratesobebi da naklovanebebebi

meTodi upiratesoba naklovaneba

martivi qceviTi Terapia

advilad dasanergia, usafrTxoa, aumjobesebs motivacias da aris damatebiTi meTodic

gankurnebis dabali maCvenebli

gangaSis sistema recidivis ganviTarebis riski dabalia, usafrTxoa

dayovnebuli pasuxi, pacientisa da ojaxis TanamSromlobis aucilebloba

desmopresini swrafi Sedegi, ar aris saWiro bavSvisa da ojaxis TanamSromloba, usafrTxoa

recidivis ganviTarebis maRali sixSire, siTxis miRebis SezRudvis saWiroeba Zilis win

16

rodesac mkurnalobis mizani simSralis miRwevaa drois mokle monakveTSi, rekomendebulia desmopresini da ara gangaSis sistema [A]. Tu mizani recidivis gareSe simSralis SenarCunebaa, am SemTxvevaSi upiratesoba gangaSis sistemas eniWeba [A]. ar aris rekomendebuli gangaSis sistemis gamoyeneba bavSvebSi, Tu Tavad bavSvs an misi ojaxis wevrebs dabali motivacia aqvT [B]. aseT dros arCevis saSualebaa desmopresini [B]. desmopresini efeqturia mcire asakis bavSvebSic, Tu sveli Rameebi iSviaTia [B]. maSin, rodesac gangaSis sistema efeqturia xSiri sveli Rameebis SemTxvevaSi [B] da amasTan rac metia sveli Rame, miT ukeTesia Sedegi. enurezis mqone bavSvebSi, romlebSic savaraudoa hiperaqtivobis sindromis arseboba, desmopresinis nacvlad mizanSewonilia gangaSis sistemis gamoyeneba [B].

cxrili #6

faqtorebi, romlebic ganapirobeben gangaSis sistemis arCevas

dadebiTi gavlena uaryofiTo gavlena gavlenas ar axdens

pacientisa da mSoblebis motivacia, xSiri sveli Rameebi

mSoblebis mier uaryofiTi damokidebuleba enurezisadmi, dRisiT gamoyofili Sardis maqsimaluri moculoba <45%, stresuli mdgomareoba rogorc bavSvis, ise mSoblis, fsiqologiuri problemebi, yuradRebis deficitis sindromi

sqesi (Ib), asaki( Ib), Catarebuli mkurnaloba (Ib), demografiuli faqtori (Ib), socialuri mdgomareoba (Ib), bavSvis cudi sacxovrebeli garemo (Ib)

cxrili #7

faqtorebi, romlebic ganapirobeben desmopresinis arCevas

dadebiTi gavlena uaryofiTo gavlena gavlenas ar axdens

sveli Rameebis mcire raodenoba

dRisiT moSarduli Sardis maqsimaluri moculobaa 75 %, hiperkalciuria RamiT. (IV)

sqesi, ojaxuri anamnezi (Ib), mSoblebis damokidebuleba enurezisadmi, Ramis ganmavlobaSi Casvelebis raodenoba, yuradRebis deficiti, motivacia, Catarebuli mkurnaloba, demografiuli faqtori, Sardis osmolaroba

17

sqess ar aqvs prognozuli mniSvneloba arc desmopresiniT da arc gangaSis sistemiT Terapiis dawyebisas [A].

asaks ar aqvs gadamwyveti mniSvneloba mkurnalobis meTodis arCevisas [A].

ojaxur anamnezs ar aqvs mniSvneloba mkurnalobis meTodis arCevisas [B].

SeniSvnebi:

1. Tu mkurnalobis mizania simSralis miReba drois mokle monakveTSi, rekomendebulia desmopresinis maqsimaluri dozis gamoyeneba.

2. rodesac mkurnalobis mizani sruli gankurnebaa, nebismieri meTodis gamoyenebisas 2-4 kviriani intervaliT unda ganxorcieldes perioduli Semowmeba motivaciis Sefasebis mizniT, pacientis wasaxaliseblad, medikamenturi mkurnalobis dros ki - dozis titraciisTvis.

3. dReisaTvis ar arsebobs mtkicebuleba romelic adasturebs romelime meTodis upiratesobas. gadawyvetileba gangaSis sistemis an desmopresinis gamoyenebis Sesaxeb erToblivad unda iqnes miRebuli pacientisa da eqimis mier.

4. im SemTxvevaSi, rodesac gangaSis sistema gamoiyeneba, mizani pacientisa da misi ojaxisTvis motivaciis SenarCunebaa.

5. mkurnalobis periodSi umciresi progresic ki (simSrale, TanamSromloba) waxalisebuli unda iqnes. Tu sawyisi warmateba ver iqna miRweuli 3-4 TveSi, xolo gangaSis sistemis gamoyenebis SemTxvevaSi - ufro adre an bavSvs aqvs gamoRviZebis problema, mkurnalobis saukeTeso saSualeba desmopresinia. Tu ukve daniSnul desmopresinze ar aRiniSneba reaqcia, saWiroa mkurnalobis Sewyveta, ganmeorebiTi Sefaseba an referali urologTan.

6. desmopresinis gamoyenebisas wylis raodenoba unda SeizRudos erT Wiqamde saRamos. mowodebulia desmopresiniT mkurnalobis 2 sqema (ix.zemoT).

7. struqturirebuli Sewyvetis ganxorcieleba (ix. cxrili #8).

8. rodesac orive saxis mkurnalobis erTi an ramdenime cikli uSedegoa, mizani xdeba stresis Semcireba an mkurnaloba droebiT unda gadaidos.

9. gaxangrZlivebuli mkurnaloba (Tveebi an wlebi, saWiroebis mixedviT) perioduli Semowmebis gareSe an motivaciuri Terapia sasargebloa araefeqturi mkurnalobis, rTuli ojaxuri mdgomareobis, cudi prognozuli faqtorebis gavlenis Sesamcireblad. mkurnaloba unda Sewydes periodulad 1-2 kviriT (mag: yovel 3-6 TveSi), raTa Sefasdes pacientis mdgomareoba mkurnalobis gareSeE da, saWiroebisas, gakeTdes referali urologTan.

18

cxrili #8 struqturirebuli Sewyveta. mkurnalobis dReebSi desmopresini iniSneba im doziT, ra doziTac mivaRwieT

sawyis warmatebas; sxva dReebSi pacienti medikamentis nacvlad unda waxalisdes warmatebiT

kvira orSabaTi samSabaTi oTxSabaTi xuTSabaTi paraskevi SabaTi

pirveli kvira desm. _ desm. desm. _ desm. _

meore kvira desm. desm. _ desm. _ _ desm.

mesame kvira _ desm. _ _ desm. _ desm.

meoTxe kvra desm. desm. desm. _ _ desm. _

mexuTe kvira _ desm. _ _ desm. _ _

meeqvse kvira _ _ _ _ _ desm. _

meSvide kvira _ _ desm. _ _ _ desm.

merve kvira _ _ _ desm. _ _ _

mecxre kvira _ _ _ _ _ _ _

meaTe kvira _ _ _ _ _ _ _

desm.- desmopresini

19

meoreuli da aramonosimptomuri enurezis mkurnaloba

enurezis gamomwvevi raime samedicino problemis ararsebobis SemTxvevaSi tardeba pirveladi enurezis Sesabamisi mkurnaloba. pacientebis umravlesobaSi enkoprezTan asocirebuli enurezis an dRis sisvelis dros, nawlavTa treiningi an Sekrulobis prevencia dRis sisveles amcirebs 89%-iT, xolo enurezis sixSires 63% - iT.

anamnezSi qceviTi problema, Zilianoba dRisiT, gadidebuli adenoidebisa da tonzilebis fonze, SeiZleba miuTiTebdes Zilis obstruqciuli apnoes arsebobaze. haergamtari gzebis qirurgiuli koreqcia aumjobesebs Ramis enurezs da dRis sisveles an saerTod kurnavs maT.39. fsiqogenuri enurezis dros efeqturia individualuri fsiqoTerapia da ojaxuri Terapia. bavSvebSi Sardvis imperatiuli surviliT, Sardis normaluri nakadiT, Sardis buStis mcire tevadobiT (urodinamikuri testis Sedegebis mixedviT) da gamosaxulebiTi kvlevis normaluri suraTiT, efeqturia antiqolinergiuli mkurnaloba28. is SeiZleba efeqturi iyos agreTve bavSvebSi dRis da Ramis Sardis SeukaveblobiT da desmopresinis araefeqturobisas8,17,28.

prevencia

miuxedavad imisa, rom ar aris cnobili moqmedebs Tu ara CamoTvlili RonisZiebebi Ramis simSralis uzrunvelyofaze, rekomendebulia [C]:

tualetis treiningis dawyeba 18 Tvis asakamde, maSin, rodesac SesaZloa bavSvi iRviZebdes mSrali safeniT.

Sesabamisi qoTnis gamoyeneba (romelzec bavSvis barZayebi da terfebi saTanadod daeyrdnoba).

SeTavazeba bavSvisTvis moSardos maSinve, rogorc ki moSardvis survili gauCndeba. sasurvelia es gakeTdes pirvelive cdaze. ar unda darCes bavSvi qoTanze sanam ar moSardavs da ar unda daatanos Tavs Zala, Tu pirvel jerze ver moSardavs.

rCeva-darigebis micema mSoblebisTvis, iqonion moTmineba treiningis dros, vinaidan mizani 3 TveSi miiRweva. ar cvalon meTodebi.

7. eTikur-samarTlebrivi sakiTxebi

enurezis marTva samedicino eTikis principebis dacviT unda

ganxorcieldes. mniSvnelovania pacientis avtonomiis dacva da pacientisa da misi ojaxis wevrebis an meurvis Tanamonawileoba

problemis gadaWris gzebis Ziebisas.

20

8. praqtikaSi adaptaciis da protokolis SemuSavebis

rekomendaciebi

rekomendaciebi gaidlainis implementaciis Sesaxeb

gaidlainis danergvis (implementaciis) xelSemwyobi faqtorebi

donori organizaciebis, dargobrivi asociaciebis, Sjsd saministros Tanadgoma da finansuri mxardaWera;

pirveladi jandacvis profesionalebis did nawils ukanaskneli 5-10 wlis manZilze gavlili aqvs mzadebis intensiuri kursi (rezidenturis moklevadiani kursi specialobaSi `saojaxo medicina~).

diplomamdeli da diplomisSemdgomi ganaTlebis saswavlo programebSi gaidlainis CarTva.

mosalodneli barierebi gaidlainis danergvis procesSi

gangaSis sistemebis xelmiuwvdomloba;

eqimebisadmi mimarTvianobis dabali done arsebul realobasTan SedarebiT, risi mizezic aris problemis gauTviTcnobiereba mosaxleobis mxridan da stigma;

damkvidrebuli praqtika da tradiciebi samedicino personals Soris.

gaidlainis implementaciis rekomendebuli meTodebi

gaidlainebis gavrceleba/xelmisawvdomobis uzrunvelyofa

gaidlainis da Tanmxlebi masalebis xelmisawvdomobis uzrunvelyofa internetis gziT, asociaciis veb-gverdi, saministro da a.S.

gaidlainebis nabeWdi da kompiuteruli versiebis (kompaqtdiskze) gamravleba da samizne kontingentSi maTi gavrceleba.

ganaTleba da treiningi

saganmanaTleblo masalebis gavrceleba.

gaidlainis integrireba ojaxis eqimTa diplomisSemdgomi samedicino ganaTlebis (rezidenturis) programebSi, maT Soris moklevadiani (gadamzadebis) programaSi;

gaidlainze dafuZnebuli uwyveti samedicino ganaTlebis programebis SemuSaveba ojaxis eqimebisTvis.

saxelmwifo sasertifikacio gamocda;

gaidlainebze dafuZnebuli kiTxvarebis CarTva saxelmwifo sasertifikacio gamocdebis testebSi specialobaSi `saojaxo medicina~

21

profesiuli konsensusis miRweva

pirveladi jandacvis profesionalebis, nevrologebis, pediatrebis da enurezis marTvaSi CarTuli profesionalebis erToblivi konferenciebis da klinikuri SemTxvevebis ganxilvebis organizeba.

sazogadoebis informireba

pacientebisaTvis sainformacio broSurebis momzadeba gaidlainSi asaxuli rekomendaciebis Sesaxeb da maTi farTod gavrceleba. es komponenti mniSvnelovania mSoblebis mozidvisa da enuresis gamo adekvaturi mimarTvianobis uzrunvelsayofad.

sadazRvevo kompaniebis informireba:

sadazRvevo kompaniebma unda gaiTvaliswinon erovnuli gaidlainiT gaTvaliswinebuli sakiTxebi resursebis ganawilebisa da xarisxis monitoringis procesSi.

klinikuri praqtikis auditis kriteriumebi:

1. ramden SemTxvevaSia Semowmebuli 5 wlisa da meti asakis bavSvebi enurezis arsebobaze rutinuli vizitis dros?

2. ramden SemTxvevaSia Sekrebili enurezisTvis specifikuri anamnezi enureziT daavadebul bavSvebSi?

3. ramden SemTxvevaSia Catarebuli saTanado fizikuri gamokvleva? 4. ramden SemTvevaSia Sefasebuli enureziT daavadebuli bavSvis

fsiqologiuri mdgomareoba? 5. ramden SemTxvevaSia Catarebuli aucilebeli laboratoriul-

instrumentuli gamokvlebebi(Sardis saerTo analizi, sisxlis saerTo analizi) pirveladi enurezis SemTxvevaSi?

6. ramden SemTxvevaSia Catarebuli saWiro laboratoriul-instrumentuli gamokvlebebi meoreuli enurezis SemTxvevaSi?

7. ramden SemTxvevaSia Canaweri pacientis istoriaSi pacientis da misi mSoblebis ganaTlebis Sesaxeb?

8. ramden SemTxvevaSia dawyebuli sworad aramedikamenturi mkurnaloba (motivaciuri Terapia, “mSrali loginis treiningi”, Sardis buStis treiningi, maRviZara saaTi, gangaSis sistema)?

9. ramden SemTxvevaSi dainiSna sworad farmakologiuri mkurnaloba (7 wlisa da meti asakis bavSvebi, rodesac arafarmakologiuri mkurnaloba araefeqturia)?

10. ramden SemTxvevaSi iyo dawyebuli farmakologiuri mkurnaloba pirveli rigis medikamentiT desmopresiniT?

11. ramden SemTxvevaSia dawesebuli monitoringi? 12. ramden SemTxvevaSia enurezi kontrolirebadi? 13. ramden SemTxvevaSia enurezi arakontrolirebadi?

22

9. gaidlainis miRebis xerxi/wyaro

gaidlaini warmoadgens sxvadasxva gaidlainebis (ix. literatura) Sejerebis da adaptaciis Sedegs.

mtkicebulebis done da rekomendaciebis xarisxi

done mtkicebulebis done xaris-

xi rekomendaciis xarisxi

I

Zlieri mtkicebuleba, eyrdnoba minimum erT sistemur mimoxilvas, romelic efuZneba swori dizainis mqone randomizebul kontrolirebad kvlevas

A

eyrdnoba I donis mtkicebulebas da Sesabamisad mtkiced rekomendebulia

II eyrdnoba kohortul kvlevebs

B

eyrdnoba II da III donis mtkicebulebas da Sesabamisad rekomendebulia

III

eyrdnoba SemTxveva-kontrolis kvlevebs

C

eyrdnoba IV donis mtkicebulebas, SeiZleba CaiTvalos Sesabamisad

IV eyrdnoba SemTxvevaTa seriebs

D

eyrdnoba V donis mtkicebulebas, saWiroebs konsesuss

V eyrdnoba eqspertTa varauds

10. alternatiuli gaidlaini ar arsebobs

11. gamoyenebuli literatura

American academy of family physicians. Evaluation and treatment of enuresis 2008

1. Nevйus T, von Gontard A, Hoebeke P, et al. The standardization of terminology of lower urinary

tract function in children and adolescents:report from the Standardisation Committee of the

International Children’s Continence Society. J Urol. 2006;176(1):314-324.

2. Fritz G, Rockney R, Bernet W, et al. Practice parameter for the assessment and treatment of children

and adolescents with enuresis. J Am Acad Child Adolesc Psychiatry. 2004;43(12):1540-1550.

3. Stein MA, Mendelsohn J, Obermeyer WH, Amromin J, Benca R. Sleep and behavior problems in

school-aged children. Pediatrics. 2001;107 (4):E60.

4. Bower WF, Moore KH, Shepherd RB, Adams RD. The epidemiology of childhood enuresis in

Australia. Br J Urol. 1996;78(4):602-606.

5. Miller K. Concomitant nonpharmacologic therapy in the treatment of primary nocturnal enuresis. Clin

Pediatr (Phila). 1993;Spec No:32-37.

23

6. Robson WL, Leung AK. Secondary nocturnal enuresis. Clin Pediatr (Phila). 2000;39(7):379-385.

7. Chiozza ML, Bernardinelli L, Caione P, et al. An Italian epidemiological multicentre study of

nocturnal enuresis. Br J Urol. 1998;(81 suppl 3): 86-89.

8. Hjalmas K, Arnold T, Bower W, et al. Nocturnal enuresis: an international evidence based

management strategy. J Urol. 2004;171(6 pt 2): 2545-2561.

9. Nevйus T. The role of sleep and arousal in nocturnal enuresis. Acta Paediatr. 2003;92(10):1118-

1123.

10. von Gontard A, Schaumburg H, Hollmann E, Eiberg H, Rittig S. The genetics of enuresis: a review. J

Urol. 2001;166(6):2438-2443.

11. Hublin C, Kaprio J, Partinen M, Koskenvuo M. Nocturnal enuresis in a nationwide twin cohort.

Sleep. 1998;21(6):579-585.

12. Center for Health Information Management and Evaluation. Missouri monthly vital statistics. Sexual

abuse and the SAFE-CARE data. Jefferson City, Mo.: Missouri Dept. of Health and Senior Services;

2001. www.dhss.mo.gov/FOCUS/Oct2001.pdf. Accessed November 26, 2007.

13. Robson WL, Leung AK, Van Howe R. Primary and secondary nocturnal enuresis: similarities in

presentation. Pediatrics. 2005;115(4):956-959.

14. McGrath KH, Caldwell PH, Jones MP. The frequency of constipation in children with nocturnal

enuresis: a comparison with parental reporting. J Paediatr Child Health. 2008;44(1-2):19-27.

15. von Gontard A, Mauer-Mucke K, Plьck J, Berner W, Lehmkuhl G. Clinical behavioral problems in

day- and night-wetting children. Pediatr Nephrol. 1999;13(8):662-667.

16. Baeyens D, Roeyers H, Demeyere I, Vertй S, Hoebeke P, Vande Walle J. Attention-

deficit/hyperactivity disorder (ADHD) as a risk factor for persistent nocturnal enuresis in children: a

two-year follow-up study. Acta Paediatr. 2005;94(11):1619-1625.

17. Bedwetting. Paediatric Society of New Zealand. Best practice evidence based guideline. Nocturnal

enuresis. http://www.paediatrics.org.nz/ documents/2005%20documents%20denise/guidelines/

Enuresis%20guideline%20final%20endorsed.pdf. Accessed November 26, 2007.

18. Swerdlin A, Berkowitz C, Craft N. Cutaneous signs of child abuse. J Am Acad Dermatol.

2007;57(3):371-392.

19. Canadian Paediatric Society. Community Paediatrics Committee. Management of primary nocturnal

enuresis. Paediatrics & Child Health. 2005;10(10):611-614.

20. Cendron M. Primary nocturnal enuresis: current concepts. Am Fam Physician. 1999;59(5):1205-1214,

1219-1220.

21. Glazener CM, Evans JH, Peto RE. Treating nocturnal enuresis in children: review of evidence. J

Wound Ostomy Continence Nurs. 2004; 31(4):223-234.

22. Glazener CM, Evans JH. Simple behavioural and physical interventions for nocturnal enuresis in

children. Cochrane Database Syst Rev. 2004; (2):CD003637.

23. Glazener CM, Evans JH, Peto RE. Complex behavioural and educational interventions for nocturnal

enuresis in children. Cochrane Database Syst Rev. 2004;(1):CD004668.

24. Glazener CM, Evans JH, Peto RE. Alarm interventions for nocturnal enuresis in children. Cochrane

Database Syst Rev. 2005;(2):CD002911.

25. Yagci S, Kibar Y, Akay O, et al. The effect of biofeedback treatment on voiding and urodynamic

parameters in children with voiding dysfunction. J Urol. 2005;174(5):1994-1997.

26. Glazener CM, Evans JH, Peto RE. Tricyclic and related drugs for nocturnal enuresis in children.

Cochrane Database Syst Rev. 2003;(3):CD002117.

27. Evans JH. Evidence based management of nocturnal enuresis [published correction appears in BMJ.

2002;324(7329):98]. BMJ. 2001;323 (7322):1167-1169.

28. Nevйus T. Oxybutynin, desmopressin and enuresis. J Urol. 2001; 166(6):2459-2462.

29. Glazener CM, Evans JH, Peto RE. Drugs for nocturnal enuresis in children (other than desmopressin

and tricyclics). Cochrane Database Syst Rev. 2003;(4):CD002238.

30. Glazener CM, Evans JH. Desmopressin for nocturnal enuresis in children. Cochrane Database Syst

Rev. 2002;(3):CD002112.

24

31. Kruse S, Hellstrцm AL, Hanson E, Hjдlmеs K, Sillйn U. Treatment of primary monosymptomatic

nocturnal enuresis with desmopressin: predictive factors. BJU Int. 2001;88(6):572-576.

32. Riccabona M, Oswald J, Glauninger P. Long-term use and tapered dose reduction of intranasal

desmopressin in the treatment of enuretic children. Br J Urol. 1998;(81 suppl 3):24-25.

33. Bradbury MG, Meadow SR. Combined treatment with enuresis alarm and desmopressin for nocturnal

enuresis. Acta Paediatr. 1995;84(9):1014-1018.

34. Robson WL, Leung AK, Norgaard JP. The comparative safety of oral versus intranasal desmopressin

for the treatment of children with nocturnal enuresis. J Urol. 2007;178(1):24-30.

35. Thumfart J, Roehr CC, Kapelari K, Querfeld U, Eggert P, Mьller D. Desmopressin associated

symptomatic hyponatremic hypervolemia in children. Are there predictive factors? J Urol.

2005;174(1):294-298.

36. Mellon MW, McGrath ML. Empirically supported treatments in pediatric psychology: nocturnal

enuresis. J Pediatr Psychol. 2000;25(4):193-214.

37. El-Anany FG, Maghraby HA, Shaker SE, Abdel-Moneim AM. Primary nocturnal enuresis: a new

approach to conditioning treatment. Urology.1999;53(2):405-408

38. Loening-Baucke V. Urinary incontinence and urinary tract infection and their resolution with

treatment of chronic constipation of childhood. Pediatrics. 1997;100(2 pt 1):228-232.

39. Firoozi F, Batniji R, Aslan AR, Longhurst PA, Kogan BA. Resolution of diurnal incontinence and

nocturnal enuresis after adenotonsillectomy in children. J Urol. 2006;175(5):1885-1888.

European Association of Urology. Monosimptomatic Enuresis.In: Guidlines on Peadiatric Urology.

2008

Evidence-based clinical practice guidelines: primary monosymptomatic nocturnal enuresis in

primary care.(Spanish Association of Primary Pediatrics

12. avtorTa jgufi

klinikuri praqtikis erovnuli rekomendacia (gaidlaini) momzadda saqarTvelos ojaxis eqimTa asociaciis mier

avtorebi:

nino gelaSvili (ojaxis eqimi), rusudan CitaiSvili (ojaxis eqimi), gia meliqiSvili (bavSvTa nevrologi), givi javaSvili (redaqtori), guram kiknaZe (redaqtori).

eqspertebi:

pediatr-nefrologTa asociacia;

saqarTvelos saojaxo medicinis profesionalTa kavSiri;

lela woworia _ saqarTvelos Sromis, janmrTelobisa da socialuri dacvis saministros janmrTelobis dacvis departamenti;

Tea TavidaSvili _ saqarTvelos Sromis, janmrTelobisa da socialuri dacvis saministros janmrTelobis dacvis departamenti.