nocturnal enuresis

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Page 1: Nocturnal Enuresis
Page 2: Nocturnal Enuresis

•Nocturnal enuresis:Nocturnal enuresis: is is uncontrolled uncontrolled urination at nighturination at night after the after the age of 5 years in girls and 6 years age of 5 years in girls and 6 years in boys.in boys.

• It is more frequent in boys than It is more frequent in boys than girls,girls, a ratio of 2:1 reflecting a ratio of 2:1 reflecting developmental variations.developmental variations.

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Enuretics have been divided Enuretics have been divided into:into: primary and secondary,primary and secondary,

depending on whether depending on whether continence has ever been continence has ever been achieved.achieved. About 10% of all those About 10% of all those suffering from enuresis suffering from enuresis

also wet in the daytime.also wet in the daytime.

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• There isThere is a strong familial a strong familial aspectaspect to nocturnal enuresis:to nocturnal enuresis:

• IIf f both parentsboth parents have a history of enuresis, have a history of enuresis,

there is an approximately there is an approximately 75%75% chance that 1 or chance that 1 or more of their children will be enuretic.more of their children will be enuretic.

• If If 1 parent 1 parent had enuresis there is about a had enuresis there is about a 40% 40% chance that a child in that family will be enuretic.chance that a child in that family will be enuretic.

• If If neither parentneither parent was enuretic, the was enuretic, the

risk decreases to risk decreases to 15%.15%.

Page 5: Nocturnal Enuresis

• In the infant, micturition In the infant, micturition occurs spontaneously as occurs spontaneously as

a spinal cord reflex.a spinal cord reflex.• The young infant The young infant sleepssleeps for for

almost almost 60% of the day,60% of the day, and and approximately approximately 40% of the 40% of the voids occur during sleep.voids occur during sleep.

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• Pathogenesis:Pathogenesis:• Nocturnal EnuresisNocturnal Enuresis is a is a

• Multifactorial condition,Multifactorial condition,The theoretical causes The theoretical causes include: include:

• 1- Premature training.1- Premature training.• 2- Insufficient training.2- Insufficient training.• 3- Emotional disturbance.3- Emotional disturbance.

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• 4- Alteration in circadian 4- Alteration in circadian antidiuretic hormone, antidiuretic hormone, (ADH) secretion. (ADH) secretion.

• 5- Sleep disturbances.5- Sleep disturbances.

• 6- And / or a delay in 6- And / or a delay in adequate adequate neuromuscular neuromuscular bladder bladder control.control.

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• RarelyRarely physical lesions physical lesions may be found in may be found in enurtics, such as:enurtics, such as:

• 1- Spina bifida.1- Spina bifida.• 2- 2- Obstructive lesionObstructive lesion of the of the distal distal

urinary outflow tract,urinary outflow tract, such as:such as:

urethral valve, urethral valve, or U. stenosis.or U. stenosis.

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• 3- Urinary tract infection.3- Urinary tract infection.

• 4- Diabetes Mellitus.4- Diabetes Mellitus.

• 5- Diabetes insipidus.5- Diabetes insipidus.

• 6- Chronic renal disease.6- Chronic renal disease.

• 7- Nervous system 7- Nervous system dysfunction. dysfunction.

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• In infancy In infancy micturitionmicturition is is controlled at the controlled at the spinal cord spinal cord level,level, with little influence with little influence from the higher centers; from the higher centers;

• Thus when the bladder is full Thus when the bladder is full

it will it will spontaneously spontaneously empty empty with no thought for with no thought for the time and place.the time and place.

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• Under normal circumstances, Under normal circumstances, bladder trainingbladder training starts in most starts in most children between the age of children between the age of

18 and 24 months, and is 18 and 24 months, and is usually completed by the age usually completed by the age of 3-4 years.of 3-4 years.

• Accidents of bed wetting should Accidents of bed wetting should be tolerated until the age of 5 be tolerated until the age of 5 years in girls, and 6 in boys. years in girls, and 6 in boys.

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•Classic treatment is Classic treatment is one of:one of:

• 1- Imiprmine hydrochloride, 1- Imiprmine hydrochloride, (Tofranil).(Tofranil).

• 2- Desmopressin acetate, 2- Desmopressin acetate, (Minirin).(Minirin).

• 3- 3- AnticholinergicAnticholinergic drugs e.g., drugs e.g., emeponium bromide emeponium bromide (Cetiprin).(Cetiprin).

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Recently,Recently, In 1996 we put In 1996 we put forward forward a new concept, based on a new concept, based on evidence explaining the act of evidence explaining the act of micturition and urinary micturition and urinary continence.continence.

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Micturition can be Micturition can be

divided into divided into 22 stages: stages:Stage-I:Stage-I: in Infancy before in Infancy before

bladder training.bladder training.Stage-II: Stage-II: in childhood after in childhood after

bladder training, (how bladder training, (how to control).to control).

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• TheThe Second stage of Second stage of micturition,micturition, ( how to control)( how to control) ::

• It is an It is an acquired behavioracquired behavior gained gained by learning and training in early by learning and training in early childhood how to maintainchildhood how to maintain a a high alpha sympathetic tone at high alpha sympathetic tone at the internal urethral sphincter, the internal urethral sphincter, thus keeping it closed all the thus keeping it closed all the timetime until voiding is needed or until voiding is needed or desired. desired.

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•Urinary continence Urinary continence depends depends on on two two main main factors:factors:

**one inherent, one inherent, and and **one acquired.**one acquired.

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• II -*The inherent factor -*The inherent factor• is the presence of is the presence of an an intact and intact and

strong strong internal urethral internal urethral sphincter.sphincter.

The internal sphincter is aThe internal sphincter is a collageno-collageno-

-muscular tissue -muscular tissue cylindercylinder that that

extends extends from the bladder neck down from the bladder neck down to the perineal membrane. to the perineal membrane.

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• II**The acquired factor:II**The acquired factor:• (Second stage of micturition)(Second stage of micturition) It is an acquired behavior gained by It is an acquired behavior gained by

learning and training in early childhood learning and training in early childhood

how to maintainhow to maintain a high alpha a high alpha sympathetic tone,(T10-L2), at sympathetic tone,(T10-L2), at the internal urethral sphincter, the internal urethral sphincter, thus keeping it closed all the thus keeping it closed all the timetime until voiding is needed or until voiding is needed or desired. desired.

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NORMAL INTERNAL URETHRAL SPHINCTER.NORMAL INTERNAL URETHRAL SPHINCTER.

3-D. ULTRASONOGRAPHY

U.B. U.B.

Closed urethradue to a strong,

intact int. u. sphincter

Page 20: Nocturnal Enuresis

Closed lumen

Intact wall, compact sheet of collagenous tissue

with muscle fibers lie on and intermingle with

the collagen fibers In the

middle part of the cylinder

3D U.S.Cross section

Page 21: Nocturnal Enuresis

Urethra.

Vagina.

Urethral lumen.

Collag. Collag. tissue tissue cylindercylinder..

Muscle layer.

MRI picture of a normal continent MRI picture of a normal continent woman.woman.

N. Internal Urethral sphincter outlined by N. Internal Urethral sphincter outlined by MRI.MRI.

Page 22: Nocturnal Enuresis

U.B.

Uterus.

Vagina.

MRI picture of a normal continent MRI picture of a normal continent womanwoman

Post. Wall Post. Wall of internal of internal urethral urethral sphincter sphincter intimately intimately related to related to the the anterior anterior vaginal vaginal wallwall

CloseClosed d

UrethUreth..

lumenlumen. . Ant.Ant.

WallWall

Of Of thethe

Sph.Sph.

Page 23: Nocturnal Enuresis

Functional disturbances,Functional disturbances,and/or and/or

Structural damage, Structural damage,

of the internal urethral of the internal urethral sphinctersphincter will lead to will lead to

Urinary incontinence,Urinary incontinence, And Voiding Troubles.And Voiding Troubles.

Page 24: Nocturnal Enuresis

Functional disturbance:Functional disturbance:(3)(3) 1.1.Failure to gainFailure to gain the acquired behavior of the acquired behavior of

having high alpha sympathetic tonehaving high alpha sympathetic tone,,

completely, or partially.completely, or partially.

Nocturnal Nocturnal Enuresis. Enuresis.

2.2. SympatheticSympathetic over activity over activity,, e.g., e.g., pain, spinal cord lesion.pain, spinal cord lesion. Retention of Retention of

urine; overflow incontinence. urine; overflow incontinence.

3. 3. SympatheticSympathetic failure failure e.g., severe fear, e.g., severe fear, deep anesthesiadeep anesthesia

Transient U.I.Transient U.I.

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Page 26: Nocturnal Enuresis

Severe Severe

fear,fear,

Transient U. Transient U. incontinence.incontinence.

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• Failure to gain the acquired Failure to gain the acquired high alpha-sympathetic tonehigh alpha-sympathetic tone (T10-L2) will leave micturition as a spinal (T10-L2) will leave micturition as a spinal cord reflex, as in early infancy and the full cord reflex, as in early infancy and the full bladder will empty spontaneously.bladder will empty spontaneously.

• ( = complete failure.)( = complete failure.)

this condition is rather this condition is rather rare, enuresis will be by rare, enuresis will be by both day and night. both day and night. (About 10% (About 10%

of all enuretics).of all enuretics).

Page 28: Nocturnal Enuresis

• More frequently More frequently there isthere is a partial a partial gain gain of alpha-sympathetic tone,of alpha-sympathetic tone, which will which will

be sufficient for good control and urinary be sufficient for good control and urinary continence during the daytime, continence during the daytime, but it will fail but it will fail during sleep.during sleep.

• There There may be may be NNoo sleep disturbance, sleep disturbance, but but falling asleep will cause loss of the acquiredfalling asleep will cause loss of the acquired rather rather weak control weak control over the internal urethral sphincter, over the internal urethral sphincter, allowing uncontrolled emptying of the bladder. allowing uncontrolled emptying of the bladder.

• ( Nocturnal Enuresis = Partial ( Nocturnal Enuresis = Partial failure;failure; 90% of enuretics) 90% of enuretics)

Page 29: Nocturnal Enuresis

• Giving an alpha- Giving an alpha- -sympathomemitic -sympathomemitic drug e.g., ephedrine drug e.g., ephedrine hydrochloride,hydrochloride,

• will increase the tone of will increase the tone of the internal urethral the internal urethral sphincter,sphincter,

• thereby preventing thereby preventing uncontrolled urination.uncontrolled urination.

Page 30: Nocturnal Enuresis

• Ephedrine is a non-catechol Ephedrine is a non-catechol amine sympathomemitic drug amine sympathomemitic drug

that has that has a dual actiona dual action::

• 1-it acts on the sympathetic 1-it acts on the sympathetic receptors, as a stimulant, receptors, as a stimulant, (agonist).(agonist).

• 2- it also 2- it also stimulate the alpha stimulate the alpha nerve endingsnerve endings to produceto produce

nor-epinephrine.nor-epinephrine.

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3-Ephedrine3-Ephedrine may also may also

stimulate the stimulate the sleep centre,sleep centre,

• preventing rapid preventing rapid falling into deep falling into deep sleep.sleep.

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• It is the second action, It is the second action, (stimulate the alpha-(stimulate the alpha-sympathetic nerve sympathetic nerve endings to produce endings to produce nor-epinephrine), nor-epinephrine), that cause that cause complete cure.complete cure.

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• At birth At birth the parasympathetic the parasympathetic systemsystem

• is the dominantis the dominant division of division of the autonomic nervous system.the autonomic nervous system.

• As one grows up, As one grows up, repeated repeated everyday life stresseseveryday life stresses increase the sympathetic increase the sympathetic tone,tone, which gradually takes the which gradually takes the upper hand. upper hand.

Page 34: Nocturnal Enuresis

• This explainsThis explains the reports of anthe reports of an annual spontaneous cureannual spontaneous cure rate rate of about of about 15%15% in those suffering in those suffering nocturnal enuresis.nocturnal enuresis.

•However nocturnal However nocturnal enuresis may persist enuresis may persist into adolescence and into adolescence and adult life.adult life.

Page 35: Nocturnal Enuresis

• Side effects of ephedrine,Side effects of ephedrine, as: as:

1-1- cardio-vascular stimulationcardio-vascular stimulation

will bewill be minimum minimum because ofbecause of the young agethe young age of the of the patients with their healthy, elastic, patients with their healthy, elastic, high capacity and highly adaptable high capacity and highly adaptable

compliant vessels and heart.compliant vessels and heart.

Page 36: Nocturnal Enuresis

Other side effects, as:Other side effects, as:

2-2- nervous system nervous system stimulation, an analeptic stimulation, an analeptic effect,effect, is an advantage as is an advantage as those patients are usually those patients are usually

deep sleepers.deep sleepers. However, it can be avoided by However, it can be avoided by

giving the evening dose giving the evening dose at bed at bed time.time.

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• Other minor side effects, Other minor side effects, include:include:

• 3-Anorexia, and upper 3-Anorexia, and upper abdominal discomfortabdominal discomfort usually usually disappears after few days disappears after few days spontaneously.spontaneously.

• 4-Occasional slight frontal 4-Occasional slight frontal headache, headache, can be relieved by can be relieved by simple analgesics. simple analgesics.

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• References:1- Dalton R. Vegetative disorders. In Nelson WE, Behrman RE, Kliengman RM,

Arvin AM, eds. Nelson Textbook of pediatrics. Phildaephia: WB Saunders, 1996;79-86.

2- Steers WD, Bawrett DM, Wein AJ. Voiding dysfunction: diagnosis, classification, and management. In: Gillenwater JY, Howards SS, Grayhack JT, Dukett JW , eds. Adult and pediatric urology, 3rd edn. St. Louis:

Mosby, 1996; 1220-1325.

3-Galdamone AA, Shulman S. Robinwitz R. Primary nocturnal enuresis. In: Gillenwater JY, Hoowarks SS, Grayhack JT, Duckett JW eds. Adult and pediatric urology, 3rd edn. St Louis: Mosby, 1966; 2728-2729.

4- Weighal JW. Detrusor sphincteric dyssynergia. In: Ashcraft K.W. ed. Pediatric urology. Philadelphia: WB Saunders, 1990; 175-210

5-Gongalez R. Urinary incontinence. In: Kelalis, King LR, Belman AB eds. Clinical Pediatric Urology, Philadelphia, WB Saunders, 1992: 285-390.

6- Wein AJ. Neuromuscular dysfunction of the lower urinary tract. In: Walsh PC, Retick AB, Stamy TA, Vaughan ED Jr, eds. Campbell’s urology, 6th edn. WB Saunders, 1992; 571-613.

7- Ganong W. Arousal mechanism, sleep and electrical activity of the brain. In: Review of medical physiology, 16th edn. Norwalk, Connecticut: Appleton & Lange, 1993; 173-182.

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8-Shmitt BD. Nocturnal enuresis: an update on treatment. Pediatr Clin North Am

1982;29:21-25 9-El Hemaly AKMA, Mousa L.A. Micturition and Urinary Continence. Int J 9-El Hemaly AKMA, Mousa L.A. Micturition and Urinary Continence. Int J

Gynecol Obstet 1996; 42: 291-2. Gynecol Obstet 1996; 42: 291-2. 10-El Hemaly AKMA, Mousa L.A.E. Stress Urinary Incontinence, a New Concept. 10-El Hemaly AKMA, Mousa L.A.E. Stress Urinary Incontinence, a New Concept.

Eur J Obstet Gynecol Reprod Biol 1996;68: 129-35. Eur J Obstet Gynecol Reprod Biol 1996;68: 129-35. 11-El Hemaly AKMA. Nocturnal Enuresis: Pathogenesis and11-El Hemaly AKMA. Nocturnal Enuresis: Pathogenesis and Treatment. Treatment. Int Urogynecol J Pelvic Floor Dysfunct 1998;9: 129-31. Int Urogynecol J Pelvic Floor Dysfunct 1998;9: 129-31. 12- Abdel Karim M. El Hemaly, Ibrahim M Kandil, Mohamed M. Radwan.12- Abdel Karim M. El Hemaly, Ibrahim M Kandil, Mohamed M. Radwan. Urethro-raphy a new technique for surgical management of Stress Urinary Urethro-raphy a new technique for surgical management of Stress Urinary

Incontinence.Incontinence. http://www.obgyn.net/urogyn/urogyn.asp?page=/urogyn/articles/new-tech-http://www.obgyn.net/urogyn/urogyn.asp?page=/urogyn/articles/new-tech-urethrourethro

13- Abdel Karim M. El Hemaly, Ibrahim M Kandil, Mohamad A. Rizk, Nabil Abdel 13- Abdel Karim M. El Hemaly, Ibrahim M Kandil, Mohamad A. Rizk, Nabil Abdel Maksoud H., Mohamad M. Radwan, Khalid Z. El Shieka, Mohamad A. K. M. El Maksoud H., Mohamad M. Radwan, Khalid Z. El Shieka, Mohamad A. K. M. El Hemaly, and Ahmad T. El Saban.Hemaly, and Ahmad T. El Saban.Urethro-raphy The New Operation for the treatment of stress urinary incontinence, Urethro-raphy The New Operation for the treatment of stress urinary incontinence, SUI, detrusor instability, DI, and mixed-type of urinary incontinence; short and SUI, detrusor instability, DI, and mixed-type of urinary incontinence; short and long term results. long term results. http://www.obgyn.net/urogyn/urogyn.asp?page=urogyn/articles urethroraphy-092804urethroraphy-092804

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14- El Hemaly AKMA, Kandil I. M. Stress Urinary Incontinence SUI facts and fiction. Is SUI a puzzle?!

http://www.obgyn.net/displayppt.asp?page=/English/pubs/features/

presentations/El-Hemaly/el-hemaly-ss

15- Abdel Karim El Hemaly, Nabil Abdel Maksoud, Laila A. 15- Abdel Karim El Hemaly, Nabil Abdel Maksoud, Laila A. Mousa, Ibrahim M. Kandil, Asem Anwar, M.A.K El Hemaly and Mousa, Ibrahim M. Kandil, Asem Anwar, M.A.K El Hemaly and Bahaa E. El Mohamady. Bahaa E. El Mohamady. Evidence based Facts on the Pathogenesis and Management Evidence based Facts on the Pathogenesis and Management of SUI. of SUI. http://www.obgyn.net/displayppt.asp?page=/English/pubs/features/presehttp://www.obgyn.net/displayppt.asp?page=/English/pubs/features/presentations/El-Hemaly02/el-hemaly02-ssntations/El-Hemaly02/el-hemaly02-ss

16- Abdel Karim M. El Hemaly, Ibrahim M Kandil, and Bahaa 16- Abdel Karim M. El Hemaly, Ibrahim M Kandil, and Bahaa E. El Mohamady. Menopause, and Voiding troubles. E. El Mohamady. Menopause, and Voiding troubles. http://http://www.obgyn.net/www.obgyn.net/displayppt.asp?page=/English/pubs/features/displayppt.asp?page=/English/pubs/features/presentations/El-Hemaly03/el-hemaly03-sspresentations/El-Hemaly03/el-hemaly03-ss

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• 17- Abdel Karim M. El Hemaly*, Ibrahim M. Kandil, Mohamad A. Rizk and Mohamad A.K.M.El Hemaly.

• Urethro-plasty, a Novel Operation based on a New Concept, for the Treatment of Stress Urinary Incontinence, S.U.I., Detrusor Instability, D.I., and Mixed-type of Urinary Incontinence.

• http://www.obgyn.net/urogyn/urogyn.asp? page=/urogyn/articles/urethro-plasty_01 18- Abdel Karim M. El Hemaly. Urinary incontinence in gynecology, a review

article.http://www.obgyn.net/urogyn/urogyn.asp?page=/urogyn/articles/abs-http://www.obgyn.net/urogyn/urogyn.asp?page=/urogyn/articles/abs-urinary_incotinence_gyn_ehemalyurinary_incotinence_gyn_ehemaly

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