Summary of The Practice Parameter For The Assessment And Treatment Of Children And Adolescents With Enuresis | American Academy of Child & Adolescent Psychiatry

Summaries

Summary of The Practice Parameter For The Assessment And Treatment Of Children And Adolescents With Enuresis

ABSTRACT
Enuresis is a symptom that is frequently encountered in child psychiatric evaluations. Careful assessment is required to identify specific urologic, developmental, psychosocial, and sleep-related etiologies. For most children with enuresis, however, a specific etiology cannot be determined. Treatment then involves supportive approaches, conditioning with a urine alarm, or medications ¾ imipramine or desmopressin acetate. The psychosocial consequences of the symptom must be recognized and addressed with sensitivity during the evaluation and treatment of enuresis.

Key words: practice parameters, practice guidelines, child and adolescent psychiatry, enuresis, bedwetting

ATTRIBUTION
The parameter was developed by Gregory Fritz, M.D. and Randy Rockney, M.D., and the Work Group on Quality Issues: William Bernet, M.D., Chair, Valerie Arnold, M.D., Joseph Beitchman, M.D., R. Scott Benson, M.D., Oscar Bukstein, M.D., Joan Kinlan, M.D., Jon McClellan, M.D., David Rue, M.D., Jon Shaw, M.D., and Saundra Stock, M.D., AACAP staff: Kristin Kroeger Ptakowski.

This summary and the full text of it is available to AACAP members on the World Wide Web (www.aacap.org) and appears in a future supplement to the JAACAP. This parameter was made available to the entire AACAP membership for review in September 2001 and was approved by the AACAP Council in June 2002. Reprints requested by the AACAP Communications Department, 3615 Wisconsin Ave., NW, Washington, D.C. 20016.

INTRODUCTION
Enuresis is a common psychosomatic symptom that presents both alone and in conjunction with other disorders in children and adolescents. It is a symptom with a number of possible etiologies. A variety of treatments that span the boundaries of child psychiatry, psychology, pediatrics, and urology have been shown to be effective. The complexity in both assessment and treatment associated with what often appears to be a benign and common symptom suggests the utility of practice parameters for clinicians confronting the problem in their patients.

These guidelines are applicable to the evaluation and treatment of child and adolescent patients. This document presumes a basic medical background in pathophysiology and familiarity with normal child development and the principles of child psychiatric diagnosis. An Executive Summary follows immediately; the main text of the practice parameter is presented subsequently.

EXECUTIVE SUMMARY
This summary provides an overview of the assessment and treatment recommendations contained in the Practice Parameter for the Assessment and Treatment of Children and Adolescents With Enuresis. This summary includes many of the most important points and recommendations that are in these practice guidelines. However, the treatment and assessment of enuretic patients requires the consideration of many important factors that cannot be conveyed fully in a summary, and the reader is encouraged to review the entire document. Each recommendation in the executive summary is identified as falling into one of the following categories of endorsement, indicated by an abbreviation in brackets following the statement. These categories indicate the degree of importance or certainty of each recommendation.

"Minimal Standards" [MS] are recommendations that are based on substantial empirical evidence (such as well-controlled, double-blind trials) or overwhelming clinical consensus. Minimal standards are expected to apply more than 95% of the time, i.e., in almost all cases. When the practitioner does not follow this standard in a particular case, the medical record should indicate the reason.

"Clinical Guidelines" [CG] are recommendations that are based on empirical evidence (such as open trials, case studies) and/or strong clinical consensus. Clinical guidelines apply approximately 75% of the time. These practices should always be considered by clinicians, but there are exceptions to their application.

"Options" [OP] are practices that are acceptable but not required. There may be insufficient empirical evidence to support recommending these practices as minimal standards or clinical guidelines. In some cases they may be the perfect thing to do, but in other cases they should be avoided. If possible, the practice parameter will explain the pros and cons of these options.

"Not Endorsed" [NE] refers to practices that are known to be ineffective or contraindicated.

DEFINITIONS
Enuresis is defined in the DSM-IV-TR as the repeated voiding of urine into the bed or clothes at least twice a week for at least 3 consecutive months in a child who is at least 5 years of age. The DSM-IV-TR definition also considers a child to be enuretic if the frequency or duration is less but there is associated distress or functional impairment. Nocturnal enuresis refers to voiding during sleep; diurnal enuresis defines wetting while awake. Primary enuresis occurs in children who have never been consistently dry through the night, while secondary enuresis refers to the resumption of wetting after at least 6 months of dryness.

ETIOLOGY AND CLINICAL PRESENTATION
There is a clear genetic component to enuresis. Compared with a 15% incidence of enuresis in children from nonenuretic families, 44% and 77% of children were enuretic when one or both parents, respectively, were themselves enuretic. Data are accumulating that link foci on two chromosomes with enuresis.

Sleep studies have demonstrated a random pattern of wetting that occurs in all stages of sleep in proportion to the amount of time spent in each stage. A subgroup of enuretic patients has been identified in whom there is no arousal to bladder distension and an unusual pattern of uninhibited bladder contractions prior to the enuretic episode. The dysfunctional arousal system during sleep may be a key etiologic factor for this subgroup of children. One specific sleep disorder, sleep apnea stemming from upper airway obstruction, has been associated with enuresis.

Developmental immaturity, including motor and language milestones, is relevant in the etiology of enuresis for some children, although the mechanism is unknown.

Identifiable psychological factors are clearly contributory in a minority of children with enuresis. These children are most frequently secondary enuretics who have experienced a stress, such as parental divorce, school trauma, sexual abuse, or hospitalization; their enuresis is a regressive symptom in response to the stress or trauma. Psychological factors can also be seen as etiologically central in the rare instance in which family disorganization or neglect has resulted in there never having been a reasonable effort made at toilet training. Other signs of neglect are usually evident in these cases.

ASSESSMENT
When enuresis is identified, either as the chief complaint or as an incidental part of an evaluation for another problem, the psychiatric assessment must be expanded to include enuresis-specific elements [MS]. In every instance both the parents and the child should be interviewed, and sensitivity to the emotional consequences of the symptom should be high. The enuresis-specific history should explore every aspect of urinary incontinence, with thorough review of the genitourinary and neurologic systems [MS]. A thorough physical examination is essential; enlarged adenoids or tonsils, bladder distension, fecal impaction, genital abnormalities, spinal cord anomaly, and neurologic signs should be noted [MS]. Routine laboratory tests need only include urinalysis and possibly urine culture; more invasive tests are pursued only with specific indications [CG]. First-morning specific gravity may be helpful in predicting who will respond to desmopressin acetate (DDAVP) treatments [OP]. A 2-week baseline record of wet and dry nights is useful [CG].

TREATMENT
Treatment is based on the findings of the assessment. Positive findings on history, physical examination, or laboratory tests are indications for specific treatments. Daytime wetting, abnormal voiding (unusual posturing, discomfort, straining, or a poor urine stream), a history of urinary tract infections or evidence of infection on urinalysis or culture, and genital abnormalities are indications for urologic referral and treatment [MS]. A history of constipation, encopresis, or palpable stool impaction suggests mechanical pressure on the bladder. Disimpaction and treatment leading to a healthy bowel regimen will often eliminate the enuresis [CG]. Snoring and enlarged tonsils or adenoids may signal sleep apnea and indicate specific treatment. Surgical correction of upper airway obstruction has led to improvement or cure of enuresis [CG].

Psychosocial problems directly contributory to enuresis (as opposed to co-occurring with or resulting from the symptom) are relatively rare. Enuresis can be assumed to be of psychological origin when a previously dry child begins wetting during a period of stress (parental divorce, out-of-home placement, school trauma, abuse, hospitalization, etc.). At an early age, control struggles between parent and child may focus on urination patterns as a "battlefield"; this struggle serves to maintain the enuresis symptom as the child matures. In the uncommon instance in which family disorganization or neglect has resulted in a failure to toilet train the child, the symptom is seen to have psychosocial etiology. Individual psychotherapy, crisis intervention, and family therapy are specific psychological treatments applied on an individual basis [CG]. Effective treatment of the underlying psychological problem eliminates the enuresis in such cases.

When the history and physical examination do not suggest a specific etiology and the urinalysis results are completely normal, uncomplicated monosymptomatic primary nocturnal enuresis is treated with nonspecific approaches. Supportive approaches should always include education, demystification, and ensuring that parents do not punish the child for enuretic episodes [MS]. Journal keeping, fluid restriction, and night awakening may also fit in the category of nonspecific supportive approaches [OP].

Conditioning, using a modern, portable, battery-operated alarm ¾ along with a written contract, thorough instruction, frequent monitoring, overlearning, and intermittent reinforcement before discontinuation ¾ makes this behavioral treatment highly effective as the first line of treatment with cooperative, motivated families [MS].

Two medications, imipramine and DDAVP, have proven efficacy in the treatment of enuresis [OP]. Imipramine in a single bedtime dose of 1 to 2.5 mg/kg has been used for many years if conditioning treatment fails or is not feasible. Many studies document 40% to 60% effectiveness, although the relapse rate is as high as 50%. The mechanism of action of imipramine in treating enuresis is unknown and not conclusively related to blood level. Because of the possibility of cardiac arrhythmia associated with tricyclic antidepressants, including imipramine, a pretreatment electrocardiogram may be obtained to detect an underlying rhythm disorder (even though the highest dose used to treat enuresis is lower than the dose commonly used to treat depression).

DDAVP is a synthetic analog of the antidiuretic hormone (ADH) vasopressin, which decreases urine production at night when taken at bedtime. It is administered intranasally as a spray in doses of 10 to 40 mg (1-4 sprays) nightly; the lowest effective dose is determined empirically with each child. DDAVP is also available in 0.2-mg tablets applied in doses of 0.2 to 0.6 mg nightly. Water intoxication is a rare side effect but is serious enough to merit electrolyte monitoring if intercurrent illness complicates the picture during treatment [CG]. Studies of DDAVP have reported success rates of 10% to 65% and relapse rates as high as 80%. DDAVP can be prescribed for short periods, such as when the child is going to camp. Long-term administration has not been associated with depression of endogenous ADH secretion. The combination of DDAVP and a sustained-release anticholinergic agent may be more effective than DDAVP alone [OP].

Bladder-stretching exercises to increase functional bladder capacity have been used without consistent evidence of effectiveness, and the effort not to void despite considerable urgency is unpleasant for both the child and the family [NE]. Despite anecdotal reports, there is no empirical evidence to suggest efficacy of hypnotherapy, dietary manipulation, and desensitization to allergens [NE].

REFERENCE
American Academy of Child and Adolescent Psychiatry (2002), Practice Parameter for the Assessment and Treatment of Children and Adolescents with Enuresis, (in press)