Enuresis

OPC-51803 is a highly selective V2R agonist and may prove useful for the treatment of CDI, urinary incontinence, enuresis and pollakiuria. It has a much higher bioavailability after oral application than desmopressin. 

Diabetes insipidus, hemophilia A, von Willebrand s disease, nodurnal enuresis... 

Non-REM parasomnias have variable prevalence rates depending on patient age and different diagnoses. Sleep talking, brux-ism, sleepwalking, sleep terrors, and enuresis occur more frequently in childhood than in adulthood. Nightmares appear to occur with similar frequency in adults and children. REM behavior disorder (RBD), an REM-sleep parasomnia, has a reported prevalence of 0.5% and frequently is associated with concomitant neurologic conditions.16 Chronic RBD is more common in elderly men and may have a familial disposition. 

The pathogenesis of parasomnias (e.g., sleepwalking, enuresis, sleep talking) is variable and not well described and involves... 

Parasomnias are characterized by undesirable physical or behavioral phenomena that occur during sleep [e.g., sleepwalking, sleep talking, bruxism (grinding of teeth), enuresis, night terrors, and RBD]. RBD patients act out their dreams during sleep, often in a violent manner. 

Explain the pathophysiology of the major types of urinary incontinence (urge, stress, overflow, and functional) and pediatric enuresis. 

List the treatment goals for a patient with urinary incontinence or pediatric enuresis. 

Considering that pharmacotherapy is inferior to select non-pharmacologic treatment modalities in pediatric enuresis, pharmacotherapy will be most valuable in patients who are not candidates for nonpharmacologic therapy due to nonadherence or who do not achieve the desired outcomes on nonpharmacologic therapy alone. 

Desmopressin is the first-line drug choice in pediatric enuresis. 

In UUI, the detrusor (bladder) muscle is overactive and contracts inappropriately during the filling phase. The amount of urine lost per episode can be as large as the entire contents of the bladder may empty. Sleep may be disrupted by nocturia and enuresis. 

Urinary frequency (greater than 8 micturitions/day), urgency with or without urge incontinence nocturia (greater than or equal to 2 micturitions/night) and enuresis may be present as well. 

Recurrent coughing, urinary incontinence, dyspareunia, vaginal itching, multiple UTIs (-) nocturia, enuresis, urgency, dysuria, frequency, lower abdominal fullness, decreased force of stream... 

The American Academy of Child and Adolescent Psychiatrists and the International Children s Continence Society (ICCS) have published practice guidelines for the assessment and treatment of pediatric enuresis.24,25... 

Five to seven million children and adolescents in the United States suffer from nocturnal enuresis. Primary enuresis is twice as common as secondary enuresis. Enuresis is twice as common in boys as compared to girls. The incidence of enuresis varies as a function of age24,25 ... 

Five to ten percent of children with enuresis will suffer the condition as adults. It may also predispose to UUI in adults. In the enuretic population, 80% to 85% are monosymptomatic, 5% to 10% are polysymptomatic, and under 5% have an organic cause. The spontaneous annual cure rate (i.e., restoration of continence) ranges from 14% to 16% (exception at about 4 or 5 years of age, it may be as high as 30%). 

The etiology of enuresis is poorly understood, but there is a clear genetic link. The incidence in children from families in whom there are no members with enuresis, where one parent had enuresis as a child, and where both parents had enuresis as children are 14%, 44%, and 77%, respectively. Loci for enuresis have been located on chromosomes 12,13, and 22. Sleep disorders are not considered major contributors with the exception of sleep apnea. Enuresis occurs in all sleep stages in proportion to the time spent in each stage. However, a small proportion of individuals are not aroused from sleep by bladder distention and have uninhibited bladder contractions preceding enuresis. 

The vast majority of children with enuresis have normal uro-dynamics, including nocturnal bladder capacity. Functional bladder capacity can be estimated using this formula age in years + 2 = ounces of capacity. In some children, there appears to be a relationship between developmental immaturity (motor and language milestones) and enuresis, but the mechanism is unknown. Drugs like lithium, clozapine, risperidone,... 

Proper assessment of the child or adolescent with enuresis should explore every aspect of urinary incontinence, especially the genitourinary and nervous systems. The minimum assessment should include24 25 ... 

Interview of child and parent(s), being sensitive to the emotional consequences of the enuresis... 

TABLE 50-5. Major Potentially Treatable Organic Causes of Enuresis... 

In the absence of an identified cause and comorbidities, monosymptomatic nocturnal enuresis is present which can be amenable to nonpharmacologic and pharmacologic therapies. Nonpharmacologic therapy should be utilized initially, provided that the patient and family are sufficiently motivated. Use of one nonpharmacologic method at a time is reasonable, provided that each is given an adequate trial period. If response is suboptimal after 6 months, a different method should be substituted or added. There is some evidence to... 

The two primary agents used to treat enuresis are desmopressin and imipramine (Table 50-7). Desmopressin is the drug of choice in pediatric enuresis. Anticholinergics have a limited role (Table 50-7). Other agents have been studied with inconclusive results.28... 

Oxybutynin has no significant effect in monosymptomatic nocturnal enuresis. Oxybutynin and related agents (see adult UI section of this chapter) should be used only if the patient has concurrent daytime urgency or frequency. 

Most of the comparisons between treatments have been made by means of meta-analyses conducted by the Cochrane Enuresis Collaborative.28,30,32-34 Unfortunately, most enuresis treatment studies have been so poorly designed they compromise the... 

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