Enuresis primary

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 ... 

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... 

Because it is stable, desmopressin is preferred for treatments especially if pressor effects are not desired. The primary indication for therapy is central diabetes insipidus, a disorder that results when ADH secretion is reduced and that is characterized by polydipsia, polyuria, and dehydration. Desmopressin is also used to reduce primary nocturnal enuresis, or bedwetting, in children. It is useful in people with mild hemophilia A or with some types of von Willebrand s disease, in which von Willebrand s factor is present at low levels. In these cases, desmopressin is given when excessive bleeding occurs or before surgery to help reduce bleeding indirectly by increasing the amounts of coagulation factors. 

A review of 18 controlled studies in otherwise typically developing children (Moffatt et ah, 1993) demonstrated that only about 24% of children were completely dry while on medication and that 94% relapsed after medication was discontinued. In the Swedish Enuresis Trial (SWEET), 399 children aged 6-12 years with primary enuresis participated in an open, multicenter trial of DDAVP (Tullus et ah, 1999). Subjects were observed for 4 weeks and had their DDAVP dose titrated over 6 weeks (20 0 pg), followed by a 1-year long-term treatment period. A total of 245 children (61%) experienced a 50% or more reduction in the number of wet nights, with resolution of enuresis in 77 children. The greatest therapeutic effect was observed in children 6-7 years of age. There were no studies on the effectiveness of DDAVP in children with MR. 

Tullus, K., Bergstron, R., Fosdal, I., Winnergard, I., and Hjalmas, K. (1999) Efficacy and safety during long-term treatment of primary monosymptomatic nocturnal enuresis with desmopressin. Acta Paediatr. 88 1274-1278. 

Lavigne and colleagues (1996), using categorical approaches with a community sample of 3860 preschoolers aged 2-5 years in a primary care pediatric sample, found the five most frequent axis I diagnoses (DSM IITR) to be ODD (17%), ADHD (2%), avoidant disorder (0.7%), overanxious disorder (0.7%), simple phobia (0.6%), and functional enuresis (0.7%). Five percent of children also met criteria for parent-child relational... 

Klackenberg, G. (1981) Nocturnal enuresis in a longitudinal perspective. A primary problem of maturity and/or a secondary environmental reaction Acta Paediatr Scand 70 453-457. 

Ornitz, E.M., Russell, A.T., Gabikian, R, Gehricke, J.G., and Guthrie, D. (2000) Prepulse inhibition of startle, intelligence and familial primary nocturnal enuresis. Acta Paediatr 89 475-481. 

About 900 000 children with primary nocturnal enuresis are treated with tablets and 400 000 with spray annually. Hyponatremia is rare (42), possibly as low as 1 per 20 000 patients exposed. 

A 37-year-old woman with primary enuresis continued her customary daily fluid intake (2 liters) when she started intranasal desmopressin 30 micrograms at night. Within 2 days she became severely hyponatre-mic, with loss of consciousness, generalized seizures, and cerebral edema. 

Hjalmas K, Hanson E, Hellstrom AL, Kruse S, Sillen U. Long-term treatment with desmopressin in children with primary monosymptomatic nocturnal enuresis an open multicentre study. Swedish Enuresis Trial (SWEET) Group. Br J Urol 1998 82(5) 704-9. 

Apakama DC, Bleetman A. Hyponatraemic convulsion secondary to desmopressin treatment for primary enuresis. J Accid Emerg Med 1999 16(3) 229-30. 

Desmopressin is used for the therapy of diabetes insipidus (AVP deficiency), primary nocturnal enuresis and von Willebrand disease (p. 152) it is given by injection or via the nasal mucosa (as snuff ). 

Indications Primary nocturnal enuresis Category Antidiuretic hormone analog Half-life 75 minutes... 

The essential feature of enuresis is repeated involuntary or intentional voiding of urine by day or night that is not caused by a general medical condition (Table 61-7). Medical causes of inappropriate voiding (e.g., diabetes mellitus, diabetes insipidus, seizure disorders, or urinary tract infections) should be ruled out. Enuresis may be primary or secondary. Primary enuresis, the most common type, is diagnosed if the child has never established urinary continence. Secondary enuresis follows an established period (3 to 6 months) of urinary continence. 

Teaching continence skills and various behavioral and conditioning methods remain the primary treatments for enuresis, and drug treatment remains a secondary approach. Combined treatment with an enuresis alarm and desmopressin may be successful for severe enuresis. ... 

Monda JM, Husmann DA. Primary nocturnal enuresis A comparison among observation, imipramine, desmopressin acetate and bedwetting alarm systems. J Urol 1995 154 745-748. 

Ginrpel GA, Warzak WJ, Kuhn BR, Walburn JN. Clinical perspectives in primary nocturnal enuresis. CUn Pediatr 1998 37 23—30. 

Janknegt RA, Zweers HM, Delaere KP, et al. Oral desmopressin as a new treatment modaUty for primary nocturnal enuresis in adolescents and... 

Desmopressin is a posterior pituitary hormone that has antidiuretic effects that decrease urinary volume and inaease urine osmolality. It is indicated in control of primary nocturnal enuresis control of central aanial diabetes insipidus and maintenance of hemostasis in patients with hemophilia A and type 1 von Willebrand disease during surgery and postoperatively. 

Another Vj receptor-mediated application is the use of desmopressin for primary nocturnal enuresis. Bedtime administration of desmopressin intranasal spray or tablets provides a high response rate that is sustained with long-term use, that is safe, and that accelerates the cure rate. Desmopressin also relieves post-lumbar puncture headache, probably by causing water retention and thereby facditating rapid fluid equilibration in the CNS. 

Vasopressin 1 Desmopressin (V2 selective) Neurogenic (pituitary) diabetes insipidus Hemophilia A (T factor VIII from liver) von Willebrand disease (T vW factor from endothelium) Primary nocturnal enuresis... 

Nervous system The safety of desmopressin in children with primary monosjmiptomatic nocturnal enuresis has been reviewed [86 ]. After 61 cases of seizures, including two deaths, the FDA asked that the prescribing information be changed in 2007 to state that desmopressin spray is no longer indicated for monosymptomatic nocturnal enuresis or in patients at risk of hyponatremia. The authors of the review concluded that hyponatremia often resulted from inappropriately high doses of desmopressin and usually occurs in the elderly people they supported continuing the use of desmopressin to treat monosymptomatic nocturnal enuresis imder appropriate medical supervision. Hyponatremia has been reported more commonly with the spray than with the oral formulation this may reflect differences in pharmacokinetics or more extensive evaluation of the spray. 

Van de Walle J, Van Herzeele C, Raes A. Is there still a role for desmopressin in children with primary monosymptomatic nocturnal enuresis A focus on safety issues. Drug Saf 2010 33(4) 261-71. 

We do not perform VCU for monosymptomatic, primary nocturnal enuresis or initially in children with daytime and nighttime wetting in the absence of severe urge, urge incontinence or UTI. 

In primary monosymptomatic enuresis nocturna and in children with minor wetting before treatment and without irritative voiding symptoms and without urinary tract infection, VCU should not be performed. 

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