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56 CPD ACTIVITY ENURESIS hesitancy, need to strain to void. • Abnormally low or high daytime voiding frequency. • These children require different management plans compared with those with MSE.3 Background The attainment of nighttime continence is a normal development milestone in children.1 The age this milestone is achieved varies between individuals.1 It’s a general expectation that children will be dry at night by the development age of five years.4 Active management and therapy is recommended from the age of six years if bedwetting is still occurring.3 Most children who experience bedwetting have no significant physical or emotional issues.1 Younger children should not be excluded from the management of bedwetting based on age alone.4 Assessing and diagnosing bedwetting in children and young people History taking is important. Factors to consider include:3,4 • Any issues with meeting growth and development milestones. • Weight loss. • Nausea. • Excessive thirst with a need to drink at nighttime (diabetes?). • Has the bedwetting started in the past few days or weeks? If so, is there a contributing systemic illness?4 • Has the child been dry for the past six months without assistance or aids, but has now commenced wetting the bed? • Is the bed wet every night or less frequently? • Have there been prolonged dry periods? • Is there daytime incontinence? • Does the child experience urgency? Genetics • Do they have voiding issues, eg, a weak stream of urine or straining to void. • Is there a history of previous urinary tract infections? • What are their bowel habits like? Is there constipation? Overflow faecal staining? • Is there heavy snoring or sleep apnoea? • Does the child have daytime drowsiness? Yawn a lot? • Does the child have behavioural issues, eg, poor concentration at school or poor social interaction with peers. • Which therapies have already been tried? » Did they work? » How adherent was the family with interventions and treatment? • Is there a family history of wetting the bed? (Enuresis has a genetic link)1,3 Doctors and parents both need to consider possible medical, emotional or physical triggers.4 Assessment of possible triggers will determine the treatment required.4 Enuresis may be due to a combination of issues, including:3,6 • Nocturnal urine production exceeding 130 per cent of expected bladder capacity. • Nocturnal bladder storage capacity. • Overactive bladder. • The ability to rouse the child from sleep. It’s speculated that children who wet the bed sleep heavily and well, but studies have also shown they have poor sleep quality.3,6 There are links in bedwetting children to having enlarged tonsils and adenoids (adenotonsillar hypertrophy), which in turn causes poor sleep quality due to sleep disordered breathing.6 The child may develop bedwetting because of their poor sleep patterns. Studies show that about 50 per cent of children with enuresis become dry by undergoing adenotonsillectomy.3 There are several theories linked to the relationship between adenotonsillar hypertrophy and enuresis. These include:3 • Constant arousal stimuli from the Karalyn Huxhagen Karalyn is a community pharmacist from Mackay, Queensland. Also an accredited consultant pharmacist, Karalyn performs medication reviews, delivers quality-use-of- medication programs and provides support services to groups such as the Mackay Regional Pain Support Group. Karalyn’s interests include pain management, asthma and COPD, aged care, wound care, travel medicine, chronic-disease programs and the health of Aboriginal, Torres Strait and South Sea Islander people. She is credentialled to provide Mental Health First Aid and immunisation services. In 2010 Karalyn was recognised with the Australia Day award for services to the health of the Mackay community. LEARNING OBJECTIVES After completing this CPD activity, pharmacists should be able to: • Describethecausesofenuresis (bedwetting) in children. • Describechildrenmostatrisk of enuresis. • Outlinenon-pharmacologicaland pharmacological treatment options for enuresis. • Identifywhentoreferchildrenwith enuresis for further assessment. 2016 Competency Standards: 3.1, 3.2. Accreditation Number: A2102RP2 (exp: 31/01/2023). Definition Based on clinical assessment the classification system of enuresis is:1,2,3,6 a) Monosymptomatic enuresis (MSE). b) Non-monosymptomatic enuresis (NMSE). MSE is defined as enuresis without any other lower urinary tract symptoms or history of bladder dysfunction. MSE is usually divided into primary and secondary enuresis.1 Primary monosymptomatic enuresis (PMSE) is when the child has never had bladder control at night and has always wet the bed.2,6 Secondary monosymptomatic enuresis (SMSE) is when the child has had bladder control at night for a period of six months but has lost control and now wets the bed again.2,3,6 Children in the NMSE group may have the following medical conditions in addition to their bedwetting:3 • Daytime incontinence. • Voiding difficulties – poor stream, Factors favouring micturition ??? Constipation Detrusor overactivity Underlying CNS disturbance High diuresis Bladder distension Inadequate arousal mechanisms Frequent arousal stimuli (disturbed sleep) Obstructed airways Behavior factors? RETAIL PHARMACY • JAN/FEB 2021 2 CPD CREDITS Factors protecting against micturition Adequate arousal mechanisms Figure 1. A hypothetical diagram of enuresis pathogenesis.5