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60 CPD ACTIVITY FROM PAGE 59 Imipramine may be started with desmopressin.3 Alternatives to imipramine such as atomoxetine or reboxetine may be trialled for their antienuretic effect.3 Other interventions Nocturnal polyuria non-responsive to desmopressin may respond to: • Dietary salt reduction. • Combining a diuretic in the morning with the desmopressin in the evening. A specialist in the field of enuresis may use combinations of various medications to find the best treatment for the patient.3 Specialists may use therapies such as botulinum toxin injections or peripheral electrical stimulation into the detrusor muscle for very resistant cases. These options have the best outcome in NMSE.3 When to refer bedwetting children for further assessment The South African guidelines on enuresis (2017) provides a good summary of pharmacotherapy for betwetting. (Figure 3).6 Referral to a doctor should occur if:1 • The child has daytime lower urinary tract symptoms. • Bedwetting continues even though the child displays awareness of toileting needs and they are unable to not wet themselves during the day and the night. If the child is resistant to alarm therapy and desmopressin, referral to a paediatrician or paediatric urologist may be required.3 A complex investigation will need to occur to determine complications that affected the outcome of the therapy. For example: • The parents did not respond to the alarm quickly and wake the child. • Parents did not use the alarm every night. • Constipation was not investigated. • Behavioural issues and comorbidities affected compliance with therapy. • A high evening salt and/or protein intake may negatively affect the desmopressin. The child will be physically examined, and a voiding chart review will occur. Treatment resistant children may undergo non-invasive urodynamic investigation with flowmetry and residual urine measurement.3 There are many devices now available to perform this testing using wireless technology, though some centres still use specialised potties and toilet systems. Investigating a small child, especially with behavioural problems, can be extremely difficult. Urodynamics can give the treating doctor information such as pathological curves or post-void residual volumes on repeated voids. These findings lead to further investigations to determine whether there is an issue of: • Anatomic obstruction. • Neurogenic bladder. Anticholinergic therapy would not be given to these patients.3 As discussed, treatment resistant children need to be investigated for constipation and/or bowel obstruction and sleep-disordered breathing. Some children will need psychologist or psychiatrist intervention and behaviour management programs. Most bedwetting issues and daytime enuresis can be managed by supportive family units and the family doctor. The more resistant cases will require referral to a specialist in this field. Accreditation number: A2102RP2 (exp: 31/01/2023). References 1. Enuresis:BedwettingandMonosymptomatic Enuresis. The Royal Children’s Hospital Melbourne Clinical Guideline. Accessed 24/11/20. 2. Bedwetting in Children and Teens: Nocturnal Enuresis. Healthychildren.org. Accessed 24/11/20. 3. Nevéus T, et al. ‘Management and treatment of nocturnal enuresis: An updated standardisation document from the International Children’s Continence Society’. Journal of Paediatric Urology, 2020; 16: 10-19. 4. ‘Bedwetting in under 19s’. NICE Clinical Guideline, October 2010. Updated October 2020. 5. Nevéus T. ‘Pathogenesis of enuresis: Towards a new understanding’. International Journal of Urology 2017. doi.org/10.1111/iju.13310 6. Adam A, Claasen F, et al. The South African guidelines on enuresis (2017). African Journal of Urology, 2018; 23: 1-13. 7. Daily Bladder Diary. Monash Children’s Hospital. Enuresis 2 CPD CREDITS RETAIL PHARMACY • JAN/FEB 2021 This activity has been accredited for 1 hour of Group One CPD (or 1 CPD credit) suitable for inclusion in an individual pharmacist’s CPD plan, which may be converted to 1 hour of Group Two CPD (or 2 CPD credits) upon successful completion of the associated assessment activity. 1. Which of the following was NOT described as a probable contributor to bedwetting in children? A) Constipation. B) Adenotonsillar hypertrophy. C) Gastroesophageal reflux. D) Overactive bladder. 2. Whichofthefollowingisariskfactorfordevelopingenuresisasachild? A) Being of Caucasian decent. B) Having a genetic link to bedwetting. C) Being underweight at birth. D) Not being breastfed at birth. 3. Whichofthefollowingarerecommendedmethodsforreducingtheincidence of bedwetting in children under five years? A) If the child wakes at night, lift and carry them to the toilet. B) Using bed protection measures. C) Supporting the parents to initiate daytime toilet training. D) All the above. 4. Whichsymptomwouldbeconsideredaredflagandcausereferraltoadoctor? A) Enuresis on intermittent nights. B) Child is crying when woken up to toilet at scheduled times. C) Daytime lower urinary tract symptoms. D) Child is continent during the day but not the night. 5. WhichofthefollowingstatementsaboutdesmopressinisINCORRECT? A) It reduces nighttime urine production to allow the bladder to better accommodate the volume. B) About one third of children will be reliably dry and another third intermittently dry, but one third of children will have no response. C) It should be taken in the morning, 60 minutes after waking. D) A trial of tapering the dose can be considered when the child has been dry for an acceptable period. 6. Which of the following statements about oxybutynin is INCORRECT? A) It relaxes bladder smooth muscle to reduce urinary urgency and frequency. B) Constipation, faecal overload and post-void residual volume must be excluded before therapy can be initiated. C) It is taken at bedtime and therapy monitored for one to two months as it may not be effective immediately. D) It is contraindicated with desmopressin.