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17-01-2010

Evaluation/Treatment of Monosymptomatic Enuresis

Neveus et al (page 441) report on a multi-institutional collaborative project from the International Children’s Continence Society on establishing a basic foundation for the evaluation and treatment of children with monosymptomatic enuresis (MNE). The authors indicate that this clinical problem can be managed by primary care physicians and the intent of the article is to provide the primary care physician or nurse practitioner with a foundation for management and treatment. When treating MNE it is critical to rule out other confounding factors such as daytime lower urinary tract symptoms, urinary infections and constipation. While the etiology of MNE is multifactorial, the 3 components that have a primary influence are nocturnal polyuria, detrusor overactivity and increased arousal thresholds.
The basis for treatment begins with understanding the problem, and the importance of a careful and complete history obtained from the child with corroborative information from the parent to eliminate comorbid conditions that potentially result in therapeutic resistant nocturnal enuresis. A history of daytime voiding with a weak stream, straining to void or continuous incontinence should trigger a referral to a specialized center. Diagnostic testing can initially be limited to urinalysis specifically looking for glucosuria, proteinuria, polyuria and bacteriuria. Routine ultrasonography is not typically necessary. A diary of voiding habits before initiation of therapy is helpful.
Treatment is approached in a basic and systematic fashion beginning with the importance of changing general lifestyle, diet and voiding patterns. Specific options of the nocturnal enuretic alarm, desmopressin, anticholinergics and tricyclic antidepressants are discussed along with the advantages, disadvantages and guidelines for each modality. The authors also provide recommendations of how to treat the therapy resistant child. While there is little evidence-based medicine to support any of the treatment plans, the recommendations are based on best practice management by leaders in the major pediatric urology societies. This is a logical approach to take for children with MNE and serves as an excellent resource for primary care colleagues.
The Journal of Urology
Volume 183, Issue 2, February 2010, Pages 414-415

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