Pediatric Enuresis

How long should a patient taper off of Desmopressin to prevent relapse?

2 weeks!

What can Desmopressin be combined with for treatment?

Alarm therapy

Which of the following treatments for pediatric enuresis has the lowest relapse rate after an adequate duration of trial?

Awakening from sleep before enuresis episodes

Which of the following agents is most appropriate for managing atonic bladder?

Bethanechol

What is the first thing you should assess with pediatric enuresis?

Careful screening to rule out functional/mechanical obstruction and constipation

Which of the following statements is true regarding pediatric enuresis?

Children should drink no more than 8 oz (240 ml) of fluid 1 hour before to 8 hours after taking oral desmopressin

Patient Education with Desmopressin

Hyponatremia symptoms and when to seek treatment Fever, increased exercise, etc. = could lead to electrolyte imbalances and when to seek treatment

What route is not recommended for pediatric enuresis?

Intranasal Form is not recommended for pediatric enuresis * Children taking intranasal desmopressin to treat bed-wetting are "particularly susceptible to severe hyponatremia and seizures", states the FDA

If rapid-onset and/or short-term dryness is a priority AND alarm treatment is considered undesirable AND alarm treatment is considered inappropriate, what treatment do you add to behavioral modifications?

Offer DDAVP (desmopressin) as initial therapy for subjects older than 7 years and consider it in 5-7 year olds

In an older male with diagnosed symptomatic benign prostatic hyperplasia, addition of which of the following may lead to acute urinary retention?

Pseudoephedrine and Oxybutynin

Monitoring with Pediatric Enuresis

Symptom Relief: - Daily diary > Number of dry nights/weeks > Accidents: number of nights with 2+ enuresis episodes - QOL AEs and adherence

MOA of Desmopressin

Synthetic analogue of vasopressin Antidiuretic!

Stimulation of muscarinic cholinergic receptors in the bladder muscle may be responsible for?

Urge incontinence and Bladder overactivity

Goals of Therapy with Pediatric Enuresis

- Reduced number of enuresis episodes - Restoration on continence - Prevention of relapse - Prevention of complications - Minimize AEs and cost - Improve QOL of child and caregivers

At what age is Desmopressin recommended?

7 years or older Can be considered in 5-7 year olds

If child is young with some dry nights, what treatment do you add to behavioral modifications?

Add reward system alone --> Reward for agreed-upon behaviors, NOT dry nights!! --> Do not penalize/punish/remove rewards previously gained for failure of agreed-upon behaviors

Therapeutic Use of Desmopressin?

DOC for pediatric enuresis (after first degree management fails) Can decrease episodes of bed-wetting by one episode per week

Which of the following is the best initial choice for preventing bedwetting in a child who plans to go for a sleepover at a friend's house?

Desmopressin

AEs with Desmopressin

Dilutional hyponatremia and seizures Must educate patient on symptoms of hyponatremia: - Nausea, vomiting, dizziness, fatigue, muscle cramps - Must contact provider if they have these symptoms Electrolyte imbalance

Which one of the following drug-induced incontinence pairs is correct?

Enalapril / stress incontinence

If the enuresis is not due to obstruction or constipation, what is the next step?

Ensure intake of adequate daily fluid needs. Avoid caffeinated beverages. Use toilet on regular basis throughout days (usually 4-7 times, including bedtime)

Which of the following is the first-line therapy for a motivated child with primary monosymptomatic enuresis?

Enuresis Alarms

What impacts the dosing of Desmopressin?

First Pass Effect!!

Initial Management of Pediatric Enuresis

First line management: - Education and advice to children and caregivers - Motivational therapy > Especially, if child is less than 5 years old

Delayed access to toileting facilities due to severe arthritic pain is a risk factor for which of the following?

Functional incontinence

Which of the following conditions may be responsible for fecal impaction in an elderly patient?

Functional incontinence

If enuresis not responsive to advice and reward system, what treatment do you add to behavioral modifications?

IF alarm treatment is considered desirable/appropriate by all parties, offer alarm therapy as initial treatment Especially in those less than 7 years old (minimum 2-3 month long trial)

What special consideration makes alarm therapy not desirable?

If parents or caregivers are having emotional difficulty coping or are expressing anger, frustration, or blame

All of the following are risk factors for stress incontinence except which of the following?

Nasal decongestant for cold symptoms So, risk factors include: 1. Traumatic childbirth 2. Radical prostatectomy 3. Surgery for BPH 4. Menopause

What is the recommended route for pediatric enuresis?

Oral

Which of the following drugs is most appropriate for managing urge incontinence?

Oxybutynin

Which of the following agents has the lowest incidence of dry mouth as a side effect according to its package insert?

Oxybutynin TDS

Dosage Forms of Desmopressin

PO, IV/SubQ, Intranasal (should not be used for PE) Bioavailability and dosing vary considerably by route - Must know!!

What do you recommend if there is a lack of response to all previous treatments or relapse after D/C of treatment?

Refer to Enuresis Specialist AND Consider: - Alarm therapy or DDAVP (whichever has not been already tried) - Combination therapy with alarm therapy + DDAVP or DDAVP + anticholinergic OR imipramine + DDAVP (latter two especially, if daytime urge UI is a significant concurrent issue)

A 52-year-old postmenopausal, overweight woman complains of small volumes of urine leakage when she coughs, laughs, or practices yoga. She denies urinary frequency or incontinence at night. Which of the following conditions is most likely the cause of her incontinence?

Stress incontinence

A 50-year-old woman is newly diagnosed with overactive bladder with urge incontinence. Her current medications include clarithromycin and fluoxetine. Which of the following agents is most likely to provide symptom control with the fewest drug interactions?

Trospium