Gotta Go Right Now: A Comprehensive Assessment of Frequent Urination and Nocturnal Enuresis Kelly Haack, M.A., and William J. Warzak, Ph.D. Department of Psychology, Munroe-Meyer Institute at the University of Nebraska Medical Center

INTRODUCTION METHOD RESULTS Participant Bartter’s Syndrome Baseline 2 Months Following BRT ¾ Bartter’s Syndrome is caused by a defect in the kidney’s ¾ The participant was a 14-year-old male with Bartter’s Syndrome. Fluid Intake and Output Fluid Intake and Output ability to reabsorb potassium. ¾ He presented with frequent daytime and nighttime voiding. 1000 ¾ As a result, the kidneys remove too much potassium from ¾ Medical History: the body. ƒ 4 years old: Renal Ultrasound showed normal kidneys and 900 1000 ¾ Excessive loss of potassium leads to muscle cramping and hypokalemia (low potassium level) was ruled out. 800 Intake 900 weakness, constipation, increased frequency of urination, 800 and growth failure. ƒ 11 years old: Ditropan XL 10 mg daily and Imipramine 35 mg 700 Intake 700 Nocturnal Enuresis daily were prescribed to treat symptoms of overactive bladder, 600

ML 600 such as frequent urination. ML 500 ¾ Nocturnal Enuresis is involuntary passing of urine while 500 ƒ 12 years old: Neurological exam was normal and neurogenic 400 asleep. 400 bladder was ruled out. Output 300 Output 300 Bartter’s Syndrome • Continued taking Ditropan and Imipramine. 200 200 and • Prescribed DDAVP 0.6 mg each evening to increase urine 100 100 concentration and decrease urine production. Nocturnal Enuresis 0 0 ¾ Adolescents with Bartter’s Syndrome often have a problem • Started use of a urine alarm; however, it was a short trial and 3:00 6:00 7:45 9:45 1:00 2:30 4:00 5:00 6:20 8:00 9:30 1:00 2:45 5:00 7:00 9:00 2:00 4:00 5:00 7:00 9:00 1:45 4:00 7:00 4:00 7:05 9:45 2:00 4:00 5:45 7:00 9:30 2:30 5:00 7:45 2:30 4:30 7:00 9:30 1:45 5:00 12:00 11:00 11:00 10:45 12:00 10:00 12:00 concentrating urine and excrete an excessive volume of he slept through it and continued to wet 5 out of 7 nights. 12:00 11:57 12:00 10:00 12:00 11:00 AM PM AM PM AM AM AM PM PM AM urine at night. ƒ 13 years old: Voiding cystourethrogram to determine cause of ¾ However, after potassium levels have normalized, nighttime urinary incontinence showed a normal bladder and urethra. ¾ Voided 10 times per 24 hour day ¾ Voided 8 times per 24 hour day voiding should resolve. ƒ 14 years old: Daily supplements of potassium and magnesium ¾ Output ranged from 90 to 190 ml ¾ Output ranged from 100 to 215 ml were prescribed. ¾ Average output for the two days was 125 ml and 131ml, ¾ Average output for the two days was 140 ml and 149ml, PURPOSE OF THE STUDY respectively. respectively. ¾ Ingested 1920 ml and voided 1255 ml on the first day. ¾ Ingested 2340 ml and voided 1120 ml on the first day. There are three purposes to this study: ¾ Ingested 1560 ml and voided 1310 ml on the second ¾ Ingested 1020 ml and voided 1190 ml on the second 1. Determine why an adolescent with normal potassium levels day. day. continues to exhibit nocturnal enuresis. ¾ Input and output balance. ¾ Input and output balance on the second day. 2. Determine the effectiveness of bladder retention training to Procedure ¾ Voided twice at night. ¾ Voided twice at night. increase bladder capacity, decrease frequency of voiding, ¾ Clinical interview of history of voiding and previous treatments. and increase the volume of voids. ¾ Gather medical records to rule-out medical conditions. Stool Frequency 3. Determine treatment options for nocturnal enuresis ¾ Voiding (Input/Output data) and stool diaries to rule-out constipation. 3 ¾ Implement Bladder Retention Training (BRT): The goal of BRT is to stretch your bladder to reduce urination 2 HYPOTHESIS frequency to around 5-6 times in 24 hours. You may be able to stretch your bladder gradually and gently by reducing the number of ¾ Low nocturnal bladder capacity/small functional bladder times you urinate in a day. Frequency capacity. 1 ¾ Functional bladder capacity is the bladder volume at which a ƒ Hold first void of the morning for 10 minutes. child experiences the sensation of the need to void (Robson ƒ When you get the feeling that you want to urinate, try and hold & Leung, 2006). onto it for longer than you usually would. 0 ¾ Causes of low bladder capacity include (Robson & Leung, ƒ At first, this may prove difficult and uncomfortable. You may 2006): find it easier to practice this at times when you feel safe, such 12345678910111213141516171819202122 ƒ Constipation. Common in Bartter’s, common for as when you are at home. Day patients treated with Ditropan, could be due to ƒ One technique to use when you feel a desire to urinate is to hypokalemia. concentrate on a task which you need to complete, such as DISCUSSION ƒ Urinary tract infection. homework or reading. ƒ Overactive bladder – voiding frequency is more than ¾ Based on medical records, urinary tract infection, urethral obstruction, and neurogenic bladder were ruled-out. average. ƒ Another technique is to sit and take a number of deep breaths, ¾ The baseline of fluid intake and output outlined the extent of the problem. ƒ Urethral obstruction. concentrating on the breathing and not the bladder sensation. ¾ The stool diary indicated the frequency of defecation to be once or twice per day with soft, medium formed stools, ruling-out constipation. ƒ Neurogenic bladder. ƒ Relaxation ¾ Intermittent BRT showed a small amount of progress. ƒ Lack of circadian rhythm of vasopressin, resulting in ƒ Drink your normal intake of liquids. ƒ The number of voids per day decreased. high nocturnal urine production that exceeds bladder capacity (Vella, Robinson, & Cardozo, 2006). People ƒ Record the date and time of urination. ƒ Ingested 420 ml more of liquid, with an average increase of 68 ml. with this pattern suffer from nocturnal enuresis. ƒ Voided 255 ml less, with an average increase of 16 ml per void. ¾ Next step: Continue BRT with a more concerted effort for one month. Currently waiting for data.