CP_0406_Cases.final 3/17/06 2:57 PM Page 67 Current p SYCHIATRY CASES THAT TEST YOUR SKILLS Chronic enuresis has destroyed 12-year-old Jimmy’s emotional and social functioning. The challenge: restore his self-esteem by finding out why can’t he stop wetting his bed. The boy who longed for a ‘dry spell’ Tanvir Singh, MD Kristi Williams, MD Fellow, child® Dowdenpsychiatry ResidencyHealth training Media director, psychiatry Medical University of Ohio, Toledo CopyrightFor personal use only HISTORY ‘I CAN’T FACE MYSELF’ during regular checkups and refer to a psychia- immy, age 12, is referred to us by his pediatri- trist only if the child has an emotional problem J cian, who is concerned about his “frequent secondary to enuresis or a comorbid psychiatric nighttime accidents.” His parents report that he wets disorder. his bed 5 to 6 times weekly and has never stayed con- Once identified, enuresis requires a thorough sistently dry for more than a few days. assessment—including its emotional conse- The accidents occur only at night, his parents quences, which for Jimmy are significant. In its say. Numerous interventions have failed, including practice parameter for treating enuresis, the restricting fluids after dinner and awakening the boy American Academy of Child and Adolescent overnight to make him go to the bathroom. Psychiatry (AACAP)1 suggests that you: Jimmy, a sixth-grader, wonders if he will ever Take an extensive developmental and family stop wetting his bed. He refuses to go to summer history. Find out if the child was toilet trained and camp or stay overnight at a friend’s house, fearful started walking, talking, or running at an appro- that other kids will make fun of him after an acci- priate age. Delays in reaching developmental dent. Asked how “wet nights” are affecting his life, milestones can predict enuresis.1 he says, “I can’t face myself in the mirror.” Also find out if either parent had enuresis during childhood. Enuresis is heritable,2 and The authors’ observations children often outgrow the problem at the same Primary nocturnal enuresis is diagnosed in chil- age as did the parent(s). dren age ≥ 5 who have never gone 6 consecutive Focus on the bedwetting and the child’s reaction months without an overnight accident. Ped- to it. Treat enuresis aggressively if it is hurting the iatricians generally discover enuresis incidentally child’s performance at school, social or emotion- VOL. 5, NO. 4 / APRIL 2006 67 For mass reproduction, content licensing and permissions contact Dowden Health Media. CP_0406_Cases.final 3/17/06 2:57 PM Page 68 CASES THAT TEST YOUR SKILLS The boy who longed for a ‘dry spell’ tion to rule out subtle dysfunction associated How would you with enuresis.1 handle this case? Perform a urinalysis and urine culture to rule out urinary tract infection (UTI). Order urodynamic studies or renal ultrasound if Visit www.currentpsychiatry.com to input your answers and compare them with enuresis persists after two unsuccessful treatment those of other readers trials, the physical examination uncovers positive findings, or the child has had a UTI. al development, or self-esteem, or if the youth Psychotherapy has a limited role in treating appears emotionally withdrawn or distressed. primary enuresis unless you suspect a psycholog- 1 Interview the child and parents separately, as ical cause. We offered Jimmy supportive coun- each often reacts differently to the problem. In seling to help alleviate emotional problems some cases, for example, the child’s bedwetting caused by bedwetting. He and his parents upsets the parents but the child hardly seems to declined but agreed to reconsider later. care. Also, children often feel more at ease talking to a doctor alone, and parents can vent frustration FURTHER HISTORY TOILET TRAINED AT 2 without upsetting their child. immy was toilet trained at age 2 and reached all While interviewing the child, listen for psy- J other age-appropriate developmental mile- chosocial stressors that can lead to enuresis, such stones, his mother says. Results of urine culture, as parents’ marital problems, problems at school, repeated urinalyses, and recent hospitalization, physical or neurologic and physical exami- sexual abuse, or the recent birth of a nations are normal. Neither Jimmy sibling. Consider physical nor his family have a history of UTI, We spend about one half-hour causes, emotional dysuria, urgency, or increased urination with the child and another half- stressors, and frequency. hour with the parents to thoroughly developmental When Jimmy was age 9, his pedia- gauge enuresis’ emotional impact. delays when trician prescribed imipramine, 25 mg/d, to To engage the child and hold his assessing enuresis try to stop his bedwetting. He did not attention during that half-hour, we respond after 6 months, so his parents offer toys or play a game. stopped giving the drug to him. Check for physical causes. According to the A few months later, Jimmy’s par- AACAP practice parameter for enuresis treat- ents heard about a “bedwetting alarm” designed to ment, you should: condition children not to urinate while asleep, but • assess nare patency and voice quality to the boy and his parents viewed this treatment as rule out enlarged adenoids “humiliating” and refused to try it. They have not • check the nasal pharynx for enlarged tonsils attempted another intervention for 2 years. • palpate the abdomen to check for bladder How would you help Jimmy? distention or fecal impaction a) urge the family to try the bedwetting alarm • examine genitalia for abnormalities b) prescribe imipramine at a higher dosage • view the back for a sacral dimple or other c) try another medication sign of a vertebral or spinal cord anomaly. d) try a different behavioral treatment Also order a thorough neurologic examina- 68 Current VOL. 5, NO. 4 / APRIL 2006 p SYCHIATRY CP_0406_Cases.final 3/17/06 2:57 PM Page 69 Current p SYCHIATRY The authors’ observations Box Having found no medical or psychological basis Enuresis: Possible causes for Jimmy’s enuresis (Box), we pondered our next clinical move. Genetics. In more than one-half of children Behavioral interventions. Parents commonly try to with enuresis, one or both parents had the stop their child’s bedwetting by restricting his or disorder during childhood. her fluid or caffeine intake, enforcing a reward sys- Developmental delay. Delayed functional tem, bladder control training, and/or awakening CNS maturation can decrease arousal. the child overnight to go to the bathroom. Enuresis is common in children with developmental disorders, including autism, Among behavioral treatments, only the bed- Rett’s syndrome, or pervasive developmental wetting alarm has shown effectiveness in clinical disorder NOS. 1,3 trials, and it carries the lowest risk of post-treat- Irregular sleep pattern associated with 3 ment relapse. Urine moistens a sensor in the bed specific sleep disorders, such as narcolepsy pad or inside cloth, triggering an alarm that awak- and sleep apnea. Also, children with enuresis ens the child when wetting starts. The child grad- sleep more soundly than do youths without ually awakens earlier in an enuretic episode until the disorder. the sensation of bladder fullness awakens him. Psychological problem. Considered a reaction Many parents/guardians and their children— to primary enuresis rather than its cause. particularly older youths—consider alarm systems Medical condition. Enlarged adenoids, tonsils, demeaning. We again suggested this treatment to constipation with fecal impaction, vertebral Jimmy and his parents, but they refused. and spinal cord anomaly, and diabetes mellitus may cause enuresis. Medication. Six months of low-dose imipramine, a tricyclic antidepressant often prescribed for enure- Source: Reference 1 sis, produced no response. We did not restart imipramine at a higher dosage because of its asso- TREATMENT MEANINGLESS RESPONSE ciation with increased arrhythmia risk. e start Jimmy on oral desmopressin, 0.2 mg at We instead considered desmopressin acetate, a W bedtime, after discussing its benefits and risks synthetic analog of ADH vasopressin that regu- with his parents. We increase the dosage to 0.4 mg lates diurnal variation, which is usually abnormal after 3 days and to 0.6 mg the following week, as in children with enuresis. Desmopressin, often the lower dosages have not worked. Serum elec- used to treat clozapine-induced enuresis in adults, trolytes, gauged before starting desmopressin and has been associated with successful outcomes in as again 2 weeks later, are normal. We see Jimmy many as 65% of children in clinical trials.1,4 every 2 weeks to check progress and monitor for Desmopressin, however, can reduce urine pro- side effects. duction. Water intoxication or hyponatremia is Soon after the second dosage increase, Jimmy’s rare but can lead to seizures or coma, and the risk accidents gradually decrease to 2 to 3 per week, but increases with the dosage. Obtain informed con- no improvement is seen after that. sent from the parents before starting this drug. Two months later, Jimmy is still avoiding sleep- Check electrolytes 2 or 3 days after the first dose, 1 overs and has trouble making friends. His parents month later, then again every 2 to 3 months. worry about his increasing frustration, hopelessness, Discontinue at once if serum sodium decreases and low self-esteem. We again offer supportive coun- significantly from baseline or is <135 mmol/L. seling, but the boy refuses. continued VOL. 5, NO. 4 / APRIL 2006 69 CP_0406_Cases.final