Paediatric Urology

Sleep Enuresis (Bed-Wetting) in Children

The most common urological problem seen in children is bed-wetting during sleep (medically referred to as sleep enuresis or nocturnal enuresis). About 10-20% of children between the ages of 5 to 6 years are known to wet their bed Apart from the commonly faced problem of changing the sheets, bed-wetting needs to be handled sympathetically because it affects the self-esteem of the child.

Nocturnal enuresis has a spontaneous resolution rate of 15% per year so that, by the age of 15, it persists in only 1% of the population. All enuretic children are psychologically normal.

The following are the various types of treatments:

• Behavioural Modification :Behavioural modification should be considered as the first line of management in enuresis. Bladder training, responsibility reinforcement, conditioning therapy using the urinary alarm, are all a part of this management - the last being considered the most effective approach available for nocturnal enuresis.



Pharmacological Therapy:

• Anticholinergic Therapy : has had an effectiveness ranging from 5% to 40%. Although these ranges increase the functional capacity of the bladder, the relapse rate is also high. The usual recommended dose of Imipramine is 25 mg for children between 5 and 8 years of age and 50 mg for older children (0.8 to 1.6 mg/kg per day), which should be given as a single dose shortly before bedtime.


• DDAVP : This drug, administered in the form of a nasal spray, has been effective in about 25% of cases. It works by reducing the urine output at night. The usual clinical dose is between 10 and 20 mcg per night for the nasal spray and 200 to 400 mcg per night for the tablets. The therapeutic effect of DDAVP is temporary. Once the treatment is stopped, 50 to 90% of children relapse and resume their original pattern of wetting.



Vesicoureteral Reflux (VUR) in Children

About 1% of children in the world have VUR. It results when the connection between the bladder and the ureter is not normal. The lower part of the ureter tunnels through the muscle of the bladder (valve mechanism). If this tunnel is too short, VUR occurs. Behaviors such as infrequent or incomplete urination and related constipation are also associated with VUR.

Urine is made in the kidneys. Normally, it only flows one way - down the ureters and into the bladder. VUR occurs when urine flows back to a kidney from the bladder, through the ureters. This can happen on either or both sides.

Your doctor can tell you how serious your child's VUR is, with a grading scale obtained by conducting an MCU. This scale ranges from Grade 1 (mild) to Grade 5 (severe). Most of the time, mild VUR will go away by itself. However, the more severe the VUR, the less likely is the possibility that it will go away on its own.

VUR can have serious consequences. Kidney infections can occur when infected urine flows back into the kidneys. The risk of kidney damage is greatest during the first 6 years of life. The goal is to find VUR early and prevent infection that could result in kidney damage.

Treatment of VUR is important to protect the kidneys, by preventing possible infections and kidney damage.

There are 3 options for managing or treating VUR:

• Antibiotics : may be used to prevent infections until VUR goes away by itself. Children must take the medications every day, and be re-tested for VUR on a regular basis.


• Surgery : can fix the ureters to stop VUR. This type of treatment cures most children. Surgery may be favoured if VUR is severe or if there are other related medical conditions.


• Endoscopic treatment : In endoscopic treatment, a substance is injected where the ureter joins the bladder.



Urinary Tract Infection in Children

Urinary tract infection is quite common in children. Surprisingly, it is as commonly, not diagnosed. Infection of the urinary tract occurs both in normal children and in those with some urinary tract abnormality.

The reason why so much of importance is placed upon the diagnosis and management of this problem is because, firstly, unlike other diseases, infants who have urinary tract infection may not have any symptoms pertaining to the urinary tract at all. The common belief that most parents have is that an infant with urinary tract infection should have symptoms such as a burning sensation while urinating, blood in the urine, difficulty in passing urine and so on.

This belief is incorrect. Infants who are less than one year of age may only not feed well and may have fever, loose stools, vomiting, etc. Unless one has a high degree of suspicion about the presence of a urinary tract infection, it can be missed.

The second reason is, if urinary tract infection is missed, it can cause disastrous results. If the kidneys are affected because of urinary tract infection, it can result in irreversible kidney damage and have negative long-term consequences. These are renal scarring, blood pressure, protein in the urine or ultimately, chronic renal failure. When these have set in, no matter what is done at a later stage, the problems cannot be set right.