הרטבה יומית

Daytime Wetting- Dirunal Enuresis
Diurnal enuresis is defined as unintended wetting in a child old enough to have developed control. Primary enuresis is often associated with structural and congenital abnormalities, and maturational delay. 3-4% of 4 1/2 year olds will wet during the daytime.

Common causes of daytime wetting

Voluntary holding of urine- This is common in 3-5 year olds who don't want to take the time to use the toilet. Less common in older children because of the embarrassment of having accidents at school or in public. These children are recognizable by there frequent fidgeting, holding of their perineal areas, and squirming. Treatment consists of talking to children and encouraging them to go when they have the urge. Also, try to predict when they have to go and encouraging them to use toilet.
UTI's- These children will have intermittent wetting and association with other symptoms of urinary tract infections.
Syndrome- Often associated with ADHD in girls. There is involuntary contraction of the detrussor muscle in the bladder. Child will often squat to decrease muscle contracture. Child has usually attained bladder control. May often respond to medications to decrease contractures such as Ditropan.
Stress incontinence- Associated with increased intra-abdominal pressure.
Less common causes of daytime enuresis
Constipation- Accumulation of stool may cause detrussor muscle contraction. Also increased incidence of UTI's.
Reflux of urine into the vagina. Will lead to leaking of urine when the child stands up. Due to failure of the labia to "open" while sitting and seen in obese females and children too small to sit on an adult toilet seat.
Labia minora fusion
Daytime frequency- may be associated with accidents
Wetting with giggling
Hinman Syndrome- trabeculted bladder, reflux, and post voiding residual of urine
Neurogenic Bladder- may have associated constipation, spinal cord abnormalities, and lower extremity abnormalities including gait disturbances.
Urethral obstruction- there may be an abnormal stream and the child may strain to urinate
Ectopic ureter- Most commonly adjacent to the urethral meatus. Child will always be wet.
Diabetes insipidus and diabetes mellitus
Evaluation
Thorough history including history of toilet training, when does the wetting occur, UTI symptoms, how often, bowel habits, gait disturbances or weakness, nature of the stream.
Physical examination- also should observe the urinary stream.
UA and culture
Ultrasound and possible VCUG
Evaluation of spine and may need radiographs of the back.
Management
Reassurance and avoid punishment. Often condition is only intermittent and self limited.
Talk to child about going to toilet when they have the urge
Treat infection
If suspect vaginal reflux, instruct on proper positioning on the toilet to avoid problem
Avoid circumstances leading to stress and associated enuresis.
Treat constipati

Treat constipation
Certain drugs to relax detrussor muscle increased activity.
Surgery to correct anatomical abnormalities.
If there is labial adhesion, application of estrogen cream and improved hygiene may break the adhesions.
Pelvic floor strengthening exercises may help if there is urge syndrome, stress, and giggle incontinence.
Reference
Robson, LM. Diurnal Enuresis. Pediatrics in Review. 1997; 18:407-412.
Casale A. Daytime Wetting Contemporary Pediatrics February 2000
Schulman S and Berry A. Helping the child with daytime wetting stay dry. Contemporary Pediatrics June 2006
Schulman S. and Berry A. Helping the child with daytime wetting stay dry. Contemporary Pediatrics June 2006

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