csa_course_case_nocturnal_enuresis.pdf

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Contact us: [email protected] visit us www.csaprep.co.uk CSA course case – Nocturnal Enuresis - CSA prep © 2011

CSA course case CANDIDATE’S BRIEF

Patient medical records • Name: Adam Cubria (7 year old) • Past medical history: Nil • Drug history: Nil • Last consultation (6months ago)

Patient complaining of coryzal symptoms for 3d. Due to go on school day trip this week. Mum unsure if well enough to go. On examination, afebrile, chest clear, heart sounds normal, ENT nad. Impression URTI. Advice given and reassured.





CSA course case – Nocturnal Enuresis ACTOR’S BRIEF • You are Francesca Cumbria, a 33 year old house wife. You are attending alone and wish to discuss

your son Adam’s enuresis (bedwetting). Adam’s is currently with his dad shopping for school clothes • Approach: You are appropriately dressed, well spoken, inquisitive mother keen to help your son stop

bet wetting • Opening statement: “Thank you for seeing me I’ve come about Adam who is still wetting the bed. Its

getting really embarrassing and I wondered if you can help.” History Open history: • Adam is 7 years old and still wets the bed at least twice a week and yet to be night dry. • Recently he is has been wetting the bed almost everyday as the new school term is about to start. • He is anxious as in 6 months time he has a school trip to the south of France where the children have

to share rooms and spend a weekend in a hotel. • Adam’s uncle also suffers from bed wetting and he was diagnosed with diabetes when he was much

older • His sister Kate aged 5 has been day and night dry for the last year. • Adam is desperate to go camping trip but worried he might not be able to go because of his bedwetting Reveal history if asked: • ICE: You are aware of the family history of diabetes and would like to put your mind at rest that Adam

does not have it. You are worried that he will get teased about his bed wetting if his friends find out and if the bullying gets out of hand he might have to change school. You have read of a spray that can stop bed wetting and would like to try it.

• If doctor fails to explore expectations say: “I heard from Adam’s friend mum that there is a spray that can help.”

• Adam is dry during the day. He open his bowels once day as usual. He does have a bottle of water by his bedside that he drinks to help him sleep. He drinks one cup of tea in the morning.

• He does not suffer with urgency, frequency or dysuria. • Adam’s problem has made it difficult for you to get a good night sleep. You wake up 4am most days to

take Adam to toilet but he can wet the bed before that. • You try your best not to get cross but your husband occasionally gets cross with Adam as he has to

get to work in the morning and needs a peaceful sleep. It has caused some tension within the household.

• You would be pleased if you were offered the medication closer to the trip and instead recommended lifestyle advice including reward charts, enuresis alarms now.

Medical history





• Adam is fit and well Drug history • No allergies Social history • Currently not being bullied at school. School nurse unaware of bet wetting problem Family history • Uncle suffered with bedwetting and diagnosed with diabetes when older





CSA course case – Nocturnal Enuresis EXAMINER DATA GATHERING Positive indicators: • Use open questions to explore the patient’s problem (nocturnal enuresis) and closed questions to

clarify possible causes of the symptoms and excluding red flag symptoms i.e. family history of diabetes, constipation, UTI

• Identifies age of child and family history of bedwetting and diabetes (uncle) • Identifies child drinks water before going to sleep • Request to see child to undertake a targeted examination: i.e. urine dipstick Negative indicators: • Doctor adopts a ‘checklist approach’ and fails to ask open questions • Questioning is not sufficiently detailed to exclude red flag symptoms and potential causes • Is disorganised or unsystematic in gathering information • The physical examination is not requested or insufficiently targeted i.e. MCS INTERPERSONAL SKILLS Positive indicators: • Explore the patient’s health beliefs and concerns (diabetes, bullying) • Explores impact of illness of family (difficulty sleeping, household tension) • Explores the presenting complaint in an empathic way • Attempts to negotiate an agreed plan with the patient i.e. lifestyle options and considering medication if

not improved closer to the time Negative indicators: • Does not inquire sufficiently about the patient’s perspective/health beliefs • Fails to explore impact on child’s symptoms upon patient’s life • Uses a rigid structure to consultations and fails to respond to patient’s contribution • Instructs the patient rather than seek common ground CLINICAL MANAGEMENT SKILLS: Positive indicators: • Recognises diagnosis of nocturnal enuresis. Considers diabetes as possible differential • Offers to exam child to exclude diabetes (urine) • Negotiates with patient management plan to include lifestyle changes i.e. avoid evening drinks, reward

systems – start charts, emptying bladder before sleeping.





• Suggest informing school (school nurse). Special arrangement can be made i.e. school can book separate room for child or with other children suffering with similar problem

• Can recommend referral to paediatric enuresis clinic for alarms • Can suggest desmopressin oral (not intranasal spray) for short course during trip Negative indicators: • Does not negotiate management plan or medical advice incorrect or inappropriate • The examination request of the problem is inadequate or poorly targeted • Follow up arrangements are inadequate





CSA course case – Nocturnal Enuresis CARDS

Child not present for examination





CSA course case – Nocturnal Enuresis APPROACH

FOCUSED HISTORY Take a brief history. Start off asking several open questions before asking a select few closed questions such as: Pattern How long has bed wetting been going on for? How many nights a week? How many

times a night? Large amount of urine? Primary / secondary Are they wet during the day? (primary/secondary) Differentials Constipation Any problems with their bowels? UTI Any pain passing urine? Do they go toilet often? With urgency? Diabetes Do they feel thirsty all the time? Distress Are they being bullied at school? Family problems (maltreatment)? Starting new

school? Arrival of a new baby? Lifestyle Excessive fluid intake? Caffeine consumption (tea, cola, chocolates)? Medical History Diabetes, ADHD Family History Diabetes, daytime or nocturnal enuresis Social History Any bullying at school? Any relationship problems? PHYSICAL EXAMINATION Monitor growth Examining the abdomen, genitalia and lower limb neurological assessment Spinal examination (meningomyelocoele, spinal cord tumour) INVESTIGATIONS Request for urine dipstick / MCS to exclude diabetes and UTI MANAGEMENT (based on NICE guidelines) Advice • Reassure: Nocturnal enuresis common problem • Offer bladder diary • Waterproof cover for mattress, absorbent quilted sheets • Avoid excessive fluid intake particularly 1 hour before bed or abnormal toileting patterns





• Empty child’s bladder before going to sleep • Rewards i.e. star charts for agreed behaviour (rather than simply dry nights) i.e. drinking correct

volume of fluid, going to toilet before sleeping, clean sheets • Punitive measures should not be used if bedwetting occurs and blame not attributed to child if

accidents occur • For under 5 – Reassure. Encourage toilet training. Take to toilet if wakes up in night. Trial of nights in a

row without nappies/start pants. Treatment • Enuresis alarm if not responded to lifestyle advice (can offer less than 7 years old) • Offer desmopressin over 7 years if rapid or short-term improvement sought i.e. social occasion or

alarm is unsuccessful or inappropriate

CSA course case – Nocturnal Enuresis MX NOTES

‘Nocturnal enuresis is when there is a delay in maturation of the control mechanism which often resolves with time.’

Nocturnal enuresis (bedwetting) is defined as involuntary wetting during sleep in the absence of congenital or acquired defects. Medical management is often considered after the child is older than 5 years old. It is a common problem and affects boys more than girls. • Most children are continent during night and day by age of 3-4 years of age. However, approximately

20% of 5 year olds wet the bed twice a week falling to 5% of 10 year olds • Primary nocturnal enuresis is when child has never stopped bed wetting whilst secondary is when

the child had been dry for the previous 6 months Management Reward systems (e.g. star charts, treats) for agreed behaviour and not simply dry nights e.g. drinking

correct volume of fluid per day, going to toilet before sleeping, clean sheets. Do not use penalty systems if patient fails.

Enuresis Alarms wakes the child when they starts urinating. They can be worn in the trouser or be a sensor pad that is placed under the child. They condition the child to wake up and go to the toilet once they start passing urine. Eventually the child learns to wake up and hold their bladder before wetting the bed. Can be trialled for 1 month until 2 weeks of uninterrupted dry nights has been achieved. Treatment may last 3-5 months. Alarms not recommended for under five as requires a degree of co-operation.

Desmopressin can be used first line in older than 7 year olds. Taken at night as a tablet. Only sips allowed 1 hour before taking medicine and up to 8 hours after. Effective for short term use or one off measures (short holiday trips). Risk of fluid overload (hyponatraemic convulsions). Side effects include: headache, nausea, abdominal pain. Treatment should not continue without review for more than 3 months





‘Desmopressin works by reducing the volume of urine produced by the kidneys so less collects in the bladder and therefore past at night’

TCAs (e.g. imipramine) have anitmuscarinic effects, prescribed by specialists. Considered when all other options explored.

csa_course_case_nocturnal_enuresis.pdf

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