PNE Treatment Algorithms

Background
Established in 1991 to specifically address the problem of pediatric nocturnal enuresis (PNE), Try for Dry has successfully assisted thousands of children to overcome bedwetting. In addition to treating patients, Try for Dry’s mission includes educating healthcare providers so they can better treat their pediatric patients.

According to Dr. Max Maizels, Professor of Pediatric Urology at Northwestern University, founder of Try for Dry and author of Getting to Dry. “It has been our experience that most primary healthcare providers have not been trained in enuresis treatment and so are unsure about how to proceed in helping their patients to become dry.”

While it is prudent to test for structural anomalies such as posterior urethral valves or vesicoureteral reflux, only about 1% of children who wet require surgery.

Recognizing that few children need pediatric urological care, Try for Dry team developed simple algorithms that assist pediatric caregivers with direct management of the problem.

PNE Syndrome Fundamentals
The basis of the PNE treatment algorithms require recognizing the problems commonly found in children with PNE:

• Nearly all fail to arouse from sleep. It is generally accepted that the child’s brain does not receive the message from the full bladder that urination is imminent.

• More than 90% of children show a reduced functional bladder capacity.

• Approximately 20% do not empty their bowels daily.

• Approximately 10% show bladder sensitivity to certain foods and/or beverages

It is important to note that while Attention Deficit Hyperactivity Disorder (ADHD) may be a co-morbidity, psychological and social issues have little to do with causing bedwetting.

Patient Consultations and Referral
First, it is important that a physical exam and test for UTI be conducted by the family doctor to rule out the possibility that urological abnormalities are causing the bedwetting.

While there are many clinical tests available, we have found this initial exam to be an adequate measure for the initial three month interval in which the Try for Dry treatments are used. If dryness is not achieved in that time, referral for a specialty consultation is recommended.

PNE Treatment Algorithms
The PNE treatment algorithms in the Try for Dry approach address the problems found in children affected by PNE.

Failure of Sleep Arousal - This factor is addressed with an enuresis alarm.

During sleep, the first squirt of urine emptied is detected by a lightweight sensor worn on the underpants, and the detector sounds a microchip enuresis alarm. Because these children are deep sleepers it is important for parents to understand that in the early stages they should be prepared to respond to the alarm and to assist the child to finish voiding in the toilet. Over a period of less than 3 months, the child should begin to respond to the bladder signals. Once a child has attained 14 consecutive dry nights, alarm use is tapered.

Reduced Functional Bladder Capacity – This factor is addressed with Oxybutynin.

Our empiric observations show that Oxybutynin – when used in conjunction with an enuresis alarm – shortens the time to achieve dryness. Oxybutynin as single treatment for PNE is not shown to be medically effective.

Nocturnal Polyuria – This factor is addressed with Desmopressin.

Desmopressin is used in sub-therapeutic doses in children 8 years or older. The medication appears to reduce the number of night time liftings to toilet. It is not used with the intention of remitting wetting.

Irregular Defecation – This factor is addressed by striving to empty the bowels daily.

A full rectum appears to reduce the sense of bladder urgency. The Try for Dry bowel program is used to make defecation more regular. The bedwetting program should not be started if there is ongoing fecal impaction.

Food sensitivities – This factor is addressed with the Try for Dry Happy Bladder Diet.

This simple diet reduces the child’s exposure to foods which may negatively impact the effort to achieve dryness. The diet is used for two weeks, an assessment of improved dryness is made, and food items are reintroduced slowly.

Motivation – This factor is addressed by offering inducements to reward dry nights.

Children benefit from a star chart and other motivational devices that keep them involved and help them track their progress with daily toileting, avoiding trigger foods, taking medication and wearing the alarm each night. Typically children receive gold stars for each dry night with a goal of achieving 14 consecutive dry days and nights.

Assisting Parents
The Try for Dry team has assembled treatment kits that include the materials necessary for parents to help their children achieve dryness. Although parents can guide their children through the Try for Dry program independently, it is most effective when supervised by a healthcare provider.

Parents may also visit the Parent Resource Center on this site to take advantage of the free information, interactive online calendar and discussion boards. Online support packages are also available for purchase.