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enuresis alarm, bladder training, motivational therapy, and pelvic floor muscle training) is more effective than each component alone or than pharmacotherapy (1)[A].

Enuresis alarms (bells or buzzers)

–Considered first line; most effective treatment

–66–70% success rate; must be used nightly for 2 to 4 months; offers cure; significant parental involvement; disruption of sleep for entire family

–If successful, it should be used until 14 consecutive dry nights achieved (2) [B].

See “Patient Education” for options.

MEDICATION

First Line

Desmopressin (DDAVP): synthetic analogue of vasopressin that decreases nocturnal urine output (2)[A]

–Intranasal DDAVP: adults only, 20 mg (2 sprays) intranasally at bedtime

–FDArecommends against use in children due to reports of severe hyponatremia resulting in seizures and deaths in children using intranasal formulations of desmopressin.

–Oral DDAVP: safe in children. Begin at 0.2 mg tablet taken at bedtime on empty stomach; after 14 days of inefficient treatment can titrate to 0.4 mg (2)

Maximally effective in 1 hour; effect lasts 8 to 10 hours.

If treatment is successful, can be continued for 3 months, then stop for 2 weeks for test of dryness

High relapse rate after discontinuation without a structured withdrawal program. If relapse occurs, oral desmopressin can continue to be prescribed in 3-month blocks.

Suspend dose in children who experience acute condition affecting fluid/electrolyte balances (fever, vomiting, diarrhea, vigorous exercise). 60–70% success: 30% of children have full response and 40% have partial response.

Pediatric Considerations

FDArecommends against using intranasal formulations of desmopressin in children due to reports of severe hyponatremia resulting in seizures and deaths (3)[A].

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Second Line

Imipramine (Tofranil): tricyclic antidepressant, anticholinergic effects; increases bladder capacity, antispasmodic properties

–Primarily in adults; use in children is reserved for resistant cases and initiated by specialists.

–Dose: adults, 25 to 75 mg and children >6 years, 10 to 25 mg PO at bedtime; increase by 10 to 25 mg at 1- to 2-week intervals; treat for 2 to 3 months; then taper.

–40% success rate but relapses after discontinuation are high (2)

–Pretreatment ECG recommended identifying underlying rhythm disorders

Anticholinergics: Monotherapy is not recommended in children.

–Oxybutynin (Ditropan, Ditropan XL, Oxytrol patch): anticholinergic; smooth muscle relaxant, antispasmodic; may increase functional bladder capacity and aids in timed voiding (4)[B]

30–50% success; 50% relapse after stopped

Ditropan: adults: 5 mg PO TID–QID; children >5 years old with overactive bladder who have failed alarm therapy and desmopressin can try 5 mg at bedtime.

Ditropan XL: adults: 5 mg/day PO; increase to 30 mg/day PO (5-, 10-mg tabs)

Oxytrol patch: 1 patch every 3 to 4 days (3.9 mg/patch) (periodic trials of the medication, that is, weekends or weeks at a time, will help determine efficacy and resolution of primary disturbance)

–Tolterodine (Detrol, Detrol LA): anticholinergic; fewer side effects than Ditropan (4)[B]

Detrol: 1 to 2 mg PO BID in adults, 2 mg at bedtime in children >5 years old

Detrol LA: 2 to 4 mg/day

Precautions

–Oxybutynin: glaucoma, myasthenia gravis, GI or genitourinary obstruction, ulcerative colitis, constipation, megacolon; use a decreased dose in the elderly.

–Tolterodine: urinary retention, gastric retention, constipation, uncontrolled narrow-angle glaucoma; significant drug interactions with CYP2D6, CYP3A3/4 substrates

–DDAVP: Avoid in patients at risk for electrolyte changes or fluid retention (congestive heart failure [CHF], renal insufficiency). Stop during gastroenteritis or other acute illness with risk of dehydration.

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– Imipramine: Do not use with monoamine oxidase inhibitors (MAOIs), hypotension, and arrhythmias; low-toxic therapeutic ratio

Combination therapy with DDAVPand oxybutynin has better results than individual use (4)[B].

ALERT

Imipramine: cardiotoxicity and death with overdose

ISSUES FOR REFERRAL

Primary NE: persistent enuresis despite nonpharmacologic and pharmacologic therapies

Diurnal incontinence or nonmonosymptomatic enuresis with voiding dysfunction or underlying medical condition

ADDITIONALTHERAPIES

Individual and family psychotherapy, crisis intervention

SURGERY/OTHER PROCEDURES

Only for surgically correctable causes (e.g., tethered cord, ectopic ureter, benign prostatic hypertrophy, obstructive sleep apnea)

COMPLEMENTARY& ALTERNATIVE MEDICINE

Acupuncture has small amounts of supportive data (3)[B].

ONGOING CARE

DIET

Limit fluid and caffeine intake 2 hours before sleep.

Limit dairy products 4 hours before sleep (decrease osmotic diuresis) (5).

PATIENT EDUCATION

Web resources for hypnosis scripts, alarms, and supplies

http://www.hypnoticworld.com/hypnosis-scripts/habits-disorders/enuresis www.bedwettingstore.com/index.htm; www.dri-sleeper.com; www.enurad.com; www.nitetrain-r.com; www.sleepydryalarm.com;

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http://www.wetstop.com; www.pottypager.com

PROGNOSIS

In children, NE is usually self-limiting; 1% will persist as adult; evaluate for organic causes.

COMPLICATIONS

UTI, perineal excoriation, psychological disturbance (especially in children)

REFERENCES

1.Baird DC, Seehusen DA, Bode DV. Enuresis in children: a case based approach. AM Fam Physician. 2014;90(8):560–568.

2.Kuwertz-Bröking E, von Gontard A. Clinical management of nocturnal enuresis [published online ahead of print August 21, 2017]. doi:10.1007/s00467-017-3778-1.

3.Jain S, Bhatt GC. Advances in the management of primary monosymptomatic nocturnal enuresis in children. Paediatr Int Child Health. 2016;36(1):7–14.

4.Bayne AP, Skoog SJ. Nocturnal enuresis: an approach to assessment and treatment. Pediatr Rev. 2014;35(4):327–335.

5.Traisman ES. Enuresis evaluation and treatment. Pediatr Ann. 2015;44(4):133–137.

SEE ALSO

Incontinence, Urinary Adult Female; Incontinence, Urinary Adult Male

Algorithm: Enuresis, Secondary

CODES

ICD10

N39.44 Nocturnal enuresis

R32 Unspecified urinary incontinence

F98.0 Enuresis not due to a substance or known physiol condition

CLINICALPEARLS

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Initial evaluation is history, exam, and urinalysis.

For PMNE in children, if the condition is not distressing to child and caretakers, treatment is unnecessary.

Behavioral and lifestyle interventions are the first-line treatment for PMNE, alarms, and desmopressin are the most effective treatments.

Dryness is possible for most children.

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EPICONDYLITIS

Kevin Heaton, DO

BASICS

DESCRIPTION

Tendinopathy of the elbow characterized by pain and tenderness at the origins of the wrist flexors/extensors at the humeral epicondyles

May be acute (traumatic) or chronic (overuse) Two types

–Medial epicondylitis (“golfer’s elbow”)

Involves the wrist flexors and pronators, which originate at the medial epicondyle

–Lateral epicondylitis (“tennis elbow”)

Involves the wrist extensors and supinators, which originate at the lateral epicondyle

May be caused by many different athletic or occupational activities

Common in carpenters, plumbers, gardeners, and athletes

Usually involves the dominant arm

Lateral epicondylitis is more common.

EPIDEMIOLOGY

Predominant age: >40 years

Predominant sex: male = female

Incidence

Common overuse injury

Lateral > medial

Estimated between 1% and 3%

Prevalence

Lateral epicondylitis: 1.3%

Medial epicondylitis: 0.4%

ETIOLOGYAND PATHOPHYSIOLOGY

Acute (tendonitis)

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– Inflammatory response to injury

Chronic (tendinosis)

–Overuse injury

–Tendon degeneration, fibroblast proliferation, microvascular proliferation, lack of inflammatory response

Repetitive wrist flexion or extension places strain across enthesis of flexor/extensor group.

Tool/racquet gripping

Shaking hands

Sudden maximal muscle contraction

Direct blow

RISK FACTORS

Repetitive wrist motions

–Flexion/pronation: medial

–Extension/supination: lateral

Smoking

Obesity

Upper extremity forceful activities

GENERALPREVENTION

Limit overuse of the wrist flexors, extensors, pronators, and supinators.

Use proper techniques when working with hand tools or playing racquet sports.

Use lighter tools and smaller grips.

DIAGNOSIS

HISTORY

Pain typically localized to lateral or medial elbow

Occupational activities

Sports participation

Direct trauma

Duration and location of symptoms

Prior treatments or medication use

Pain with gripping

Sensation of mild forearm weakness

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PHYSICALEXAM

Localized pain just distal to the affected epicondyle

Increased pain with wrist flexion/pronation (medial)

Increased pain with wrist extension/supination (lateral)

Medial epicondylitis

–Tenderness at origin of wrist flexor tendons

–Increased pain with resisted wrist flexion and pronation

–Normal elbow range of motion

–Increased pain with gripping

Lateral epicondylitis

–Tenderness at origin of wrist extensors

–Increased pain with resisted wrist extension/supination

–Normal elbow range of motion

–Increased pain with gripping

DIFFERENTIALDIAGNOSIS

Elbow osteoarthritis

Epicondylar fractures

Posterior interosseous nerve entrapment (lateral)

Ulnar neuropathy (medial)

Synovitis

Medial collateral ligament injury

Referred pain from shoulder or neck

DIAGNOSTIC TESTS & INTERPRETATION

Initial Tests (lab, imaging)

No imaging is required for initial evaluation and treatment of a classic overuse injury.

Follow-Up Tests & Special Considerations

Anterior-posterior/lateral radiographs if decreased range of motion, trauma, or no improvement with initial conservative therapy. Assess for fractures or signs of arthritis.

For recalcitrant cases

–Musculoskeletal ultrasound (US) reveals abnormal tendon appearance (e.g., tendon thickening, partial tear at tendon origin, calcifications). US can also guide injections of steroid and/or anesthetic.

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–MRI can show intermediate or high T2 signal intensity within the common flexor or extensor tendon or the presence of peritendinous soft tissue edema.

Diagnostic Procedures/Other

Infiltration of local anesthetic with subsequent resolution of symptoms supports the diagnosis if clinically in doubt.

TREATMENT

GENERALMEASURES

Initial treatment consists of activity modification, counterforce bracing, oral or topical NSAIDs, ice, and physical therapy:

Observation: If left untreated, symptoms typically last between 6 months and 2 years. For patients with good function and minimal pain, consider conservative management using a “wait and see” approach based on patient preference.

Modify activity, encourage relative rest, and correct faulty biomechanics.

Counterforce bracing with a forearm strap is easy and inexpensive. Systematic reviews are inconclusive about overall efficacy, but initial bracing may improve the ability to perform daily activities in the first 6 weeks.

Consider nighttime wrist splinting for repetitive daily activities if counterforce bracing fails.

Ice frequently after activities Physical therapy

–Begin once acute pain is resolved. Infiltration of local anesthetic can reduce pain and allow for physical therapy.

–Eccentric strength training and stretching program

–US therapy

–Corticosteroid iontophoresis

–Dry needling

MEDICATION

First Line

Topical NSAIDs: Low-quality evidence suggests topical NSAIDS are significantly more effective than placebo with respect to pain and number

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needed to treat to benefit (NNT = 7) in the short term (up to 4 weeks) with minimal adverse effects (1)[A].

Oral NSAIDs: Unclear efficacy with respect to pain and function, but may offer short-term pain relief; associated with adverse GI effects (1)[A]

Second Line

Corticosteroid injections: Short-term (≤8 weeks) reduction in pain. No benefits found for intermediate or long-term outcomes (2)[A].

ISSUES FOR REFERRAL

Failure of conservative therapy

ADDITIONALTHERAPIES

Platelet-rich plasma (PRP) injections

–Injection of concentrated autologous PRPleads to a local inflammatory response. Platelets degranulate, release growth factors, and stimulate the physiologic healing cascade.

–PRPtreatment of chronic lateral epicondylitis significantly reduces pain and increases function. The benefit exceeds that of corticosteroid injection

even after a follow-up of 1 year (3)[A]. Autologous blood injections

– Stimulates the inflammatory cascade within the degenerated tendon by providing cellular and humoral mediators for regeneration

US-guided percutaneous needle tenotomy

–Injection of a local anesthetic followed by US-guided tendon fenestration, aspiration, and abrasion the underlying bone; thought to break apart scar

tissue and stimulate inflammation and healing Prolotherapy

–Injection of a dextrose solution into and around the tendon attachment stimulates a localized inflammatory response, leading to increased blood flow to stimulate healing.

Glyceryl trinitrate (GTN) transdermal patch

–Nitric oxide (NO) is a small free radical generated by NO synthases. NO is expressed by fibroblasts and is postulated to aid in collagen synthesis. Topical application of GTN theoretically improves healing by this mechanism. 1/4 of a 5-mg/24-hr GTN transdermal patch is applied once daily for up to 24 weeks.

–Significant decreases in pain are seen at 3 weeks and 6 months compared to

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