enuresis

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Adolesc"><U><B>Conduct Disorder in Children and Adolescents </B></U></A></div> <div> <A HREF="id22.htm" TARGET="_top" TITLE="Specific Growth Curve Deviations "><U><B>Specific Growth Curve Deviations </B></U></A></div> <div> <A HREF="id23.htm" TARGET="_top" TITLE="Common Medical and Surgical Problems"><U><B>Common Medical and Surgical Problems</B></U></A></div> <div> <A HREF="id24.htm" TARGET="_top" TITLE="Chronic Abdominal Pain in Childhood: Dia"><U><B>Chronic Abdominal Pain in Childhood: Diagnosis and Management </B></U></A></div> <div> <A HREF="id25.htm" TARGET="_top" TITLE="child devlpt"><U><B>child devlpt</B></U></A></div> <div> <A HREF="id26.htm" TARGET="_top" TITLE="ACETAMINOPHEN OVERDOSE"><U><B>ACETAMINOPHEN OVERDOSE</B></U></A></div> <div> <A HREF="id27.htm" TARGET="_top" TITLE="SHAKEN BABY SYNDROME"><U><B>SHAKEN BABY SYNDROME</B></U></A></div> <div> <A HREF="id28.htm" TARGET="_top" TITLE="NEONATAL JAUNDICE (HYPERBILIRUBINEMIA)"><U><B>NEONATAL JAUNDICE (HYPERBILIRUBINEMIA)</B></U></A></div> <div> <A HREF="id29.htm" TARGET="_top" TITLE="Hyaline Membrane Disease (Respiratory Di"><U><B>Hyaline Membrane Disease (Respiratory Distress Syndrome) (HMD) (RDS</B></U></A></div> <div> <A HREF="id30.htm" TARGET="_top" TITLE="infectious disease"><U><B>infectious disease</B></U></A></div> <div> <A HREF="id32.htm" TARGET="_top" TITLE="HEMORRHAGIC DISEASE IN A NEW BORN"><U><B>HEMORRHAGIC DISEASE IN A NEW BORN</B></U></A></div> <div> <A HREF="id33.htm" TARGET="_top" TITLE="OPTIC NERVE GLIOMA"><U><B>OPTIC NERVE GLIOMA</B></U></A></div> <div> <A HREF="id36.htm" TARGET="_top" TITLE="New Born Assessment "><U><B>New Born Assessment </B></U></A></div> <div> <A HREF="id38.htm" TARGET="_top" TITLE="laryngomalacia"><U><B>laryngomalacia</B></U></A></div> <div> <A HREF="id39.htm" TARGET="_top" TITLE="CRANIOSYNOSTOSIS "><U><B>CRANIOSYNOSTOSIS </B></U></A></div> <div> <A HREF="id40.htm" TARGET="_top" TITLE="DANDYWALKER MALFORMATION "><U><B>DANDY-WALKER MALFORMATION </B></U></A></div> <div> <A HREF="id41.htm" TARGET="_top" TITLE="DEJERINESOTTAS DISEASE "><U><B>DEJERINE-SOTTAS DISEASE </B></U></A></div> <div> <A HREF="id42.htm" TARGET="_top" TITLE="DOWN SYNDROME "><U><B>DOWN SYNDROME </B></U></A></div> <div> <A HREF="id43.htm" TARGET="_top" TITLE="Respiratory Syncytial Virus (RSV)"><U><B>Respiratory Syncytial Virus (RSV)</B></U></A></div> <div> <A HREF="id44.htm" TARGET="_top" TITLE="FABRY DISEASE "><U><B>FABRY DISEASE </B></U></A></div> <div> <A HREF="id45.htm" TARGET="_top" TITLE="PRADERWILLI SYNDROME "><U><B>PRADER-WILLI SYNDROME </B></U></A></div> <div> <A HREF="id37.htm" TARGET="_top" TITLE="new born fun"><U><B>new born fun</B></U></A></div> <div> <A HREF="id46.htm" TARGET="_top" TITLE="RETT SYNDROME "><U><B>RETT SYNDROME </B></U></A></div> <div> <A HREF="id47.htm" TARGET="_top" TITLE="Alexander Disease"><U><B>Alexander Disease</B></U></A></div> <div> <A HREF="id49.htm" TARGET="_top" TITLE="leukemia"><U><B>leukemia</B></U></A></div> <div> <A HREF="id17.htm" TARGET="_top" TITLE="Contact Me"><U><B>Contact Me</B></U></A></div> </td> <td valign="top" height=370 BGCOLOR="#FFFFFF" TEXT="#080000"> <div> enuresis</div> <div> DEFINITION:</div> <div> The involuntary voiding of urine after the age of 6 years. </div> <div> EPIDEMIOLOGY:</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">incidence: 25-33% of 4 year old children, 15% of 5-6 year olds, 5-7% of 7 year olds, 1% of 15 year olds </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">age of onset: </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">by definition after the age of 6 </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">risk factors: </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">family history </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">75% if both parents affected </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">40% if one parent affected </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">sex </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">M > F (nocturnal) </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">F > M (diurnal) </div> <div> DIFFERENTIAL DIAGNOSIS:</div> <div> 1. Organic</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">bladder instability </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">constipation </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Diabetes Mellitus or Insipidus </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">renal (medullary) damage </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">urinary tract infection </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">neurologic dysfunction </div> <div> 2. Non-Organic</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">deep sleeper </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">emotional disturbance </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">excessive water drinking </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">learned ("holding-on") behaviour </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">mental retardation </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">sexual abuse </div> <div> DEFINITIONS:</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Nocturnal: nighttime bedwetting </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Diurnal: daytime wetting +/- nighttime bedwetting </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Primary: has never been dry for longer than 6 months </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Secondary: wetting after a minimal 6 month period of dryness (less common than primary enuresis) </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Relapse: more than 2 wet nights in 2 weeks </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Initial Success: 14 consecutive dry nights within a 16 wk treatment </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Continued Sucess: no relapse in the 6 months after initial success </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Complete Success: no relapse in the 2 years after initial success </div> <div> PATHOGENESIS:</div> <div> 1. Development of Bladder Control</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">babies - void 12-16 times per day </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">1-2 years - develop an awareness of a full bladder </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">2-4 years - recognize the sensation of voiding </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">develop the ability to "hold-on" </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">4-5 years - can initiate voiding voluntarily (even before the bladder is full) </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">6-7 years - can hold as necessary and void at any degree of filling </div> <div> 2. Nocturnal Enuresis</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">a developmental issue </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">delay in the development of the nocturnal release of ADH </div> <div> 3. Diurnal Enuresis</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">a behavioural issue </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">"holding-on" -> overflow incontinence </div> <div> CLINICAL FEATURES:</div> <div> 1. History </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">primary or secondary </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">nocturnal or diurnal </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">frequency </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"># of times per week </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0"># of times per night </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">risk factors </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">family history </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">recurrent UTI (frequency, dysuria) </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">constipation or encopresis </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">neurologic defects </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">diabetes mellitus (polyuria, polydypsia) </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">"holding-on" behaviour </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">squatting </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">squirming </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">dancing </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">starer </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">"holding-on" features </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">do not void when first arise in the morning </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">void only 2-3 times per day (normal 5-7 times/day) </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">short bathroom duration </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">motivation of child and family </div> <div> 2. Physical Examination</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">growth parameters </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">blood pressure </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">genital examination </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">neurologic examination </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">reflexes </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">abnormalities of extremities or spine </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">rectal examination (constipation) </div> <div> INVESTIGATIONS:</div> <div> 1. First Line</div> <div> 1. Primary Enuresis</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">complete urinalysis </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">R & M, C & S, osmolality (day & night) </div> <div> 2. Secondary Enuresis</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">complete urinalysis </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">renal ultrasound </div> <div> 2. Second Line</div> <div> 1. Imaging Studies</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">renal ultrasound </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">VCUG - measures bladder capacity </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">cystoscopy </div> <div> 2. Osmolality</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">9 urine samples over 3 consecutive days at 1600, 2200 and 1st am samples while the child is fluid restricted to 25cc/ kg/day </div> <div> 3. Bladder Capacity</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">normal capacity in average child is age + 2 = ounces (i.e., 6 year old will have a bladder capacity of 8 ozs.) </div> <div> MANAGEMENT:</div> <div> 1. Patient and Family Counselling</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">to provide reassurance and emotional support </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">describe scope of enuresis in society </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">explain correctable organic causes of enuresis </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">explain that enuresis is a self-resolving condition and not a disease </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">explain that child has no control over condition </div> <div> 2. Correct any underlying causes</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">UTI (antibiotics prophylaxis for recurrent UTI - Septra qhs) </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">constipation </div> <div> 3. Manage daytime wetting before nighttime wetting</div> <div> 4. Principles of therapy (3)</div> <div> 1. Increase Bladder Capacity</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">for daytime wetting </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">double fluid intake in order to make "holding-on" more difficult </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">oxybutynin or an anticholinergic agent to control bladder instability </div> <div> 2. Establish Circadian Rhythm of Serum ADH</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">DDAVP (desmopressin) </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">an analogue of antidiuretic hormone (ADH) </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">acts by duplicating the normal nighttime increase in </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">ADH </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">initially use 10 ug intranasally qhs x 3 nights and if no effect increase to 20 ug intranasally qhs x 3 nights and if no effect increase to 30 ug intranasally qhs x 3 nights and if no effect increase to 40 ug intranasally qhs x 3 nights </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">high rate of recurrence once terminated (not curative) </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">works best in those older than 8 years </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">response within 1 week </div> <div> 3. Patient Conditioning</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Alarm Systems </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Palco </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">works best in older children ( > 6 years) </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">10% spontaneous remission but 30% non-responders </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">child and family must be motivated for this to work </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">expect response over 3-4 weeks with low relapse rate </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">if 2 wks dry -> challenge </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">if 2 wks dry on challenge -> cured </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Reward System </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">child takes responsibility for problem - changes sheets, star system </div> <div> 5. Others</div> <div> 1. Imipramine</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">an antidepressant thought to decrease the level of sleep in those children who are deep sleepers </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">initial dose of 25 mg po qhs; may be increased to 50 then 75 mg po qhs </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">dose dependent and once dryness achieved a gradual withdrawal over a few months is necessary </div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">effectiveness is not related to serum levels </div> <div> 2. Voiding Routine</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.gif" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">void q1.5-2h </div> <bR> <bR> <div> <TABLE BORDER="0" CELLPADDING="1" CELLSPACING="1" WIDTH="628" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="VOID" RULES="NONE" ALIGN="BOTTOM" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=TOP COLSPAN=3 BGCOLOR=#800080 HEIGHT= 19 WIDTH="620"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="19" ALIGN="bottom" WIDTH="620" HSPACE="0" VSPACE="0"></tD> </tR> <tR> <tD VALIGN=TOP COLSPAN=3 HEIGHT= 62 WIDTH="620"><div> <B>TABLE 1</B> </div> <div> Possible Etiologies of Primary Nocturnal Enuresis<FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <bR> </tD> </tR> <tR> <tD VALIGN=BOTTOM HEIGHT= 38 WIDTH="89"><div> <B>Factor</B> </div> <bR> </tD> <tD VALIGN=BOTTOM WIDTH="333"><div> <B>Pathophysiology</B> </div> <bR> </tD> <tD VALIGN=BOTTOM WIDTH="196"><div> <B>Evidence</B> </div> <bR> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 57 WIDTH="89"><div> Developmental delay</div> </tD> <tD VALIGN=TOP WIDTH="333"><div> Delayed functional maturation of the central nervous system causing failure of arousal</div> </tD> <tD VALIGN=TOP WIDTH="196"><div> Spontaneous cure rate as children grow older, animal studies </div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 57 WIDTH="89"><div> Genetics</div> </tD> <tD VALIGN=TOP WIDTH="333"><div> Unclear</div> </tD> <tD VALIGN=TOP WIDTH="196"><div> Family history, gene identification, linkage analysis</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 38 WIDTH="89"><div> Sleep disorder</div> </tD> <tD VALIGN=TOP WIDTH="333"><div> Deep sleep</div> </tD> <tD VALIGN=TOP WIDTH="196"><div> Sleep studies</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 76 WIDTH="89"><div> Behavior and psychologic disorders</div> </tD> <tD VALIGN=TOP WIDTH="333"><div> Unclear</div> </tD> <tD VALIGN=TOP><NOBR><div> Result rather than cause</div> </NOBR></tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 76 WIDTH="89"><div> Anatomy</div> </tD> <tD VALIGN=TOP WIDTH="333"><div> None found</div> </tD> <tD VALIGN=TOP WIDTH="196"><div> Children with primary nocturnal enuresis have normal physical examinations</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 57 WIDTH="89"><div> Antidiuretic hormone levels</div> </tD> <tD VALIGN=TOP WIDTH="333"><div> Low level of nighttime antidiuretic hormone secretion in children with primary nocturnal enuresis causes urine overproduction</div> </tD> <tD VALIGN=TOP WIDTH="196"><div> Hormone studies<FONT SIZE="1" COLOR="#000000" FACE="Arial" >5,6</FONT></div> </tD> </tR> <tR> <tD VALIGN=TOP COLSPAN=3 BGCOLOR=#800080 HEIGHT= 19 WIDTH="620"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="19" ALIGN="bottom" WIDTH="620" HSPACE="0" VSPACE="0"></tD> </tR> </TABLE></div> <bR> <div> Urodynamic and radiologic evaluation are not necessary in children with straightforward primary nocturnal enuresis. </div> <div> <B>Treatment </B></div> <div> The first step toward proper treatment is to have the child's parents complete a questionnaire that reviews the child's history of enuresis. The physician should also consider the following points: children younger than six years of age are generally not evaluated if they have enuresis and no other ongoing urologic problems; treatment modalities will not be successful if the parents and the child do not have a cooperative attitude, and treatment will be unsuccessful if the family's social structure and home environment do not provide consistent support and care for the child. </div> <div> Consistent follow-up is essential in gauging the results of therapeutic intervention. Objective documentation using a diary can help the physician, the patient and the family monitor progress. Improvement is usually defined as a 50 percent reduction in the number of nights that bed-wetting occurs. Cure or resolution of primary nocturnal enuresis is defined as only one or two wet nights over a three-month period, and documentation that the child has wakened spontaneously and gone to the bathroom to void. </div> <div> Treatment of nocturnal enuresis can be divided into two broad categories: nonpharmacologic and pharmacologic. Nonpharmacologic treatment of enuresis includes motivational therapy, behavior modification (conditioning therapy), bladder-training exercises, psychotherapy, diet therapy and hypnotherapy. Because of increased awareness that primary nocturnal enuresis can be a significant psychosocial stressor, pharmacologic treatment of primary nocturnal enuresis has evolved significantly over the past 15 years, and safer, more effective medications are now available. </div> <div> <B>Nonpharmacologic Methods</B></div> <div> <I>Motivational Therapy.</I> Motivational therapy for the treatment of nocturnal enuresis involves reassuring the parents and the child, removing the guilt associated with bed-wetting and providing emotional support to the child. The child should be instructed about taking responsibility for his or her bed-wetting. In other words, children with nocturnal enuresis should be helped to understand the condition and to realize that while they did not cause the problem, they do have a role in the treatment plan. </div> <div> Positive reinforcement for desired behavior should be instituted. One way to carry out a program of motivational therapy is to set up a diary and chart, with a reward system for each night the child stays dry. </div> <div> The cure, or resolution rate for children receiving motivational therapy has been estimated to be only 25 percent (a figure close to the 15 percent rate of spontaneous resolution), yet up to 70 percent of children with primary noctural enuresis show marked improvement.<FONT SIZE="1" COLOR="#000000" FACE="Arial" >23</FONT> Long-term follow-up is necessary, however, and a relapse rate of approximately 5 percent has been reported.<FONT SIZE="1" COLOR="#000000" FACE="Arial" >24</FONT> </div> <div> Motivational therapy appears to be a reasonable first-line approach to treating children with primary nocturnal enuresis, especially younger children. However, if therapy is not successful within three to six months, a different treatment option (e.g., behavior modification or pharmacologic therapy) should be offered. </div> <div> Hypnotherapy, diet therapy and psychotherapy are treatment modalities that have not been widely used in children with primary nocturnal enuresis. Hypnotherapy has had good success rates in limited trials, but there has been no long-term follow-up. Diet therapy also may be an option for some patients. Children with a higher caffeine intake may be more prone to enuretic episodes. Foods suspected to be contributing agents for enuresis include dairy products, chocolate, and citrus fruits and juices.<FONT SIZE="1" COLOR="#000000" FACE="Arial" >25</FONT> </div> <div> <I>Behavioral Conditioning.</I> Behavioral conditioning in the treatment of primary nocturnal enuresis is based on the use of a signal alarm device. When the child voids in bed, a moisture-sensing device that has been placed near the genitals is activated and triggers an alarm. This evokes a conditioned response of waking and inhibiting urination. </div> <div> Various alarm devices are currently available. The alarm is either a sound or a vibratory device. We prefer the vibratory alarm because we have found it to be more effective than the sound devices in waking children. We do not recommend using the alarm with children younger than seven years of age. </div> <div> Alarm therapy requires a cooperative and motivated child and family. Parental involvement is very important when using alarm devices. Involvement includes recording the child's responses to the device and monitoring his or her progress. Again, use of a diary and a reward system may help reinforce the desired behavior. Parents should be told that this form of therapy will require a long-term commitment as results may not be evident for several months. </div> <div> Long-term success using signal alarm devices has been reported in approximately 70 percent of children with primary nocturnal enuresis.<FONT SIZE="1" COLOR="#000000" FACE="Arial" >26</FONT> We recommend that children use the alarm devices until they experience three weeks of complete dryness. Relapse rates are higher when the alarm system is discontinued after shorter dry periods. Overall, relapse occurs in 20 to 30 percent of patients. Relapse is certainly not incompatible with restarting alarm treatment, and results are generally good with consistent use. </div> <bR> <div> <TABLE BORDER="0" CELLPADDING="1" CELLSPACING="1" WIDTH="628" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="VOID" RULES="NONE" ALIGN="BOTTOM" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=TOP COLSPAN=3 BGCOLOR=#800080 HEIGHT= 19 WIDTH="620"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="19" ALIGN="bottom" WIDTH="620" HSPACE="0" VSPACE="0"></tD> </tR> <tR> <tD VALIGN=TOP COLSPAN=3 HEIGHT= 62 ><NOBR><div> <B>TABLE 2</B> </div> <div> Some Alarm Devices for the Treatment of Primary Nocturnal Enuresis<FONT SIZE="3" COLOR="#000000" FACE="Arial" > </FONT></div> <bR> </NOBR></tD> </tR> <tR> <tD VALIGN=BOTTOM HEIGHT= 38 WIDTH="206"><div> <B>Device</B> </div> <bR> </tD> <tD VALIGN=BOTTOM WIDTH="206"><div> <B>Manufacturer</B> </div> <bR> </tD> <tD VALIGN=BOTTOM WIDTH="206"><div> <B>Cost*</B> </div> <bR> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 56 WIDTH="206"><div> Wet-Stop</div> </tD> <tD VALIGN=TOP WIDTH="206"><div> Palco Labs</div> <div> Santa Cruz, Calif.</div> <div> 800-346-4488</div> </tD> <tD VALIGN=TOP WIDTH="206"><div> $65.00 </div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 56 ><NOBR><div> Nytone Enuretic Alarm</div> </NOBR></tD> <tD VALIGN=TOP><NOBR><div> Nytone Medical Products</div> <div> Salt Lake City, Utah</div> <div> 801-973-4090</div> </NOBR></tD> <tD VALIGN=TOP WIDTH="206"><div> 53.50</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 56 WIDTH="206"><div> Potty Pager</div> </tD> <tD VALIGN=TOP WIDTH="206"><div> Ideas for Living</div> <div> Boulder, Colo.</div> <div> 800-497-6573</div> </tD> <tD VALIGN=TOP WIDTH="206"><div> 49.95</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 56 WIDTH="206"><div> Nite Train'r</div> </tD> <tD VALIGN=TOP><NOBR><div> Koregon Enterprises </div> <div> Beaverton, Ore.</div> <div> 800-544-4240</div> </NOBR></tD> <tD VALIGN=TOP WIDTH="206"><div> 69.00</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 56 WIDTH="206"><div> Sleep Dry</div> </tD> <tD VALIGN=TOP WIDTH="206"><div> Star Child Labs</div> <div> Aptos, Calif.</div> <div> 800-346-7283</div> </tD> <tD VALIGN=TOP WIDTH="206"><div> 45.00 </div> </tD> </tR> <tR> <tD VALIGN=TOP COLSPAN=3 HEIGHT= 57 WIDTH="620"><bR> <div> *--Manufacturers' prices, rounded to the nearest dollar. Shipping and handling charges are not included. </div> </tD> </tR> <tR> <tD VALIGN=TOP COLSPAN=3 BGCOLOR=#800080 HEIGHT= 19 WIDTH="620"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="19" ALIGN="bottom" WIDTH="620" HSPACE="0" VSPACE="0"></tD> </tR> </TABLE></div> <bR> <div> <B>Another method of behavioral conditioning involves waking the child two to three hours after he or she has gone to sleep, eliciting a conditioned response of waking when the bladder is full. The success rate of this technique is unknown. Most parents who use this technique report having difficulties in gaining their child's cooperation with this program. </B></div> <bR> <div> <B>Bladder-Training Exercises. It is possible that functional bladder capacity may be reduced in children with enuresis, causing premature bladder emptying during the night.27 As mentioned previously, urodynamic studies have not demonstrated a reduced functional bladder capacity in children with enuresis.20 </B></div> <bR> <div> <B>However, in some children with a small bladder capacity, the use of bladder-retention training during the day may help increase bladder capacity at night. This training is accomplished by having the child hold his or her urine for increasing periods of time. In one study27 of children undergoing six months of bladder-retention training, 66 percent of children reported some improvement, and 19 percent experienced complete resolution of symptoms. Bladder capacity increased significantly in patients who responded to this therapy. However, this is the only study to document such improvements, and results from this study must be validated by more data. </B></div> <bR> <div> <B>Pharmacologic Therapy</B></div> <div> <B>Pharmacologic therapy for the treatment of primary nocturnal enuresis is usually reserved for use in children older than seven years of age. Two approaches to drug therapy can be used. One approach is to increase bladder capacity. The other is to reduce the amount of urine produced by the kidneys. Again, a careful examination and medical history, including a history of previous treatment, should be performed before drug therapy is initiated. </B></div> <bR> <div> <B>Several medications are available for the treatment of primary nocturnal enuresis (Table 3); however, none of these medications cures enuresis. Instead, they provide a stopgap measure until the children are able to wake on their own during the night to void. Parents should not expect immediate results and should be made aware of the potential side effects of the medications. Because both the parent(s) and the physician are generally reluctant to use medication as a first-line treatment, drug therapy is often reserved for use in children who have shown no success with other treatment modalities. In some cases, however, family circumstances and/or the need for quick symptomatic relief may make drug therapy a valuable first-line option. </B></div> <bR> <div> <B> </B></div> <div> <B>TABLE 3 </B></div> <div> <B>Pharmacologic Therapy for the Treatment of Primary Nocturnal Enuresis </B></div> <div> <B>--------------------------------------------------------------------------------</B></div> <div> <B> </B></div> <div> <B>Drugs </B></div> <div> <B>--------------------------------------------------------------------------------</B></div> <div> <B> Cost* </B></div> <div> <B>--------------------------------------------------------------------------------</B></div> <div> <B> </B></div> <div> <B>Imipramine (Tofranil) 30 tablets, 25 mg, $14.00; generic: 30 tablets, 25 mg, $1.75 to $2.00 </B></div> <div> <B>Oxybutynin (Ditropan) 90 tablets, 5 mg, $44.00; generic: $27.00 to $33.25; 480 mL, generic: $40.00 to $53.00 </B></div> <div> <B>Hyoscyamine (Levsin) 90 tablets, 0.125 mg, $34.25; generic: 90 tablets, $11.75 to $14.00 </B></div> <div> <B>Levsinex Timecaps 60 capsules, $43.75; generic: 60 capsules, $14.25 to $15.00† </B></div> <div> <B>Desmopressin acetate (DDAVP) 5-mL nasal spray, $121.25‡; 0.1 mg, 60 tablets, $96.75; 0.2 mg, 60 tablets, $156.25 </B></div> <bR> <div> <B>--------------------------------------------------------------------------------</B></div> <bR> <div> <B>*--Estimated cost to the pharmacist based on average wholesale prices, rounded to the nearest quarter dollar, in Red book. Montvale, N.J.: Medical Economics Data, 1997. Cost to the patient will be higher, depending on prescription filling fee. </B></div> <bR> <div> <B>†--Check product for generic equivalency. </B></div> <bR> <div> <B>‡--Not available in generic form. </B></div> <div> <B> </B></div> <div> <B> </B></div> <div> <B> </B></div> <div> <TABLE BORDER="0" CELLPADDING="1" CELLSPACING="1" WIDTH="627" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="VOID" RULES="NONE" ALIGN="BOTTOM" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=TOP COLSPAN=2 BGCOLOR=#800080 HEIGHT= 19 WIDTH="621"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="19" ALIGN="bottom" WIDTH="621" HSPACE="0" VSPACE="0"></tD> </tR> <tR> <tD VALIGN=TOP COLSPAN=2 HEIGHT= 62 ><NOBR><div> <B>TABLE 3</B> </div> <div> Pharmacologic Therapy for the Treatment of Primary Nocturnal Enuresis </div> <bR> </NOBR></tD> </tR> <tR> <tD VALIGN=BOTTOM HEIGHT= 38 WIDTH="310"><div> <B>Drugs</B> </div> <bR> </tD> <tD VALIGN=BOTTOM WIDTH="310"><div> <B>Cost*</B> </div> <bR> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 38 WIDTH="310"><div> Imipramine (Tofranil)</div> </tD> <tD VALIGN=TOP WIDTH="310"><div> 30 tablets, 25 mg, $14.00; generic: 30 tablets, 25 mg, $1.75 to $2.00</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 38 WIDTH="310"><div> Oxybutynin (Ditropan)</div> </tD> <tD VALIGN=TOP WIDTH="310"><div> 90 tablets, 5 mg, $44.00; generic: $27.00 to $33.25; 480 mL, generic: $40.00 to $53.00</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 38 WIDTH="310"><div> Hyoscyamine (Levsin)</div> </tD> <tD VALIGN=TOP WIDTH="310"><div> 90 tablets, 0.125 mg, $34.25; generic: 90 tablets, $11.75 to $14.00</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 38 WIDTH="310"><div> Levsinex Timecaps</div> </tD> <tD VALIGN=TOP WIDTH="310"><div> 60 capsules, $43.75; generic: 60 capsules, $14.25 to $15.00†</div> </tD> </tR> <tR> <tD VALIGN=TOP HEIGHT= 38 ><NOBR><div> Desmopressin acetate (DDAVP)</div> </NOBR></tD> <tD VALIGN=TOP WIDTH="310"><div> 5-mL nasal spray, $121.25‡; 0.1 mg, 60 tablets, $96.75; 0.2 mg, 60 tablets, $156.25</div> </tD> </tR> <tR> <tD VALIGN=TOP COLSPAN=2 HEIGHT= 113 WIDTH="621"><bR> <div> *--Estimated cost to the pharmacist based on average wholesale prices, rounded to the nearest quarter dollar, in Red book. Montvale, N.J.: Medical Economics Data, 1997. Cost to the patient will be higher, depending on prescription filling fee. </div> <div> †--Check product for generic equivalency. </div> <div> ‡--Not available in generic form. </div> </tD> </tR> <tR> <tD VALIGN=TOP COLSPAN=2 BGCOLOR=#800080 HEIGHT= 19 WIDTH="621"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="19" ALIGN="bottom" WIDTH="621" HSPACE="0" VSPACE="0"></tD> </tR> </TABLE></div> <bR> <bR> <div> <B><IMG SRC="05a04040.gif" border=0 width="4" height="4" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></B><FONT SIZE="3" COLOR="#000000" FACE="Arial" >No pharmacologic method cures enuresis, but pharmacology can be used as a stopgap measure until patients are able to wake and void on their own.</FONT></div> <bR> <bR> <bR> </td> </tr></table></body>