BİRİNCİL VE İKİNCİL UYKUDA ALTINA İŞEYEN ÇOCUKLARDA TANI, SAĞALTIM VE İZLEM FARKLILIKLARI

Amaç:Bu çalışmada uykuda altına işeme şikayeti ile başvuran hastalarda genelde önerilen laboratuvarincelemelerinin gerekliliği, verilen sağaltımlara alınan yanıtların araştırılması ve bu bulguların birincil ve ikinciluykuda altına işeyen olgularda karşılaştırılması planlandı.Yöntem:Bu çalışmaya birincil ve ikincil tek belirtili uykuda altına işeme tanısı alan 169 olgu (ortalama yaş 9,482,60 yaş, %59,2'si erkek, %40,8'i kız) dahil edildi. Sağaltıma başlamadan önce her hastaya açlık kanşekeri, böbrek fonksiyon testleri, gaitada parazit, tam idrar bakısı, idrar kültür antibiyogramı ve böbrekultrasonografisi istendi. Sonuçlara göre hastalara körlemesine önce davranış sağaltımı yanıt alınamazsa alarmcihazı, imipramin tablet, desmopressin nazal sprey ve gerekenlere oksibutinin sağaltımlarından birisi verildi.Veriler SPSS 10,0 programında ki-kare testiyle değerlendirildi.Bulgular:Altına işeme yakınmasıyla (gece+gündüz) polikliniğimize başvuran tüm olguların %85,2'si birincil,%14,8'i ikincildi. Sadece ikincil gündüz idrar kaçırma oranı ise %12,2 idi. %78,7 çocukta ailede altına işemehikayesi mevcuttu. Polikliniğimize başvuran hastaların %84,6'sı daha önce hiç sağaltım almamıştı. Tümolgularda açlık kan şekeri, böbrek fonksiyon testleri ve karın ultrasonografi normaldi. %3,6'sında idrarkültüründe üreme oldu. %13,6 çocukta gaitada parazit saptandı. Cins, aile hikayesi, gaitada parazit, gündüz idrarkaçırma sıklığı ve enkopresis açısından birincil ile ikincil altına işeyenler arasında anlamlı bir fark yoktu. Birincilolanlarda her gece idrar kaçırma oranı ikincil olanlara göre daha fazla saptandı. İkincil altına işeyen çocuklardatam idrar bakısı ve idrar kültürü birincil altına işeyenlere göre anlamlı olarak daha patolojikti. Birincil olanlardavranış sağaltımına ikincil olanlardan daha iyi cevap veriyorlardı. Diğer sağaltım yöntemlerinde iki gruparasında anlamlı fark saptanmadı.Sonuç:Uykuda altına işeme yakınmasıyla başvuran çocuklarda özellikle ikincil olanlarda mutlaka idrar veparazit incelemeleri yapılmalı ve altta yatan bir neden olup olmadığı araştırılmalı ve buna uygun sağaltımyapılmalıdır. Birincil olanlarda ise her olguda öncelikle ucuz ve uygulanımı kolay olan davranış sağaltımıdenenmelidir

Anahtar Kelimeler:

Uykuda altına işeme, tanı, sağaltım

The Differences in Diagnosis, Treatment and Follow up in Primary and Secondary Enuresıs Nocturna in Children

Aims: In this study, we planned to evaluate the response to the medical treatment, the need for laboratory investigations in, primary and secondary enuretic children and to compare the results between former and the latter. Materials and methods: This research was done in 169 children (mean age 9,48 2,60 (5-15), 59,2% male) who had the diagnosis of primary and secondary monosymptomatic enuresis nocturna. Before the treatment, blood glucose level, renal function tests, presence of parasite in faeces, urine analysis, urine culture and renal ultrasound were assessed in all of the patients. According to the results of these tests one of the following treatment strategies were planned behavioural therapy, alarming device, imipramine, desmopressine nazal spray and if necessary oxibutinine. The results were evaluated with chi square test in SPSS 10,0 programme. Results: Among children who applied to our outpatient clinic with complaint of bed wetting, 85,2% had primary enuresis and 14,8% had secondary enuresis. The rate of secondary enuresis diurna was 12,2%. Family history of enuresis was present in 78,7% of children. Eighty four percent of children who applied to our outpatient clinic had never taken any treatment. Blood glucose levels, renal function tests and renal ultrasound were normal in all. 3,6% of the children had urinary infection detected by urine culture. Parasites were detected in faeces in 13,6% of children. There was no significant difference in sex, family history, present of parasite, frequency of enuresis diürna and encopresis between primary and secondary enuretics. Primary enuretics were found to have higher frequency of enuresis than secondary enuretics. Urine analysis and urine culture were more significantly pathologic in secondary enuretics compared to primary enuretics. Response to behaviour therapy was better in primary enuretics than secondary enuretics. We didn't find a significant difference between primary and secondary enuretics, in different treatment models. Conclusion: Urine analysis and parasite search in feaces should be done in children who present with enuresis nocturna, especially ones with secondary reasons. In addition, whether there is any underlying reason is present or not, such a cause should be searched and suitable treatment should be given. Conditioning therapy as an affurtable and easy treatment option should be the initial choice for used in primary enuretics.

Keywords:

Enuresis nocturna, diagnosis, treatment,

PDF

___

1. Rushton H.G. Enüresis. In: Kelalis P, Ring L, Belman B. Clinical Pediatric Urology Third Ed. Volume 1, Philadelphia: W.B. Saunders Company, 1992: 365- 379.
2. Rushton HG. Enuresis. In: Kher KK, Makker SP editors. Clinical Pediatric Nephrology. New York: Mc Graw Inc, 1992: 399-419.
3. Meadow SR. Enuresis. In: Edelmann CM Jr, Bernstein J, Meadow SR, Spitzer A, Travis LB. Pediatric Kidney Disease Second Edition. Little Brown Company, 1992: 2015-25.
4. Jalkut M.W. Enuresis. Pediatric Clinics Of North America. Philadelphia: W.B. Saunders Company, 2001: 48(6).
5. Koff SA, Enuresis. In: Walsh-Retik-Stamey-Vaughan Campbell's Urology, Seventh Edition, Volüme 2, Philadelphia: W.B. Saunders Company, 1993: 2055- 2068.
6. Norgaard J, Rittig S, Djurhuus JC. Nocturnal enuresis: An approach to treatment based on pathogenesis. The Journal of pediatrics 1989; 114: 705-710.
7. Norgaard JP, Pedersen EB, Djurhuus JC. Diurnal antidiuretic hormone levels in enuretics. The Journal of Urology 1985; 134: 1029-1031.
8. Rittig S, Knudsen UB, Norgaard JP et al. Abnormal diurnal rhythm of plasma vasopresin and urinary output in patients with enuresis. Am. J. Physiology 1989; 256: 664-671.
9. Steffns J, Netzer M, Isenberg E, Alloussi S, Ziegler M. Vasopressin deficiency in primary nocturnal enuresis. Eur Urol 1993; 24: 366-70.
10. Djurhuus JC, Rittig S. Current trends, diagnosis and treatment of enuresis. Eur Urol 1998; 33: 30-33.
11. Eiberg H, Berendt I, Mohr J. Assignment of dominant inherited nocturnal enuresis (ENUR 1) to chromosome 13q. Nat Genet 1995; 10: 354-356.
12. Riccabona M, Oswald J, Glauninger P. Long-term use and tapered dose reduction of intranazal desmopressin in the treatment of enuretic children. BJU 1998; 81:24- 25.
13. Berman S. Enuresis (Bedwetting). In: Barton D. Schmitt MD. Pediatric Decision Making, St. Louis, Missouri. Mosby Year Book, Inc. Third edition, 1996: 38-39.
14. Gilman RH, Marquis GS, Miranda E. Prevalence and symptoms of Enterobius vermicularis infections in a Peruvian shanty town Trans R Soc Trop Med Hyg. 1991;85:761-4.
15. Knudsen UB, Rittig S, Norgaard JP. Longterm treatment of nocturnal enuresis with desmopressin. Urol Res 1991;19:237-40.
16. Ouedraogo A, Kere M, Ouedraogo T, Jesu F. Epidemiology of enuresis in children and adolescents aged 5-16 years in Ouagadougou.Arch Pediatr 1997; 4: 947-51.
17. Monda JM, Husmann DA. Primary nocturnal enuresis: a comparison between observation, imipramine, desmopressin acetate and bed-wetting alarm systems. J Urol 1995;154: 745-8.
18. Birkasova M, Birkas O, Flynn MJ. Desmopressin in the management of nocturnal enuresis in children: a double-blind study. Pediatrics 1978; 62:970-4.
19. Tuvemo T. DDAVP in childhood nocturnal enuresis. Acta Paediatr 1978; 67:753-5.
20. Janknegt RA, Smans AJ. Treatment with desmopressin in severe nocturnal enuresis in childhood. Br J Urol 1990; 66: 535-7.
21. Terho P. Desmopressin in nocturnal enuresis. J Urol 1991; 145:818-20.
22. Hunsballe JM, Hansen TK, Rittig S, Pedersen EB, Djurhuus JC. The efficacy of DDAVPis related to the circadian rhythm of urine output in patients with persisting nocturnal enuresis. Clin Endocrinol (Oxf) 1998; 49: 793-801
23. Moffatt ME, Harlos S, Kirshen AJ, Burd L. Desmopressin acetate and nocturnal enuresis: how much do we know? Pediatrics 1993; 92: 420-5.
24. Butler R, Holland P, Devitt H. The effectivenes of desmopressin in the treatment of childhood nocturnal enuresis: predicting response using pretreatment variables. British journal of Urology 1998; 81: 29-36.
25. Hjalmas K, Hanson E, Hellström AL. Long-term treatment with desmopressin in children with primary monosymptomatic nocturnal enuresis: an open multicentre study. British J Urol 1998; 82: 704-9.