Shikha Mishra

Shikha Mishra

Assam Medical School, India

Title: Enuresis and combination treatment modalities


Dr. Shikha Mishra is a young physician from India who has recently graduated from Assam Medical School in Assam. She is aspiring to match into a residency program in the USA and is currently in the United States for her Clinical Rotations. She has passion for teaching and serving underserved populations and is looking forward to a long career as a teaching clinician.


Nocturnal Enuresis is reported as one of the most common urologic complaints in pediatric patients throughout the world. The stressful, stigmatizing condition of enuresis purportedly reaching prevalence rates 14% (male dominance 16% versus female 12%)represents organic underlying pathology, genetic predisposition, psychological and emotional triggers, and commonly standard maturation process implying majority self-resolution. Potential domestic and interpersonal detrimental outcomes necessitates appropriate management via social, educational, therapeutic avenues, demanding apace awareness and ensuing counsel. Primary classification is reserved for patients having never attained aneuretical status, in contrast to Secondary Enuresis describing regression to enuresis episodes post dryness attainment for more than six months. Reinforcement methods including automated moisture triggered devices and other parent-caregiver-child behavioral modification strategies are plausible primary approaches, to be followed by more aggressive measures in cases persisting with advancing age, after necessary investigation for alternative organic explanations and proper disease classification. Pharmacological approaches in those greater than six years is more appropriate but flexibility can be applied individually based on motivation, and familial factors. Desmopressin monotherapy initiation along with regulation of fluid intake schedules tends to be among first line after establishment of normal functional bladder capacity. Similarity in mechanism between Desmopressin and AntiDiuretic Hormone effectively reduce diuresis. Desmopressin monotherapy demonstrates 30% total dryness and additional approximate 40% patients with partial improvement. Relapse rates with monotherapy being 65% reduced to 46% with Desmopressin and alarm combination. Multiple other drugs are seen in clinical practice including but not limited to tricyclic antidepressants, anticholinergics, indomethacin and diazepam, various combinations employed with varying degrees of success. Amitriptyline, Nortriptyline, Imipramine Tricyclic psychoactive agents though producing significant reduction in enuresis episodes are mirrored by sideeffect profiles potentially rendering functional uselessness to the patient. Tricyclics produces 4.2 times likelihood of aversion of enuretic episode compared to placebo alone. Oxybutynin anticholinergic mechanism targeting detrusor overactivity was shown to improve outcomes when combined with Desmopressin in event of poor response to monotherapy. Desmopressin with Tolterodine efficacy was reported as 54% versus 34 % with Desmopressin and Placebo combination.