Enuresis

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????? ?????? Enuresis

• ????? ??????
• ?. ?????? ?????
• ???????? ?? ?? ???????
• ???? ?????? ????????
• ????? ???

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?????

• ???? ????? ?????????(?????)?? ????? ???? ??? ???
  ??? ?????? ???????.
• ????? ?????
• ??? ????? ?????? Primary ?? Persistant bed
  wetting ??? ?????? ?????? ??????? ?????? ?????
  never dry at night.
• ??? ????? ??????? ?? ???????? Regressive or
  secondary ??? ???? ?????? ??? 6???? ??? ??? ??
  ????????, ??? ????? ????????? ????? ???? ????
  ??? ?????? ???? ????? ????? ???? - ?? ????
  ??? ????? ???????, ??? ????? ???? Temporary
  ??????? ???.

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????? ?????? ??????? Complicated Enuresis

• ??? ??? ???? ????
• ???? ????? ????? ??????.
• ?? ??? ???? Poor stream.
• ????? ????? ????? ?? ??? ??? ??????.
• ??? ????? ?? ????? ????.
• ????? ????? ??????.

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• mono symptomatic uncomplicatecd enuresis
• ?????? ??? nocturnal
  enuresis
• ?????? ??? Secondary
  enuresis

8
???? ??????? ????? ????? ??? ???? ?????
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• 25-30 ?? ??????? ????? ??? ???? ?????.
• ???? ?????? ????.
• ??? ??? ?????? ???? ????? ? 15 ?????? ??????
  ??????? ?????? ?? ?? ????????.

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???? ????? ??? ????? ????????
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(No Transcript)
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??? ??????? sphinctor control

• ??? ?????? ??????? ?????.
• ??? ?????? ??????? ??????.
• ??? ?????? ??????? ??????.
• ??? ?????? ??????? ?????.

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• ?????? ??????? ???????? ????? ???? ?????? ?????
  ?????? ???? ????? ???????? ?????? ????????
  ???????? ??? ?????? ?????? ??? ?????? ??????
  ??????? ???????? ??????? ??????? ??????.
• ??? ???? ?????? ??? ?????? 20??? ?? ??????
  ???????? 40 ?? ?????? ???? ????? ?????, ??? ????
  ????? ??? ??? ?????? ????? ??? ?????.
• ?? ??? 2- 3 ????? ???? ?????? ??????? ??? ???
  ???4 ????? ????? ?????? ????? ??????.

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????? ????? ??????

• Multifactorial
• ??????
• ?????- ????????.
• ??????- ???? ???????.
• ??????- ????? ???????? ???????.
• ??????- ?????? ????? ??????.
• ??????- ?????? ????? ADH.
• ??????- ???????.
• ??????- ?????? ?????????? ????????.

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?????-????????

• ?? ??? ???.
• ??? ????? ?? ??? coca kola ??????2.5 5??? ??
  ???????, ??? ????(12?????) ????3060??? ???72
  ???.
• ??????? ?????????????? ?? 2 ??? / ?? ????? ????.
• ??????? ???? ???? ??? FDA ??6???/????? ????.
• ????? ?????? ?????? ?? ??????3060???/???(?????30
  ??).
• ???????? ???????? ??????? ???? ????????.
• ???? ???? ??? ????? ????????? ?? ????? ????????.

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??????-???? ???????

• 1/3??????? ????????? ?? ???? ??????? ?????? ?2/3
  ???? ?? ???? ??????? ?????????
• ?? ???? ????? ??????? ????? ???? ???? ??? ????,
  ???? ???? ??????? ?????? ??????40 ?? ???????
  ?????? ?40 ????? ?20 ?????

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??????-????? ???????? ??????? functional bladder
capacity

• ????? ????? ???????? ??????? ?? ?????, ??? ????
  ??? ???? ??? ????? ?? ????? ???????? ???????
  ????? ????? ????????? ?? ??????? ?? ??????? ????
  ????? ??? ??? 50.

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??? ??????? ????????
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??????-?????? ????? ??????dysfunctional voiding

• ???? ???? ??uroflow study ?????? ??????
  ?????? ??? ????? ??????? ?? ??????? ??? ??????
  residual volume ??? ???? ??? ????? ?????? ?????
  ????? ???? ?????????? ?????? ???? ?????? ?????
  double voiding.

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??????-?????? ????? ADH

• ?? ??????? ???????? ???? ????? ?????? ????? ?????
  ???? ???? ????? ADH, ???? ???????
• ???? ???? circadian rhythm?? ???? ?????.
• ????? ??? ????? ????? ????????? ?????.
• ????????? ??? ???? ??? ?? ??? ?????
  ?????.
• ??? ???? ??? ????? ??? ???? ????? ???? ???????
  ????? ???????? ???? ??????? ?? ?????.

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??????-???????

• ??? ????? ?????? ???? ????? ?? ?????? ??????
  ????? ???? 1.
• ??? ????? ????? ??? 9411 ???? ?? ?? ??????? ????
  ???? bacteruria ??? 1.5?? ???????? ???? 5.6??
  ???? ??? ?????? ???? ??? ????? ?????? ????
  ??????? ??????.
• ??????? ????? ????? cystitis cystica ????? ?????
  ??????- ???? ????- ?? ??? ????- ?? ??? ??? ????
  ?????? ??????? ???? ????? ????? ??? ???? ????
  ????????.
• ?????? ????? ?????? ???? ?? ???? ??? ???? ?????
  ??????? ?? ?????? ???????? ???????? ???? ???????
  ????? ????? ??????? ???????.

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??????-?????? ?????????? ????????

• ???? ????? ?????? ?? ????????? ??????? ????.
• ?????? ??????? ?? ????? ???? ??? ?????? ??
  ???????? ?? ??? ?????.

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????? ???????

• ?????? ?? ??? ???? ??????? - ???? - ?????
• ??? ???? ????? ?? ?? ????.
• ?? ???? ??? ??????? ????? ?? ????? urgency ?? ???
  ???? ?? ????? ?? ????? ???? ????? ??????
  posturing.
• ?? ???? ??? ????? ????? ?? ?????.
• ?? ?????? ????? ????????, ?? ?? ???? ???????
  ?????????.
• ?? ???? ??? ??????.
• ??? ?????? ????? ?? ????? (??? ?? ???????!).
• ?? ?? ?????? ?????????? ???????????.
• ?? ?? ?????? ??????? ?????.
• ?? ???? ????? ????? ???????????.
• ??? ???? ?????? ???? ?????, ???? ???? ?????.

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??? ???? ?????? ?? ??? 24 ????
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????? ???????

• ??? ??? ??????? ????????????? ????? ???? ??? ????
  ???? ????? ?? complex enuresis.
• ??? ????? ?????? ?????hairy patch, dimple,
  sacral agenesis.
• ??? ??????? ????????? ?? ???? hypospadias or
  epispadias.
• ??? ????? ?? ???? ????? ????? ?? ??? ??????.
• ??? ??? ?????????, ?????.........
• ??? ?????? ??????? ?? L5 ???? S3

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??????????? ????????

• ??? ????? ???? ??????? ??????, ???????? ???????,
  ????? ????? ??????, ?? ??? ?????.
• ???? functional bladder capacity ???? ??? ???
  ???? ?? ????? ??? ????? ????? ???? ????? ?? ????
  ??? ??????? ?????? ???????? ??? ?????.
• Uro-flow study ??? ???? ????? ????? ?????? ??
  slow stream ?? ???? ???? ?????? ??? ????? ???????
  post-void residual ????? ?? ????? ??????? ??????
  double void.
• Urography.
• cystourography.
• renal sonography.

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?????? treatment

• ????? ?????? ???????? ??? ?? ???????, ????? ??
  ?????? ?? ??? 7- 8 ????? socialization.
• ??? ??? ????? ??? ??? ??????? ??? ??? ?????
  ??????? ??? ????.
• ???? ????? ????? 15 ?? ?? ???.
• ?15?? ???? ??? ????? ?????? ????? ??? ?????.
• ?15?? ???? ??? ????? ?????? ????? ??? ?????.

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????? ??????

• ????? ??????
• ????? ????????? Responsibility Reinforcement.
• ???? ????? ???????.
• ????? ??????? bladder training.
• ????? ??????? arousal system.
• ?????? ???????
• ??????? ???????.
• ?????? ???????? ???????? ??????.
• ?????? ???????.
• ????????????.

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????? ??????behavior modification

• ?????
• ????? ?????????.
• ???? ????? ???????.
• ????? ???????.
• ????? ???????.

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- ????? ????????? Responsibility Reinforcement

• ??? ????? ????? ??? ????? ?????.
• ??? ???? ???? ?????? ???? ????? ????????? ?? ???
  ??????.
• ?????? ????? ?? ??? ???????.
• ???? ?????? 25.
• ???? ?????? 70.

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- ???? ????? ???????

• ????? ??????? ?? ??? ????? ???? ????? ????????
  ??? ????? ???????? ?? ???? ??????? ?? ???? ??????
  ??????? (???? ?? ???? ??? ???? ?????).
• ???? ???? ?????????
• ????? ???????
• 40 ??????
• 40 ?????
• 20 ?????

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- ????? ??????? bladder training

• ??? ?? ???? ???? ??? ????? ????? ??? ?? ?????
  ???????? ???????, ???????? ??? ??? ????? ?????
  ???? ???? ?? ??? ??????? ????? ?? ??? ????
  ??????, ????? ?? ????? ?? ???? ??? ???? ??????
  ???? ????? ?? ?? ???, ?????? ???? ??? ??? ??????
  ??? ????? ?? ????? (???? ????).
• ??? ??????? ???? ??? ??????? ????? 35.
• ???? ?????? 35.

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- ????? ??????? arousal system

• ??? ??????? ???? ??? ???????? ??? ??? ????? ?????
  ????? ??? ??????, ???? ??? ???? ?????? ????? ???
  ????? ?????? ????.
• ???? ?????? ?????? ??? 30- 60 ????? ??????.
• ???? ?????? 40 70 .
• ???? ????? 20 30 .
• ???? ??????? ?????? 16 17 ?????.
• ????? ?????? ????? ??? ????? ???????? ????? ?????.

37
?????? ???????

• ?????
• ??????? ???????.
• ?????? ???????? ???????? ??????.
• ?????? ???????.
• ????????????.

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??????? ??????? antibiotics

• ????? ??? ????? ??? ??????? ??? ??? ????? ?????
  ??? ?????? ???????? ??????? ??? ?? ??? ??? ?????
  ??????(???? cystitis cystica).
• ???? ??????? ??????? ???????? ?? ???????? ?? ???
  ???? ????? ?????.
• ??? ???? ????? ????? ?? ??? ????? ????? ?????? ??
  ??? ??? ?????? ??????? ???? ????? ??? ????
  ??????? ?????????.

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?????? ???????? ???????? ?????? tricyclic anti
depressants

• Imipramine
• ?????? ??? 1960.
• ?? ????? ???? ????? ???????.
• ?? ????? ???? ???? ??? ??????? ??????? ???????.
• ??????? ?????? ???????? ???? ??? ???? ?????.
• ???? ADH.
• ?????? 25 ??? ??????? 5 - 8 ?????.
• 50 ??? ??????? ?????? ?? 8 ?????.

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• ??? 30 ?? ??????? ??? ?? imipramine ??????
  ???????? ?? ????????, ???????? ??? ??? ??????
  ???(3- 5 ?????)???? ?? ???? ?????? ???????
  ??????.
• ????????? ???????? ??? ?????, ?????
• - ?????. - ????????
  ?????.
• - ????? ?????. - ?????? ?? ???????.
• ?????? ?????? ??????? ??
• - ?????? ??? ?????. - ???? ?????.
• - ?????? ?????. - ????????.

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• ????? ??????
• ?????? ???? ?????? ??? 50- 80.
• ???? ????? 60.
• ???? ????? ????? ???????? ???? ???????, ????
  ?????? ????? ???? 3 ???? ?? ????? ?? ???? ??????
  ????????.

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?????? ??????? anticholinergics

• ??? ??? ??? ?? ??? ????? ???? ????? ???????
  ???????.
• ????? ?????? ??? ??? ?? 5-40 ????? ??? ???
  placebo.
• ???? ??? ??? ?? ???? bladder instability ????????
  ?? urodynamics ??? ???? ?????? ?? ????? ?????,
  ???? ?????, ??? ???? ???? ?????.
• ???? ??? ??? oxybutynin ???? ??????? ???? ?? ???
  ???? ????? ????? 2.5 ??? ????? ??????.

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????????????desmopressin acetate

• ??? ??????? ?????? ???????.
• DDAVP ?? ??????? ?????? ???????? ??????????? ??
  ????? ????.
• ????? ??? 1990 ??? FAD approved.
• ????? ??? ??????? ????? ??? ????? ????
  circadian rhythm ?? ??????, ??? ??? ??????? ????
  ???? ????? ?????.
• ??? ???? ??? ????? ???? ????? ??? ADH ????? ?????
  ?????.

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• ???? ????? ??? ????? ADH ????? ????? ?? ???????,
  ??? ????? ????? ??? ADH ??? ????? ???? ???????
  ??????.
• ???? ???? ????? ??? ADH ????? ???? ?????? ?????
  ?????? Diversion.
• ??? ???? ??? ??????? ????? ?????? ?????? ??????
  ?? ??? ?? ?????? ?????? ?? DDAVP, ??? ??? ??????
  ?? ???? ??? ??? ???? ??? ??????? ??????.
• ???? ???? ????? ??? ????? ??? ??????? ?? ????
  DDAVP.

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• ???? ??? DDAVP ??????? ????? ????? ??? ?? ?????
  ??? ADH ???? ???? pufs 0.1??? ????? ?????? ???
  ????? ????? ??? 0.4 ??? ?? ???? ?????????.
• ??? ??? ??? ????? ?????? ??? ????? ????? ???????
  ???, ????? ???? 0.2 ??? ??? ????? ?????? ???? 0.6
  ???(3 ????) ?????? ???? 3 ???? ?? ???? ????????.
• ???? ????? 60 ???? ??? ????? ?????? ?????.
• ???????? ?????? hyponatremia ??? ??????? ??????
  ??????.

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Elimination Dysfunction(ED)Hinman
syndrome?????? ???????

• ????? ?? ?????? ????? ?????? ??????? ????? ???
  ?????(??? ????)????? ?????? ??? ??????? ?????
  ??????? ?????? ???????? ??????? detrasor
  sphincter dyssynergia ????? ?????? nonurogenic
  neurogenic bladder ?? ???? ??? ???? ?? ????
  ?????? ?????? ????? ??? ????? ?????.

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????????? ????????

• ???? ?????? Irritative voiding.
• ??? ????.
• ????? ????? ?????.
• ?????? ?? ??????? ?????? ??????.

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???????

• ??? ???? ??????? ?????? exclusion.
• ??? ???? ?????? ?? ?????? ?? ??? ????? ?? ????
  ????? ?? Club foot ?? ???? ????? ?? ???? ?????.
• ??? ???? ?????.
• ??? ???? post.or ant. urethral valve.
• ??? ???? prune belly.
• ??? ???? ??? ???? ?? ???? ?? ????.

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??????? ???????

• ??? ??????? ???? ???? ?? ????? ?? ?????? ????.
• ????? ????? ?????.
• ????? urgency.
• ???? ????? frecuency.
• ??? ?? ?????? ????.
• ??????? ????.
• ???? ????.

50
??????? ???????

• ??? ????? fecal incontinence.
• ????? ????.
• ??? ????.
• Encopresis ?????? ??????.
• Fecal staining ???? ??????? ???????? ???????.

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???????

• ??? ??? ??? ???? ?? ???? ????.
• ????? ?? ???? ????? ? ??? ???? ?????.
• ???? ????? ?????? ????? ????? ???? ??? ?????.
• ????? ????? ????? uroflow (?????? - ????? ???
  ?????) ?? ???? ??????? ???????.
• ????? video urodynamic ?? ??????? ???????
• ???? ??? ?????.
• ????? ?? ???? ???????.
• ?????? ????? ?? ??????? ???????
  ???????.
• ??? ????????? ??????.

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??????

• ????? ??????? ???????? ???????? ?? ????????
  ?????? ??????? ???????? (????? - ?????), ???? ???
  ???? ????? ????? ?????? ???? ?????? ?? 3 ????? ??
  Double Voiding(?? ?????? ?????? ??? ????????? ??
  ?????? ????? ??? ????? ???????).
• ?? ??? ???? ????? ?? ?????? ????? ???? ??????? ??
  ?????? ?????? 0.5 ?/?? ?? ??? ????? ?? ????? 5
  ???? ?????(6 ????? ????? 11 ? ?? ???????), ????
  ????? ????? ?????? ??????.
• ????? alpha-Blocker Therapy(Doxazocin) ???????
  ??????? ???? ????? ??????? ????? ?? ??????? .
• Biofeed back ?????? ?????? ?????? ???????? ???
  ????? ????? ???? ????? ????? ????? ??????? ?????
  ?????? ?????? ???????, ??????? ?????? 80 ??
  ???????, ??????? ?? 14 ?? ???????.
• ????? ??????.
• ?????? ??????? External Urinary Diversion.

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• Thank you