Enuresis

Eugene R. Hershorin, MD

Enuresis - BASICS

Enuresis - description

Involuntary urination after age of expected bladder control; generally reserved for children ≥6 years:

• Generally refers to nocturnal enuresis or bedwetting–urinary incontinence only at night
• May include small group of children incontinent of urine during daytime as well as nighttime
• Primary enuresis: Never continent of urine during time frame considered (daytime, nocturnal, or both)
• Secondary enuresis: Had continent period of at least 6 months, then relapse of enuresis
• Most (80%) of nocturnal enuresis is primary.

Enuresis - epidemiology

• Female > Male (3:1)
• Frequency, severity, longevity of primary nocturnal enuresis (PNE) increases with positive family history.

Enuresis - incidence

• 43–47% if one parent was enuretic
• 15% if neither parent was enuretic
• Twice as high in monozygotic twins as dizygotic twins

Enuresis - prevalence

• At age 5, 15% of children have PNE.
• ~15% of children with enuresis spontaneously remit each year, so that by age 10, only 5% still have nocturnal enuresis.
• ~1% of adolescents have nocturnal enuresis.

Enuresis - risk factors

Enuresis - genetics

No specific genetic abnormality described

Enuresis - etiology

• PNE:
  • Underlying treatable cause uncommon
  • Any condition causing polyuria
  • Theories: Deep sleep with failure of signal of increased bladder pressure to reach consciousness; maturational delay with bladder emptying at lower volume secondary to small bladder capacity; failure to concentrate urine or to decrease urinary volume at night compared with dry peers
• Diurnal enuresis, day and night:
  • As above
  • Urinary reflux into vagina with seepage after conclusion of voiding
  • Abnormal anatomy with insertion of ureter into urethra or vagina
  • Incontinence with increased abdominal pressure (laughing, coughing, increased intravesicular pressure)
• Secondary enuresis:
  • Any condition causing polyuria
  • UTI
  • Encopresis
  • Emotional stress or trauma including physical and sexual abuse, divorce, depression, new sibling, household moving, new school

Enuresis - DIAGNOSIS

Enuresis - signs & symptoms

Enuresis - history

• Onset: Primary versus secondary
• Nocturnal versus diurnal
• Dry period (even if only weeks)
• Frequency
• Pattern of urination:
  • Constantly wet pants (dribbling)
  • Frequent small amounts of urine
  • Dysuria
  • Frequency
  • Hesitancy
  • Dry when sleeping away from home
• Past medical history:
  • Obstipation/constipation/stool incontinence
  • Behavioral/developmental history
  • Toilet training history
  • Medications
  • Neurologic symptoms
  • Other medical problems
• Family history:
  • 1 parent or 2
  • Child awareness
• Social history:
  • For whom does this pose problem—parent or child
  • Effect on child:
    • Ability to sleep away from home without embarrassment
    • Teasing at school
    • Emotional effects
• Social changes:
  • Divorce
  • New significant other for parent
  • New sibling
  • Household move
  • Change in school
  • Death or illness in family
  • Other change in home environment
• Past interventions and effectiveness:
  • Attempt at treatment or punishment and its effectiveness

Enuresis - physical exam

• Vital signs
• Growth parameters and pattern
• Neurologic exam:
  • Gait, tone, sensory, motor, deep tendon reflexes, cremasteric reflex
  • With funduscopy: To rule out intracranial pressure
• Abdominal exam: To rule out masses, especially renal mass
• Genitalia: Rule out adhesions, vulvovaginitis, balanitis, stenosis, foreign bodies.
• Urinary stream
• Rectal examination: Tone, perianal sensation, anal wink
• Spine: Bony defects, cutaneous signs of underlying spinal defects

Enuresis - tests

Enuresis - lab

• Urinalysis:
  • Specific gravity
  • Glucose
  • Protein
  • Blood
  • Urine:
    • 1st morning void for specific gravity and protein
• Urine culture: Usually not necessary if no symptoms

Enuresis - imaging

• Rarely necessary in primary enuresis
• Only if suggestion of anatomic or functional abnormality of genitourinary system
• Consider renal ultrasound, voiding cystourethrogram, radionuclide renal scan

Laboratory evaluation rarely yields specific diagnosis. Balance risks and costs with unlikelihood of yield. Evaluation should generally involve no more than urinalysis.

Enuresis - differencial diagnosis

• UTI/Urethritis
• Obstipation/constipation
• Water intoxication
• Diabetes mellitus
• Diabetes insipidus
• Sickle cell disease or trait
• Nephritis/Nephrosis
• Anatomic abnormalities of the urinary tract
• Sleep disorders
• Depression
• Anxiety
• Behavioral disorders
• Medications (sedatives, soporifics, antihistamines, diuretics, caffeine, methylxanthines)
• Spinal cord disease
• Cognitive disorders
• Seizure disorders
• Legitimate safety issues in going to bathroom alone
• Substandard living conditions (cold bathrooms, poor facilities)

Enuresis - TREATMENT

Enuresis - initial stabilization

Specific therapy to address specific anatomic, infectious, or functional renal problems

Decision to treat is a balance of the effect on the child of nontreatment (social, emotional) with the potential side effects of medication.

Enuresis - general measures

• If the problem is affecting only the parents and child is not affected, the treatment should be education and support for the parents:
  • Prognosis for self-resolution
  • Benign nature
  • Available interventions if child becomes concerned
• Avoid all negative interventions.
• Fluid restriction before bed—controversial:
  • May create arguments with parents
  • Success rate low
• Retention training/bladder stretching exercises— controversial
• Cognitive behavioral interventions:
  • Formal programs developed and used by pediatric psychologists: High rate of success; involve “Over Correction Techniques”—frequent practice and rewards for voiding procedures along with enuresis alarm
  • Positive reinforcement for dry nights
  • Use of praise, stickers, token economies
  • Bell and pad alarm systems: Most effective of behavioral interventions more effective in conjunction with formal behavioral program; high relapse rate after remission and cessation of alarm usage; 2nd remission very frequent with reintroduction of alarm system; 2nd relapse rare
• Hypnotism:
  • Appears to work by increasing subconscious awareness of bladder pressure during sleep, allowing increased awareness during sleep of intravesicular pressure
  • Use of bell and pad alarm may increase success rate.

Enuresis - medication

Avoid medication intervention before age 6–8 years.

• Desmopressin (DDAVP):
  • Can be used intermittently only on sleep-out nights
  • Effective in 70% of PNE
  • If used chronically, monitor electrolytes and fluid status appropriately.
  • Available in nasal spray and tablets
• Imipramine:
  • Tricyclic antidepressant
  • Eighty percent effective
  • No longer 1st- or 2nd-line choice for benign condition because of risk of QTc prolongation and controversial risk of sudden cardiac death and risk of ingestion in siblings
• Oxybutynin: Used in patients with documented detrusor instability

Enuresis - FOLLOW UP

Enuresis - prognosis

• 99% percent of cases resolve without treatment.
• Spontaneous resolution is ~15% per year after age 5.

Enuresis - complications

• Physical:
  • Vulvovaginitis
  • Diaper dermatitis
• Emotional:
  • Embarrassment
  • Poor self-esteem
  • Reluctance to sleep out with peers or nonimmediate family
  • Depression

Enuresis - bibliography

1. Bosson S, Lyth N. Nocturnal enuresis. Clin Evid. 2002;7(Jun):341–348.
2. Butler RJ. The body-worn alarm in the treatment of childhood enuresis. Br J Clin Pract. 1990;44:237–241.
3. Devlin JB. Predicting treatment outcome in nocturnal enuresis. Arch Dis Child. 1990;65:1158–1161.
4. Essen J. Nocturnal enuresis in childhood. Dev Med Child Neurol. 1976;18:577–589.
5. Forsythe WI. Enuresis and spontaneous cure rate: Study of 1129 enuretics. Arch Dis Child. 1974;49:259–263.
6. Glazener CM, Evans JH, Peto RE. Tricyclic and related drugs for nocturnal enuresis in children. Cochrane Database Syst Rev. 2003:CD002117.
7. Jalkut MW. Enuresis. Pediatr Clin North Am. 2001;48:1461–1488.
Koff S. Enuresis. In: Walsh PC, Retick AB, Stamey TA, et al., eds. Campbell’s Urology. 7th ed. Philadelphia: WB Saunders; 1998:2055–2068.
8. Meadow R. Childhood enuresis. BMJ. 1970;4:787–789.
9. Moffatt ME. Desmopressin acetate and nocturnal enuresis: How much do we know? Pediatrics. 1993;92:420–425.
10. Starfield B. Increase in functional bladder capacity and improvements in enuresis. J Pediatr. 1968;72:483–487.
11. Wille S. Comparison of desmopressin and enuresis alarm for nocturnal enuresis. Arch Dis Child. 1986;61:30–33.

Enuresis - CODES

Enuresis - icd9

307.6 Enuresis

788.30 Urinary incontinence, unspecified

Enuresis - FAQ

• Q: Do the medications cure the enuresis?
• A: None of the medications cures the problem.

  DDAVP increases reabsorption of water in the kidney, resulting in decreased bladder volumes.

  Tricyclic antidepressants cause urinary retention by the noradrenergic effects on bladder contraction and detrusor relaxation.

  Oxybutynin decreases detrusor irritability, resulting in larger bladder capacity before emptying.

  The medications result in nonemptying of the bladder during sleep, but do not affect the underlying cause. Any resolution that occurs after cessation of medication treatment is probably from the natural resolution of the problem with age.

• Q: Isn’t it important to cure the enuresis when the parents bring it up as a problem?
• A: Developmental resolution of nocturnal enuresis occurs at a range of ages, and in almost all cases, the enuresis resolves spontaneously.

  The most important historical point is for whom is the enuresis is a problem. If the child is not affected by the enuresis and it is only the parents who desire a cure, the important intervention is to educate them on the natural history of the problem and to let them know about the available interventions and their success rates, for when the child desires a cure.

• Q: Are there any other interventions available for use only on sleep-out nights?
• A: One helpful tip is to allow the child to take a sleeping bag with him or her on sleep-outs.
  Inside the sleeping bag is a pull-up. When the child gets into the sleeping bag, he or she can change into the pull-up without anyone knowing. In the morning, the child puts his or her underwear back on, leaving the damp pull-up in the sleeping bag; the parent can take it out when the child gets home.

Book Source Details

• Book Title: The 5-Minute Pediatric Consult
• Author(s): M. William Schwartz MD; et al.
• Year of Publication: 2008
• Copyright Details: The 5-Minute Pediatric Consult, Copyright © 2008 Lippincott Williams & Wilkins.

Other Book Chapters Related to Enuresis

Read excerpts from these other book chapters related to Enuresis:

Copyright Details: The 5-Minute Pediatric Consult, Copyright © 2008 Williams & Wilkins.

More About Causes of Enuresis

• Back to symptom: Enuresis: Introduction (review 71 causes)
• Next Book Extract About Enuresis: Medications causing Enuresis
• All Book Extracts: All Online Book Extracts for Enuresis

More About This Book: Title: The 5-Minute Pediatric Consult Authors: M. William Schwartz MD; et al. Publisher: Lippincott Williams & Wilkins Copyright: 2008 ISBN: 0-7817-7577-9

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