Enuresis

Enuresis is defined as urinary incontinence. The age of achieving daytime or night-time continence can vary considerably. Nocturnal enuresis (night-time bedwetting) can be normal in children up to age 8. Daytime continence is usually achieved by age 4. Enuresis can be primary (i.e., the patient has never been dry) or secondary (develops after a period of dryness). Primary enuresis (particularly nocturnal enuresis) is usually a developmental issue, whereas secondary enuresis is more likely due to a pathogenic, identifiable cause.

Differential Diagnosis

• Urinary tract infection (UTI)
  –Most common cause of new onset, secondary enuresis
  –Common pathogens: E. coli (85%), Klebsiella pneumoniae, Proteus vulgaris, Pseudomonas aeruginosa, and other gram-negatives

• Primary nocturnal enuresis
  –Normal in children up to 8 years
  –Often there is a strong family history
  –Affected family members may not achieve night-time continence until adolescence
• Dysfunctional voiding
  –Unstable (uninhibited) bladder of childhood
  –Infrequent voiding
  –Neurogenic bladder
• Psychosocial stress
• Chronic constipation
  –Often associated with encopresis
• Chronic kidney disease
• Nephrogenic diabetes insipidus (DI)
• Central DI
• Diabetes mellitus (DM)
• Ectopic ureter
• Posterior urethral valves
• Urethral stricture
• Developmental delay
• Neurologic disease
  –Tethered cord
  –Spina bifida
  –Spinal tumors
  –Spinal dysraphism
• Sexual abuse
• Prostatic tumor or abscess
• Hydrocolpos or hematocolpos
• Osteomyelitis of vertebral body with compression of the spinal cord
• Spinal epidural abscess
• Obstructive sleep apnea
• Giggle micturition

Workup and Diagnosis

• History
  –Primary vs secondary; daytime vs night-time
  –Previous urinary tract infection or renal disease
  –Poor growth, recurrent dehydration
  –“Curtsying” or urinary withholding/delay maneuvers
  –Stooling frequency
  –Psychosocial stressors, social withdrawal, poor performance in school (depression or sexual abuse)
  –Developmental delay
• Family history: Primary nocturnal enuresis, polyuria; early infant death (suggests nephrogenic DI)
• Symptoms
  –Fever, flank pain (UTI), dysuria, urgency, frequency (cystitis or dysfunctional voiding)
  –Fatigue and polyuria (renal disease)
  –Headache or vision changes (intracranial process)
• Physical exam
  –Affect, developmental assessment, growth parameters (height/weight), blood pressure
  –Pallor (e.g., due to anemia of renal failure)
  –Neuro: Reflexes, anal wink, sensation, strength
  –Spinal exam (hair tufts, clefts suggest spina bifida)
  –GU exam
• Labs: Urinalysis, urine culture, chemistry panel
• Additional evaluation based on the clinical situation
  –Spinal MRI for sacral dimple or hair cleft
  –Ultrasound/VCUG for UTI or other kidney /bladder disease

Treatment

• UTI
  –Empiric antibiotics (e.g., co-trimoxazole) after culture
  –Adjust antibiotics based on bacterial sensitivities
• Primary nocturnal enuresis
  –Behavioral measures (limit fluids at night, enuresis alarms, reward system)
  –Consider pharmacologic treatments (i.e., DDAVP) for short-term use (e.g., vacations, sleepovers)
• Dysfunctional voiding
  –Unstable bladder of childhood
  –Treat with anticholinergic agents (e.g., oxybutynin)
  –Other causes are treated with behavior interventions (e.g., timed voiding and positive reinforcements)
  –Manage constipation, if present
• Nephrogenic DI: Treat with large volumes of fluid intake, close attention to fluid status during acute illnesses
• Central DI: Treat with DDAVP

Book Source Details

• Book Title: In A Page: Pediatric Signs and Symptoms
• Author(s): Jonathan E. Teitelbaum, Kathleen O. Deantonis, Scott Kahan
• Year of Publication: 2007
• Copyright Details: In A Page: Pediatric Signs and Symptoms, Copyright © 2007 Lippincott Williams & Wilkins.

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Copyright Details: In A Page: Pediatric Signs and Symptoms, Copyright © 2008 Williams & Wilkins.

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More About This Book: Title: In A Page: Pediatric Signs and Symptoms Authors: Jonathan E. Teitelbaum, Kathleen O. Deantonis, Scott Kahan Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 1-4051-0427-9

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