Enuresis

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Editor(s)-in-Chief: C. Michael Gibson, M.S.,M.D. [1] Phone:617-632-7753; Angela Botts, M.D., Beth Israel Deaconess Medical Center Geriatric Medicine [2]; Associate Editor(s)-in-Chief: Kiran Singh, M.D. [3]

Overview

Enuresis is the involuntary urination beyond the age of anticipated control. The two major forms of enuresis are diurnal enuresis (or daytime wetting), and nocturnal enuresis (bedwetting or nighttime wetting). Enuresis impacts the child and is associated with poor school performance. It also has a major psychosocial burden on the family and results in poorer quality of life in parents.

Historical Perspective

• Enuresis has been a major social problem since ancient times.
• Initially enuresis was considered a manifestation of psychiatric disturbance. It has been followed by the clearer theory of maturational delay with the role of hereditary factors.
• After multiple studies, it has been found that enuresis may be the cause and not the result of a psychiatric disorder.
• As early as 1550 BC, the problem of childhood incontinence was described in the Ebers papyrus.
• Prayers became an important supplemental component of the treatment options in the middle ages.
• Belladonna, camphor, opium, and ergot were administered to enhance the bladder muscle tone in the eighteenth century.
• In 1948, a direct conditioning based treatment modality called the alarm or bell-and-pad system was introduced.
• Initially, psychotherapy was accepted as the only possible method to treat enuresis, and there was a lot of skepticism about the conditioning treatment.

Classification

• Enuresis is broadly divided in two types: daytime wetting and nocturnal enuresis.
• According to International Children’s Continence Society (ICCS), enuresis consists of wetting by a child who has passed his or her fifth birthday.
• Enuresis is considered significant if it occurs more than once per month and at a frequency of at least three times per three months. Enuresis is termed frequent if there are more than three episodes a week.
• If there are concomitant daytime voiding symptoms such as incontinence, frequency, urgency, or low voided volume, the condition is termed nonmonosymptomatic enuresis (NMEN). If bedwetting and nocturia are the only symptoms, the condition is known as monosymptomatic enuresis (MEN).
• MEN occurs without any other symptoms of bladder dysfunction whereas NMEN is associated with dysfunction of the lower urinary tract with or without daytime incontinence.
• Primary enuresis is used for a child that was never continent, whereas the term secondary enuresis is used for new-onset symptoms after a dry period of at least six months.

Pathophysiology

• Some of the underlying pathophysiological mechanisms for enuresis are:
  • Altered antidiuretic hormone profile
  • Sleep arousal failure
  • Delayed bladder maturation
  • Abnormal bladder function
  • Detrusor instability
  • Excess urine production during sleep
• Nocturnal enuresis may be associated with lower urinary tract symptoms such as urgency, frequency, and wetting – with reduced bladder storage, and an overactive bladder. These may be further associated with constipation.
• Nocturnal enuresis often occurs early in the night, mainly in sleep stage 2 and deep sleep. Children with nocturnal enuresis and nocturnal polyuria differ in hemodynamics and autonomic activation at night compared to healthy controls.
• Children with nocturnal enuresis often have sleep-disordered breathing and disturbed sleep due to awakenings and arousals. Periodic limb movements (PLM) have also been seen in children with refractory enuresis.

Differential Diagnosis

Enuresis should be differentiated from other causes

• Medication side effects
• Neurogenic bladder
• Renal diseases
• Constipation
• Diabetes Mellitus
• Detrussor areflexia or overactivity
• Urinary tract infection
• Posterior urethral valve
• Emotional disturbances
• Underlying conditions resulting in polyuria such as sickle cell disease, and diabetes insipidus
• Spinal dysraphism
• Nephronopthisis
• Psychogenic polydipsia
• Pinworm infection
• Upper airway tract obstruction
• Other urological dysfunction
• Other neurological diseases

Epidemiology and Demographics

Prevalence

• The prevalence of enuresis is
  • 5,000-10,000 per 100,000 (5%-10%) among children 5 years of age
  • 3,000-5,000 per 100,000 (3%-5%) among children 10 year of age
  • 1,000 per 100,000 (1%) among individuals 15 years of age or older

Risk Factors

• The risk factors for the development of enuresis are
  • Delayed or lax toilet training
  • Genetic predisposition
  • Encopresis
  • Psychosocial stressors
  • Family history of enuresis(such as maternal history, and sibling history of bedwetting)
  • Low socioeconomic status
  • Snoring
  • Heavy and late supper

Comorbidities

• Enuresis exists with various comorbid conditions
  • Attention-deficit hyperactivity disorder (ADHD)

Diagnostic Criteria

DSM-V Diagnostic Criteria for Enuresis

“

A. Repeated voiding of urine into bed or clothes, whether involuntary or intentional. AND B. The behavior is clinically significant as manifested by either a frequency of at least twice a week for at least 3 consecutive months or the presence of clinically significant distress or impairment in social, academic (occupational), or other important areas of functioning. AND C. Chronological age is at least 5 years (or equivalent developmental level). AND D. The behavior is not attributable to the physiological effects of a substance (e.g., a diuretic, an antipsychotic medication) or another medical condition (e.g., diabetes, spina bifida, a seizure disorder). Specify whether: Nocturnal only: Passage of urine only during nighttime sleep. Diurnal only: Passage of urine during waking hours. Nocturnal and diurnal: A combination of the two sub types above.

”

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