Nocturnal enuresis

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Chapter 33 NOCTURNAL ENURESIS

Jonathan M. Wong

General Discussion

Enuresis refers to the persistence of inappropriate voiding of urine beyond the age of anticipated bladder control, which is age 4 to 5 years at the latest. The International Children’s Continence Society, in order to standardize the diagnosis, has defined nocturnal enuresis as “the involuntary loss of urine that occurs only at night. It is normal voiding that happens at an inappropriate and socially unacceptable time and place.” In the past, various classification schemes were also used to describe this problem such as nocturnal versus diurnal, primary versus secondary, and uncomplicated versus complicated.

Children are not considered to be enuretic until they have reached 5 years of age. Mentally disabled children should have reached a mental age of four years before being considered enuretic. A child of 5 to 6 years of age has nocturnal enuresis if he or she has two or more bedwetting episodes per month. A child older than 6 years of age has nocturnal enuresis if he or she has one or more wetting episodes per month.

Nocturnal enuresis affects some five to seven million children in the United States, making it the most common pediatric urologic complaint. At 5 years of age, 15% to 25% of children still wet the bed; males predominate. The spontaneous resolution rate of nocturnal enuresis is about 15% per year. Thus, 8% of 12-year-old boys and 4% of 12-year-old girls are enuretic. Only 1% to 3% of adolescents are still wetting the bed.

Despite its prevalence, nocturnal enuresis is not completely understood, and the condition is believed to be multifactorial. Organic causes are responsible for nocturnal enuresis in fewer than 5% of cases. Such organic causes should be searched for and ruled out if the history suggests their presence.

Medications Associated with Nocturnal Enuresis

Diuretics

Causes of Nocturnal Enuresis

The current belief is that enuresis is a multifactorial condition involving genetic, familial, psychological, urologic, and hormonal factors. It is also likely related to a maturational delay in affected patients. The following is a list of causes:

Foods that increase nocturnal urine production

• Positive family history in 65%-85% of bedwetting patients

Hormonal causes

• It is postulated that normal development includes the establishment of a circadian rhythm in the release of arginine vasopressin, the antidiuretic hormone. Patients with nocturnal enuresis may be delayed in achieving this circadian rise, and hence develop nocturnal polyuria.

Irregular food and drink intake

Neurogenic bladder

Posterior urethral valves

Psychological causes

• Although nocturnal enuresis was once thought to be the result of psychological problems, it is now believed that these problems are the result of bedwetting.

• Bedwetting is not thought to be an act of rebellion.

Sleep arousal dysfunction

Urinary tract infection (UTI)

Urologic causes

• Diminished functional bladder capacity

Key Historical Features

The history and physical examination should be directed at excluding causes of complicated enuresis, such as spinal cord injuries (neurogenic bladder), UTI, posterior urethral valves in boys, and ectopic ureter in girls. A voiding diary may be helpful in quantifying the historical information.

Detailed toilet training history

Onset and pattern of wetting

Number of dry nights per month

Most consecutive dry nights

Evening fluid intake

Bladder emptied at bedtime

Voiding behavior, especially small frequent voids that suggest bladder instability or small functional bladder capacity

Urine stream

Sleep pattern

Parasomnias

Daytime urinary symptoms

Dysuria

Bowel habits, especially constipation

Encopresis

Family’s and patient’s attitude toward the bedwetting

Polyuria/number of times per day that the child voids

Polydipsia

Gait disturbance

Nighttime snoring

Present and past treatments for nocturnal enuresis and their results

Medical history

• Neurologic problems

• Injury to the genital or back area

Birth history, especially any complications

Surgical history

Family medical history

Social history

Suggested Work-Up

Urinalysis

To assess specific gravity (for diabetes insipidus) and urinary glucose level (for diabetes mellitus) as well as to evaluate for the presence of infection or blood

If the history, physical examination, and urinalysis do not suggest a secondary cause of nocturnal enuresis, no further work-up is needed.

Additional Work-Up

Urine culture	If symptoms suggest a UTI or if the urinalysis suggests infection
Voiding cystourethrogram and renal ultrasound	To evaluate for vesicoureteral reflux if the urine culture reveals an infection
Serum glucose	If the history or urinalysis suggests diabetes mellitus
Sleep study	If a sleep disorder is suspected