II. Definition: Enuresis (DSM-IV Classification)

  1. Repeated voiding of urine into bed or clothes
    1. Involuntary or intentional
  2. Clinically Significant criteria (one of the following)
    1. Twice weekly for at least 3 consecutive weeks
    2. Significant distress
    3. Impaired functioning
  3. Age 5 years or older
  4. Secondary cause not present
    1. Medication (e.g. Diuretics)
    2. Diabetes Mellitus
    3. Spina bifida
    4. Seizure Disorder

III. Categories: Enuresis

  1. Primary or Secondary
    1. Primary Enuresis (80%)
      1. No history of urinary continence for more than 6 months
    2. Secondary Enuresis (20%)
      1. Enuresis recurs after 6 months of urinary continence
      2. Typically associated with new psychosocial stressors or medical or behavioral condition
  2. Monosymptomatic or nonmonosymptomatic
    1. Monosymptomatic Enuresis
      1. Nighttime bed wetting without other symptoms
    2. Non-monosymptomatic Enuresis (associated with more significant abnormality)
      1. Daytime lower urinary tract symptoms (e.g. urgency, frequency, incomplete emptying) or
      2. Daytime Incontinence or
      3. Dysuria or
      4. Holding maneuvers (e.g. leg crossing)
  3. Timing
    1. Nocturnal Enuresis only (80%)
    2. Nocturnal and diurnal (20%)

IV. Epidemiology: Prevalence of Enuresis

  1. Age 2 years: 82%
  2. Age 3 years: 49%
  3. Age 4 years: 26%
  4. Age 5 years: 15-25%
  5. Age 7 years: 5-10%
  6. Age 12 years: Boys: 8%; Girls 4%
  7. Age 18 years: Boys: 1%: Girls rare

V. Pathophysiology

  1. Maturation delay
    1. Enuresis Prevalence decreases with age
    2. "Bladder full" signal does not yet work
      1. Inability to awaken in response to the stimulus of a full Bladder
  2. Other predisposing factors
    1. Excessive nighttime urine production
    2. Decreased Bladder functional capacity
  3. Strong association with Family History
    1. Gene markers on Chromosome 5, 12, 13 and 22
    2. Both parents with Enuresis: 77% chance of Enuresis
    3. One parent with Enuresis: 44% chance of Enuresis
      1. Relative Risk if Father with Enuresis: 7.1
      2. Relative Risk if mother with Enuresis: 5.2

VI. Causes: Secondary (3%)

  1. Bladder Dysfunction or unstable Bladder (3-5%)
  2. Medically treatable
    1. Urinary Tract Infection, especially in girls (18 to 60% of cases)
    2. Diabetes Insipidus
    3. Diabetes Mellitus
    4. Hyperthyroidism
    5. Sickle Cell Anemia
    6. Fecal Impaction or Constipation often with comorbid Encopresis and treatment resistance (33-75% of cases)
    7. Overactive Bladder or dyfunctional voiding (<41% of cases)
  3. Surgically treatable
    1. Ectopic Ureter
    2. Lower Urinary Tract Obstruction
    3. Neurogenic Bladder (e.g. Spinal Dysraphism)
    4. Bladder calculus or foreign body
    5. Obstructive Sleep Apnea secondary to large adenoids (10 to 54% of cases)
  4. Psychiatric illness (in only 20%)
    1. More common in enuretic girls
    2. Suggested by Enuresis both night and day
    3. More likely if Enuresis persists in older child
  5. Regressive Enuresis (occurs after being dry)
    1. Associated with stressful environmental event

VII. History

  1. Voiding History
    1. Consider a two week voiding diary
    2. Does child meet DSM-IV criteria for Enuresis above?
    3. Has the child ever been dry for a 6 month period? (primary or secondary)
    4. Is there daytime Enuresis? (complicated Enuresis)
    5. Characterize the Enuresis
      1. How many days per week?
      2. How many times per night?
      3. What time of night does Enuresis occur?
  2. Urinary Tract Infection symptoms
    1. Dysuria
    2. Urinary urgency or Urinary Frequency
  3. Bowel habit changes
    1. Infrequent or difficult stool passage
    2. Encopresis
    3. Constipation with hard stools at a frequency of <4 times per week
  4. Functional Bladder disorder or neurogenic Bladder signs
    1. Frequent Urination with voids >7 per day
    2. Urine urgency
    3. Withholding urine until last minute
    4. Wets more than once nightly
    5. Small volumes from incomplete emptying
    6. Dribbling, straining to obtain even a weak urine stream
  5. Nocturnal Polyuria
    1. Enuresis on only a few nights per week
    2. Voids large volumes when Enuresis occurs
    3. Soaked absorbant underpants or voids large first-morning void despite Enuresis?
    4. Excessive water intake prior to bed?
    5. Weight loss associated with polydipsia and Polyuria (Diabetes Mellitus)?
  6. Other related history
    1. Birth complications
    2. Neurologic disorders (motor disorders, Learning Disorders, Developmental Delay)?
    3. Genitourinary surgeries
    4. Family History of Enuresis
    5. Behavioral problems
    6. Snoring and Daytime Somnolence (Obstructive Sleep Apnea)
    7. Sickle Cell Anemia

VIII. Examination

  1. Height and weight
    1. Evaluate for Growth Delay or Failure to Thrive (e.g. Diabetes Mellitus, Chronic Kidney Disease)
  2. Head and Neck Exam
    1. Evaluate for Tonsillar Hypertrophy (and consider enlarged adenoids) suggestive of pediatric Sleep Apnea
  3. Abdominal and flank exam
    1. Costovertebral Angle Tenderness (CVA Tenderness)
    2. Abdominal masses
    3. Bladder enlargement
  4. Genitourinary exam and Rectum
    1. Males
      1. Hypospadias, meatal stenosis, Phimosis
    2. Females
      1. Labial adhesions
    3. Sexual abuse signs
      1. Excoriations at the perineum or perianal region
      2. Prepubertal Vulvovaginitis
    4. Rectum
      1. Fecal Impaction or signs of soiling (Constipation, Encopresis)
      2. Decreased sphincter tone (may be comorbid with neurogenic Bladder)
  5. Back exam
    1. Dimple, hair tuft, Lipoma or other skin findings in the midline superior to the gluteal cleft (Spinal Dysraphism signs)
  6. Neurologic Exam
    1. Gait Evaluation for neurologic deficits
    2. Lower limb motor weakness or reflex abnormality

IX. Labs

  1. Urinalysis
    1. Signs of Urinary Tract Infection
    2. Urine Specific Gravity
    3. Urine Glucose
  2. Other labs to consider
    1. Fingerstick Blood Sugar
    2. Basic metabolic panel including Renal Function

X. Imaging

  1. Consider as indicated
  2. Renal Ultrasound and Bladder Ultrasound
    1. Indicated for suspected urinary tract malformation or Chronic Kidney Disease
  3. MRI Lumbar Spine
    1. Indicated for suspected Spinal Dysraphism

XI. Management: Referral Indications

  1. Non-monosymptomatic Enuresis
  2. Recurrent Urinary Tract Infection
  3. Urinary tract malformations
  4. Prior pelvic surgery
  5. Neurologic disorders (e.g. neurogenic Bladder)
  6. Failure to respond after age 7 years old to adequate trial of bed alarm and Desmopressin
  7. Psychiatric disorder
  8. Dysfunctional voiding (or urinary tract malformation)
  9. Chronic Kidney Disease

XII. Management: General

  1. Discussion topics
    1. Reassure parents with age-related norms
    2. Counsel family regarding conflict surrounding Enuresis
  2. Assess for organic causes (see above)
    1. Complete history and physical with Urinalysis
      1. No further evaluation necessary if normal results
    2. Treat reversible underlying causes
      1. Constipation
        1. Consider pediatric gastroenterology Consultation for Encopresis
      2. Acute Urinary Tract Infection
        1. Consider imaging and Consultation for Recurrent Urinary Tract Infection
      3. Obstructive Sleep Apnea
        1. Consult regarding Tonsillar or adenoid hypertrophy
      4. Diabetes Mellitus
    3. Obtain Consultation for complicated secondary causes
      1. See referral indications above

XIII. Management: Non-Pharmacologic Therapies

  1. Indicated for monosymptomatic Enuresis (no secondary disorder suspected)
  2. Appropriate Toilet Training
    1. Scheduled voiding times (especially in evening)
    2. Behavior Modification
      1. Bed-Wetting Alarm
        1. Most effective treatment for Nocturnal Enuresis
      2. Visualization techniques
      3. Void just before bedtime
      4. Limit fluids 1 hour before bedtime
      5. Scheduled awakening during night to void
        1. Some experts do not recommend
    3. Positive reinforcement system
      1. Charts the child's progress of dry nights
      2. Given stickers on calendar or points per dry night
  3. General Recommendations
    1. Enlist support and cooperation of child
    2. Older children launder their own soiled clothes
      1. Should not be punishment
      2. Allows child's participation and responsibility
  4. Avoid harmful measures
    1. Waking child repeatedly during the night to void
      1. Interferes with sleep
      2. Aggravates child and parent
    2. Punishing or shaming the child for wetting the bed
    3. Intimidating the child or lowering his self esteem
    4. Postponing the child's bedtime to decrease Bedwetting

XIV. Management: Pharmacologic Therapies

  1. Try to avoid medications if possible
    1. Medications are only effective briefly
    2. Drug tolerance is common
    3. Symptoms are exacerbated after drug is discontinued
    4. Adverse effects are common
    5. If used, avoid in under age 6 years
  2. Medications: Primary Nocturnal Enuresis
    1. Imipramine (or Desipramine)
      1. Typical dose: 25 mg nightly
      2. Not first line due to Cardiac Arrhythmia risk
      3. As effective as Desmopressin
      4. Higher rate of adverse effects compared with dDAVP
    2. dDAVP (Desmopressin, ADH)
      1. Typical dose: 0.2 mg
      2. Restrict fluid intake 1 hour before taking dDAVP
      3. Nasal form is no longer approved for Enuresis due to Hyponatremia (Water Intoxication)
        1. Can also occur with oral form, but less commonly
        2. Robson (2007) J Urol 178(1):24-30. [PubMed]
      4. For intermittent use on overnights or summer camp
      5. Effective in children with nocturnal Polyuria (but high relapse rate)
        1. Not effective in low nighttime Urine Output or small Bladder capacity
  3. Medications: Urge Incontinence or Diurnal Enuresis
    1. Oxybutynin (Ditropan)
      1. Dose: 2.5 to 5 mg orally three times daily
      2. Anticholinergic side effects
      3. Consider in combination with dDAVP

XV. Course

  1. Annual resolution rate of Nocturnal Enuresis: 15%

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Related Studies

Ontology: Enuresis (C0014394)

Definition (MSHCZE) Pomočování, mimovolní močení vyskytující se po 4. roku věku. Vyskytuje se nejč. v noci (enuresis nocturna), méně často ve dne (enuresis diurna). Dítě popř. i dospělý močí ve spánku i ve věku, kdy již normálně ovládá svůj močový měchýř. (cit. Velký lékařský slovník online, 2013 http://lekarske.slovniky.cz/ )
Definition (NCI) An elimination disorder characterized by urinary incontinence, whether involuntary or intentional, which is not due to a medical condition and which occurs at or beyond an age at which continence is expected (usually 5 years).
Definition (CSP) inability to control the flow of urine and involuntary urination.
Definition (MSH) Involuntary discharge of URINE after expected age of completed development of urinary control. This can happen during the daytime (DIURNAL ENURESIS) while one is awake or during sleep (NOCTURNAL ENURESIS). Enuresis can be in children or in adults (as persistent primary enuresis and secondary adult-onset enuresis).
Concepts Sign or Symptom (T184)
MSH D004775
ICD9 307.6
ICD10 R32
SnomedCT 274255006, 207171001, 1891009, 68191002, 268776008, 158470001, 154929003, 162121000, 139398002, 8009008
English Enuresis, ENURESIS, [D]Enuresis (context-dependent category), [D]Enuresis NOS (context-dependent category), [D]Enuresis NOS, Enuresis [D], enuresis (diagnosis), enuresis, Enuresis [Disease/Finding], Enuresis NOS, [D]Enuresis, Enuresis (& [bedwetting]) (disorder), Enuresis (& [bedwetting]), Enuresis [D] (situation), Enuresis (finding), [D]Enuresis NOS (situation), [D]Enuresis (situation), Enuresis, NOS, Enuresis (finding) [Ambiguous], Enuresis [D] (finding)
French ENURESIE, Enurésie, Énurésie
Portuguese ENURESE, Enuresia, Enurese
Spanish ENURESIS, [D]enuresis, SAI (categoría dependiente del contexto), [D]enuresis (categoría dependiente del contexto), enuresis (hallazgo), enuresis, [D]enuresis (situación), [D]enuresis, [D]enuresis, SAI, [D]enuresis, SAI (situación), enuresis (concepto no activo), enuresis [D] (hallazgo), enuresis [D], Enuresis
German ENURESIS, Enuresis, Einnässen
Japanese 遺尿, イニョウ
Swedish Enures
Czech enuréza, Enuréza, bezděčné pomočování
Finnish Kastelu
Croatian ENUREZA
Polish Moczenie się mimowolne
Hungarian Enuresis
Norwegian Psykogen enurese, Enurese, Ikke-organisk enurese, Ufrivillig urinlating, Funksjonell enurese
Dutch bedplassen, Enuresis
Italian Enuresi

Ontology: Bedwetting (C0270327)

Definition (MEDLINEPLUS)

Many children wet the bed until they are 5 or even older. A child's bladder might be too small. Or the amount of urine produced overnight can be more than the bladder can hold. Some children sleep too deeply or take longer to learn bladder control. Children should not be punished for wetting the bed. They don't do it on purpose, and most outgrow it. Until then, bed-wetting alarms, bladder training and medicines might help.

Definition (SNOMEDCT_US) Intermittent incontinence of urine while sleeping, regardless of whether intermittent daytime urinary incontinence is also present or not.
Definition (SCTSPA) Incontinencia intermitente de orina durante el sueño, independientemente de la presencia de incontinencia urinaria en horas del día.
Definition (MSH) Involuntary discharge of URINE during sleep at night after expected age of completed development of urinary control.
Concepts Sign or Symptom (T184)
MSH D053206
ICD9 788.36
ICD10 N39.44
SnomedCT 8009008, 268776008, 162122007, 154929003, 68191002
English NOCTURNAL ENURESIS, Bedwetting, Nocturnal enuresis (disorder), Nocturnal enuresis (finding), Enuresis, Nocturnal, Incontinence, Nighttime Urinary, Nighttime Urinary Incontinence, Nocturnal Enuresis, Urinary Incontinence, Nighttime, ENURESIS, NOCTURNAL, 1, BEDWETTING, ENUR1, Nocturn incontinence of urine, Nocturnal only enuresis, unable to restrain urination at night while asleep (symptom), unable to restrain urination at night while asleep, enuresis, Noct. enuresis, Nocturnal Enuresis [Disease/Finding], bed wet, wetting bed, bed wetting, bed wets, wets bed, bedwetting/enuresis, enuresis bedwetting, bedwetting, bed-wetting, wet bed, bedwetting enuresis, Enuresis, enuresis nocturnal, nocturnal enuresis, nocturnal enuresis (diagnosis), Bed wetting, Nocturnal enuresis, Wets bed, Nocturnal incontinence of urine, Bedwetting/enuresis, enuresis; nocturnal, nocturnal; enuresis, Bed-wetting
Spanish enuresis nocturna (hallazgo), Enuresis nocturna, Mojar la cama, Enuresis Nocturna, Mojar la Cama, enuresis nocturna (trastorno), moja la cama, incontinencia nocturna, Orinarse durante el Sueño, Micción Nocturna Involuntaria, Orinarse en la Cama, Incontinencia Urinaria Nocturna, Micción Involuntaria Nocturna, enuresis nocturna
Dutch nachtelijk bedplassen, bedwateren, Enuresis, enuresis; nachtelijk, nachtelijk; enuresis
French Enurèse noct, Enurésie nocturne, Énurésie nocturne, Incontinence nocturne des urines, Incontinence urinaire nocturne
German Bettnaessen, naecht.l Enuresis, naechtliche Enuresis, Enuresis nocturna, Bettnässen
Italian Enuresi, Enuresi notturna, Incontinenza urinaria notturna
Portuguese Enurese nocturna, Incontinência Urinária Noturna, Enurese Noturna, ENURESE NOCTURNA, Micção Involuntária Noturna, Micção durante o Sono, Micção Noturna Involuntária
Swedish Nattenures
Japanese ヤニョウ, 夜尿, 夜間遺尿症, 尿失禁-夜間, 遺尿症-夜間, 夜間遺尿, 夜尿症, 夜間尿失禁
Finnish Yökastelu
Czech noční enuréza, moč - noční inkontinence, Noční enuréza, Enuresis nocturna, Noční pomočování, noční pomočování, enuresis nocturna
Polish Moczenie mimowolne nocne, Mimowolne moczenie nocne
Hungarian Enuresis nocturna, enuresis nocturna, ágybavizelés
Norwegian Sengevæting, Enurese, nattlig, Ufrivillig urinlating om natta