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Enuresis
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Enuresis
, Nocturnal Enuresis, Bedwetting, Urinary Incontinence in Children
Definition
Enuresis (DSM-IV Classification)
Repeated voiding of urine into bed or clothes
Involuntary or intentional
Clinically Significant
criteria (one of the following)
Twice weekly for at least 3 consecutive weeks
Significant distress
Impaired functioning
Age 5 years or older
Secondary cause not present
Medication (e.g.
Diuretic
s)
Diabetes Mellitus
Spina bifida
Seizure Disorder
Categories
Enuresis
Primary or Secondary
Primary Enuresis (80%)
No history of urinary continence for more than 6 months
Secondary Enuresis (20%)
Enuresis recurs after 6 months of urinary continence
Typically associated with new psychosocial stressors or medical or behavioral condition
Monosymptomatic or nonmonosymptomatic
Monosymptomatic Enuresis
Nighttime bed wetting without other symptoms
Non-monosymptomatic Enuresis (associated with more significant abnormality)
Daytime lower urinary tract symptoms (e.g. urgency, frequency, incomplete emptying) or
Daytime
Incontinence
or
Dysuria
or
Holding maneuvers (e.g. leg crossing)
Timing
Nocturnal Enuresis only (80%)
Nocturnal and diurnal (20%)
Epidemiology
Prevalence
of Enuresis
Age 2 years: 82%
Age 3 years: 49%
Age 4 years: 26%
Age 5 years: 15-25%
Age 7 years: 5-10%
Age 12 years: Boys: 8%; Girls 4%
Age 18 years: Boys: 1%: Girls rare
Pathophysiology
Maturation delay
Enuresis
Prevalence
decreases with age
"
Bladder
full" signal does not yet work
Inability to awaken in response to the stimulus of a full
Bladder
Other predisposing factors
Excessive nighttime urine production
Decreased
Bladder
functional capacity
Strong association with
Family History
Gene
markers on
Chromosome
5, 12, 13 and 22
Both parents with Enuresis: 77% chance of Enuresis
One parent with Enuresis: 44% chance of Enuresis
Relative Risk
if Father with Enuresis: 7.1
Relative Risk
if mother with Enuresis: 5.2
Causes
Secondary (3%)
Bladder
Dysfunction or unstable
Bladder
(3-5%)
Medically treatable
Urinary Tract Infection
, especially in girls (18 to 60% of cases)
Diabetes Insipidus
Diabetes Mellitus
Hyperthyroidism
Sickle Cell Anemia
Fecal Impaction
or
Constipation
often with comorbid
Encopresis
and treatment resistance (33-75% of cases)
Overactive Bladder
or dyfunctional voiding (<41% of cases)
Surgically treatable
Ectopic Ureter
Lower
Urinary Tract Obstruction
Neurogenic
Bladder
(e.g.
Spinal Dysraphism
)
Bladder
calculus or foreign body
Obstructive Sleep Apnea
secondary to large adenoids (10 to 54% of cases)
Psychiatric illness (in only 20%)
More common in enuretic girls
Suggested by Enuresis both night and day
More likely if Enuresis persists in older child
Regressive Enuresis (occurs after being dry)
Associated with stressful environmental event
History
Voiding History
Consider a two week voiding diary
Does child meet DSM-IV criteria for Enuresis above?
Has the child ever been dry for a 6 month period? (primary or secondary)
Is there daytime Enuresis? (complicated Enuresis)
Characterize the Enuresis
How many days per week?
How many times per night?
What time of night does Enuresis occur?
Urinary Tract Infection
symptoms
Dysuria
Urinary urgency or
Urinary Frequency
Bowel
habit changes
Infrequent or difficult stool passage
Encopresis
Constipation
with hard stools at a frequency of <4 times per week
Functional
Bladder
disorder or neurogenic
Bladder
signs
Frequent Urination
with voids >7 per day
Urine urgency
Withholding urine until last minute
Wets more than once nightly
Small volumes from incomplete emptying
Dribbling, straining to obtain even a weak urine stream
Nocturnal
Polyuria
Enuresis on only a few nights per week
Voids large volumes when Enuresis occurs
Soaked absorbant underpants or voids large first-morning void despite Enuresis?
Excessive water intake prior to bed?
Weight loss associated with polydipsia and
Polyuria
(
Diabetes Mellitus
)?
Other related history
Birth complications
Neurologic disorders (motor disorders,
Learning Disorder
s,
Developmental Delay
)?
Genitourinary surgeries
Family History
of Enuresis
Behavioral problems
Snoring and
Daytime Somnolence
(
Obstructive Sleep Apnea
)
Sickle Cell Anemia
Examination
Height and weight
Evaluate for
Growth Delay
or
Failure to Thrive
(e.g.
Diabetes Mellitus
,
Chronic Kidney Disease
)
Head and
Neck Exam
Evaluate for
Tonsillar Hypertrophy
(and consider enlarged adenoids) suggestive of pediatric
Sleep Apnea
Abdominal and flank exam
Costovertebral Angle Tenderness
(
CVA Tenderness
)
Abdominal masses
Bladder
enlargement
Genitourinary exam and
Rectum
Males
Hypospadias
, meatal stenosis,
Phimosis
Females
Labial adhesions
Sexual abuse signs
Excoriations at the perineum or perianal region
Prepubertal
Vulvovaginitis
Rectum
Fecal Impaction
or signs of soiling (
Constipation
,
Encopresis
)
Decreased sphincter tone (may be comorbid with neurogenic
Bladder
)
Back exam
Dimple, hair tuft,
Lipoma
or other skin findings in the midline superior to the gluteal cleft (
Spinal Dysraphism
signs)
Neurologic Exam
Gait
Evaluation for neurologic deficits
Lower limb motor weakness or reflex abnormality
Labs
Urinalysis
Signs of
Urinary Tract Infection
Urine Specific Gravity
Urine Glucose
Other labs to consider
Fingerstick
Blood Sugar
Basic metabolic panel including
Renal Function
Imaging
Consider as indicated
Renal
Ultrasound
and
Bladder Ultrasound
Indicated for suspected urinary tract malformation or
Chronic Kidney Disease
MRI
Lumbar Spine
Indicated for suspected
Spinal Dysraphism
Management
Referral Indications
Non-monosymptomatic Enuresis
Recurrent Urinary Tract Infection
Urinary tract malformations
Prior pelvic surgery
Neurologic disorders (e.g. neurogenic
Bladder
)
Failure to respond after age 7 years old to adequate trial of bed alarm and
Desmopressin
Psychiatric disorder
Dysfunctional voiding (or urinary tract malformation)
Chronic Kidney Disease
Management
Gene
ral
Discussion topics
Reassure parents with age-related norms
Counsel family regarding conflict surrounding Enuresis
Assess for organic causes (see above)
Complete history and physical with
Urinalysis
No further evaluation necessary if normal results
Treat reversible underlying causes
Constipation
Consider pediatric gastroenterology
Consultation
for
Encopresis
Acute
Urinary Tract Infection
Consider imaging and
Consultation
for
Recurrent Urinary Tract Infection
Obstructive Sleep Apnea
Consult regarding
Tonsil
lar or adenoid hypertrophy
Diabetes Mellitus
Obtain
Consultation
for complicated secondary causes
See referral indications above
Management
Non-Pharmacologic Therapies
Indicated for monosymptomatic Enuresis (no secondary disorder suspected)
Appropriate
Toilet Training
Scheduled voiding times (especially in evening)
Behavior Modification
Bed-Wetting Alarm
Most effective treatment for Nocturnal Enuresis
Visualization techniques
Void just before bedtime
Limit fluids 1 hour before bedtime
Scheduled awakening during night to void
Some experts do not recommend
Positive reinforcement system
Charts the child's progress of dry nights
Given stickers on calendar or points per dry night
Gene
ral Recommendations
Enlist support and cooperation of child
Older children launder their own soiled clothes
Should not be punishment
Allows child's participation and responsibility
Avoid harmful measures
Waking child repeatedly during the night to void
Interferes with sleep
Aggravates child and parent
Punishing or shaming the child for wetting the bed
Intimidating the child or lowering his self esteem
Postponing the child's bedtime to decrease Bedwetting
Management
Pharmacologic Therapies
Try to avoid medications if possible
Medications are only effective briefly
Drug tolerance is common
Symptoms are exacerbated after drug is discontinued
Adverse effects are common
If used, avoid in under age 6 years
Medications: Primary Nocturnal Enuresis
Imipramine
(or
Desipramine
)
Typical dose: 25 mg nightly
Not first line due to
Cardiac Arrhythmia
risk
As effective as
Desmopressin
Higher rate of adverse effects compared with
dDAVP
dDAVP
(
Desmopressin
, ADH)
Typical dose: 0.2 mg
Restrict fluid intake 1 hour before taking
dDAVP
Nasal form is no longer approved for Enuresis due to
Hyponatremia
(water
Intoxication
)
Can also occur with oral form, but less commonly
Robson (2007) J Urol 178(1):24-30. [PubMed]
For intermittent use on overnights or summer camp
Effective in children with nocturnal
Polyuria
(but high relapse rate)
Not effective in low nighttime
Urine Output
or small
Bladder
capacity
Medications:
Urge Incontinence
or Diurnal Enuresis
Oxybutynin
(
Ditropan
)
Dose: 2.5 to 5 mg orally three times daily
Anticholinergic
side effects
Consider in combination with
dDAVP
Course
Annual resolution rate of Nocturnal Enuresis: 15%
References
Cendron (1999) Am Fam Physician 59(5):1205-20 [PubMed]
Evans (2001) West J Med 175:108-11 [PubMed]
Redsell (2001) Child Care Health Dev 27(2):149-62 [PubMed]
Thiedke (2003) Am Fam Physician 67:1499-510 [PubMed]
Ullom (1996) Am Fam Physician 54(7):2259-71 [PubMed]
Wan (1997) Pediatr Clin North Am 44:1117-31 [PubMed]
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