Nocturnal Enuresis

Enuresis (Bed-Wetting)
• Enuresis is defined as the repeated voiding of
urine into clothes or bed at least twice a week for
at least 3 consecutive months in a child who is at
least 5 yr of age.
• Diurnal enuresis defines wetting while awake and
nocturnal enuresis refers to voiding during sleep.
• Primary enuresis occurs in children who have
never been consistently dry through the night,
whereas secondary enuresis refers to the
resumption of wetting after at least 6 months of
dryness.

Normal Voiding and Toilet Training
• Urine storage consists of sympathetic and pudendal
nerve–mediated inhibition of detrusor contractile
activity accompanied by closure of the bladder neck
and proximal urethra with increased activity of the
external sphincter.
• The infant has coordinated reflex voiding as often as
15-20 times per day. Over time, bladder capacity
increases.
• At 2-4 yr, the child is developmentally ready to begin
toilet training.
• In children up to the age of 14 yr, the mean bladder
capacity in ounces is equal to the age (in years) plus 2.

• To achieve conscious bladder control, several
conditions must be present:
awareness of bladder filling,
cortical inhibition (suprapontine modulation) of reflex
(unstable) bladder contractions,
ability to consciously tighten the external sphincter to
prevent incontinence,
normal bladder growth, and
motivation by the child to stay dry.
• The transitional phase of voiding is the period when
children are acquiring bladder control.
• Girls typically acquire bladder control before boys, and
bowel control typically is achieved before bladder
control.
Normal Voiding and Toilet Training

Epidemiology
• Prevalence estimates vary significantly.
• At age 5 yr, 7% of boys and 3% of girls have enuresis;
• by age 10 yr the percentages are 3% and 2%, respectively:
by age 18 yr, 1% for men and less than 1% for women.
• Primary enuresis accounts for 85% of cases.
• Enuresis is more common in lower socioeconomic groups,
in larger families, and in institutionalized children.
• There is an estimated spontaneous cure rate of 14-16%
annually.
• Diurnal enuresis is more common in girls and rarely occurs
after the age of 9 yr;
• overall, 25% of children have diurnal enuresis.

Etiology
• The cause of enuresis likely involves biologic,
emotional, and learning factors.
• Compared with a 15% incidence of enuresis in
children from nonenuretic families, 44% and
77% of children were enuretic when one or
both parents, respectively, were themselves
enuretic.
• Linkage studies have implicated several
chromosomes with varying patterns of
transmission.

• Children with nocturnal enuresis might
hyposecrete arginine vasopressin (AVP) and
• may be less responsive to the lower urine
osmolality associated with fluid loading.
• Many affected children also appear to have small
functional bladder capacity.
• There is some support for a relationship among
sleep architecture, diminished capacity to be
aroused from sleep, and abnormal bladder
function.
• Psychosocial stressors may be contributory.
Etiology

• Children with enuresis should be evaluated with a
detailed history and physical exam, taking into
consideration the underlying organic causes of
secondary enuresis.
• Particular attention should be paid to
manifestations of UTIs; chronic kidney disease;
spinal cord disorders; constipation; and the
thirst, polyuria, and polydipsia associated with
both type of diabetes.
Evaluation

Diagnosis and Differential Diagnosis
• Laboratory evaluation should include a
• Urinalysis and urine culture will rule out
infectious causes and glycosuria(DM) or a low
specific gravity (DI)
• bladder ultrasonography should be performed
when the bladder is perceived to be full and after
voiding.
• Children with combined nocturnal and diurnal
enuresis are more likely to have abnormalities of
the urinary tract, making ultrasonography or
uroflowmetry indicated.

Secondary etiologies of urinary incontinence include:
urinary tract infections (UTIs), pinworm infection,
chronic kidney disease, spinal dysraphism,
hypercalcemia, neurogenic bladder,
hypokalemia, hyperthyroidism,
chemical urethritis, sleep-disordered breathing,
constipation, drugs (valproic acid, clozapine)
diabetes mellitus or insipidus, giggle or stress incontinence.
sickle cell anemia, seizures,
Differential Diagnosis

Treatment
• Given the steady progression in the
spontaneous remission rate of enuresis each
year, there is some question as to whether
enuresis should be treated.
• Family conflict, parent-child antagonism,
and/or peer teasing due to the enuresis are
good reasons to institute treatment for
enuresis with resultant beneficial effects on a
child's well-being and self-esteem.

• indications for urologic referral and
treatment includes:
Daytime wetting,
Abnormal voiding (unusual posturing,
discomfort, straining, and/or a poor urine
stream),
History of UTIs and/or evidence of infection
on urinalysis or culture, and
Genital abnormalities
Treatment

• The treatment of monosymptomatic
nocturnal enuresis should be marked by a
conservative, gentle, and patient approach.
• Treatment can begin with:
• parent-child education,
• charting with rewards for dry nights,
• voiding before bedtime,
• night awakening 2-4 hr after bedtime,
• making sure that parents do not punish the
child for enuretic episodes.
Treatment

In addition, the child should be encouraged to
avoid holding urine and to void frequently
during the day (to avoid day wetting).
These children also need ready access to
school toilets.
Furthermore, if constipation and fecal
impaction are problems, children should be
encouraged to have a daily bowel movement
and taught optimal relaxation of pelvic floor
muscles to improve bowel emptying.
Treatment

TREATMENT REGIMEN FOR ENURESIS
• Limit fluids to 8 oz at supper 3 to 3.5 hours before bedtime; no fluids thereafter.
• Empty the bladder before sleeping.
• Make a bedtime “resolution” to stay dry.
• Discuss mode of action of drugs or moisture alarm and drug side effects; dispense drug or alarm.
• Advise that medication or alarm is the “coach” and the child is the “player.”
• Advise that positive internal and external biofeedback signals help hasten central nervous system
control of the bladder.
• Keep a calendar of dry and wet nights.
• Encourage the child's participation in cleaning up personal clothing and bedclothes.
• Schedule follow-up visits or phone calls at least every 2 wk, with positive reinforcement for dry
nights and efforts.
• Continue use of alarm until 28 consecutive dry nights are achieved, then stop; use medications as
directed.
• If bedwetting returns on tapering or discontinuation of medication or alarm, restart nightly
medication or alarm.
• If the child is not dry every night, despite motivation and efforts, substitute or add another drug
or alarm and rule out undisclosed diurnal voiding problems.
Treatment

• If this approach fails, urine alarm treatment is
recommended.
• Application of an alarm for a period of 8-12 wk can be
expected to result in a 75-95% success in the arrest of
bedwetting.
• The underlying conditioning principle likely lies in the
alarm's being an annoying awakening stimulus that causes
the child to awaken in time to go to the bathroom and/or
retain urine in order to avoid the aversive stimulus.
• Urine alarm treatment has been shown to be of equal or
superior effectiveness when compared to all other forms of
treatment.
Treatment

• Pharmacotherapy for nocturnal enuresis is second-line
treatment.
• Desmopressin acetate (DDAVP) is a synthetic analog of the
antidiuretic hormone (ADH) vasopressin, which decreases
nighttime urine production.
• The fast action of DDAVP suggests a role for special
occasions (e.g., sleepovers), when rapid control of
bedwetting is desired.
• Unfortunately, the relapse rate is high when DDAVP is
discontinued.
• DDAVP is also associated with rare side effects of
hyponatremia and water intoxication, with resulting
seizures.
Treatment

• Although imipramine has some usefulness,
less than 50% of children respond, and most
relapse when the medication is discontinued.
Bothersome side effects and potential
lethality in overdose also limit this
medication's usefulness.
• Much less commonly used, oxybutynin and
tolterodine are antimuscarinic drugs, which
may be effective by reducing bladder spasm
and increasing bladder capacity.
Treatment

MEDICATIONS FOR TREATMENT OF
MONOSYMPTOMATIC ENURESIS
GENERIC NAME
(TRADE NAME)
DOSAGE
FORMULATION
DOSAGE REGIMEN MECHANISM OF ACTION COMMENTS
Desmopressin
acetate (DDAVP)
Nasal spray pump:
10 ?g/0.1 mL spray
1 spray (10 ?g) per
nostril qhs,
increasing to 40 ?g
Decreased urine volume, possible effect
on sleep arousal through its action as a
central nervous system
neurotransmitter
Can cause nasal irritation;
risk of water intoxication
(headache, seizures); hence,
restrict fluids 3 hr before the
dose
Tablets: 0.1 mg, 0.2
mg
0.2 mg PO qhs,
increasing up to 0.6
mg
Imipramine
hydrochloride
(Tofranil)
Tablets: 10 mg, 25
mg, 50 mg; Tofranil
PM capsule 75, 100,
125, 150 mg
1.5-2 mg/kg 2 hr
before bedtime, not
to exceed 2.5 mg/kg
or 75 mg maximum
Anticholinergic effect on bladder,
increased resistance of bladder outlet,
possible central inhibition of
micturition reflex, possible effect on
sleep arousal by central noradrenergic
facilitation
Can cause sleep
disturbance, mood
alteration, decreased
appetite, risk of cardiac
arrhythmia with overdose

Nocturnal Enuresis

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Nocturnal Enuresis