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Enuresis

BASICS

DESCRIPTION

  • Primary nocturnal enuresis (NE): 80% cases; never established urinary continence on ≥6 consecutive months.
  • Secondary NE: 20% cases; resumption of enuresis after ≥6 months of continence.
  • NE: intermittent nocturnal incontinence after expected bladder control age (≥5 years).
  • Primary monosymptomatic NE (PMNE): bedwetting without bladder dysfunction or LUT symptoms.
  • Nonmonosymptomatic NE (NMNE): bedwetting with LUT symptoms (frequency, urgency, daytime wetting, hesitancy, straining, weak/intermittent stream, post-void dribbling, discomfort, incomplete emptying).

Alert: Adult-onset NE without daytime incontinence warrants full urologic evaluation.

SYSTEMS AFFECTED

  • Nervous system, renal/urologic.

SYNONYMS

  • Bed-wetting, sleep enuresis, nocturnal incontinence, primary NE.

EPIDEMIOLOGY

INCIDENCE

  • Family history dependent.
  • Spontaneous resolution: ~15% per year.

PREVALENCE

  • 5-7 million children affected in U.S.
  • 10% of 7-year-olds; 3% of 11-12-year-olds; 0.5-1.7% at 16-17 years.
  • 2-3x more common in males.
  • Nocturnal > daytime incontinence ratio 3:1.

GERIATRIC CONSIDERATIONS

  • Infrequent; often with daytime incontinence.

ETIOLOGY AND PATHOPHYSIOLOGY

  • Interrelated factors: sleep arousal disorder, low nocturnal bladder capacity, nocturnal polyuria.
  • Functional and organic causes; many theories without absolute confirmation.
  • Detrusor instability.
  • Arginine vasopressin (AVP) deficiency or decreased stimulation.
  • CNS maturational delay.
  • Severe NE linked to bladder overactivity and frequent cortical arousals.
  • Organic urologic causes (1-4%): UTI, occult spina bifida, ectopic ureter, lazy bladder, wide bladder neck, posterior urethral valves, neurogenic bladder.
  • Organic nonurologic: epilepsy, diabetes mellitus, food allergies, obstructive sleep apnea, chronic renal failure, hyperthyroidism, pinworm infection, sickle cell disease.
  • NE occurs during all sleep stages.

GENETICS

  • Autosomal dominant inheritance with high penetrance (~90%).
  • 1/3 cases sporadic.
  • 75% of children have first-degree relative with NE.
  • Higher concordance in monozygotic twins (68%) vs dizygotic (36%).
  • Both parents affected → 77% child risk; one parent → 44%.
  • Parental age of resolution predicts child's NE resolution.

RISK FACTORS

  • Family history.
  • Emotional/environmental stressors (divorce, death).
  • Constipation/encopresis.
  • Organic diseases (1% monosymptomatic NE).
  • Psychological disorders: depression, anxiety, social phobia, conduct disorder, ADHD (especially ages 9-12).
  • Altered mental status, impaired mobility.

COMMONLY ASSOCIATED CONDITIONS

  • Obstructive sleep apnea (10-54%).
  • Constipation (33-75%).
  • Behavioral problems (ADHD in 12-17%).
  • Overactive bladder/dysfunctional voiding (up to 41%).
  • UTI (18-60%).

DIAGNOSIS

HISTORY

  • Lower urinary tract symptoms (LUTS).
  • Fluid intake, voiding, stooling patterns (voiding diary).
  • Psychosocial history (patient, family, school, bullying).
  • Family history of enuresis.

PHYSICAL EXAM

  • ENT: adenotonsillar hypertrophy (sleep apnea).
  • Abdomen: enlarged bladder, kidneys, fecal masses.
  • Back: sacral dimpling, hair tufts.
  • GU exam: males (meatal stenosis, hypospadias, phimosis); females (vulvitis, vaginitis, labial adhesions, ureterocele, abuse signs).
  • Rectal exam: tone, fecal soiling/impaction.
  • Neurologic exam: lower extremities focus.

DIFFERENTIAL DIAGNOSIS

  • Primary NE, delayed urinary control, UTI, spina bifida occulta, obstructive sleep apnea, idiopathic detrusor instability, myelopathy, neuropathy, anatomic abnormalities.
  • Secondary NE: acute stress, bladder outlet obstruction, neurologic disease.

DIAGNOSTIC TESTS

  • Urinalysis mandatory (children).
  • Urine culture for infection, hematuria, proteinuria, glycosuria.
  • Imaging not usually necessary; consider renal/bladder ultrasound if indicated.
  • VCUG, IV pyelogram rarely indicated.
  • MRI if spinal dysraphism suspected.
  • Urodynamics if daytime symptoms or refractory.

TREATMENT

GENERAL MEASURES

  • Nonpharmacologic approaches first line.
  • Behavioral: scheduled waking, positive reinforcement, bladder training, diet modification.
  • Educate on sleep fragmentation, bladder capacity, urine production.
  • Limit fluids 2 hrs before bedtime.
  • Encourage voiding before bed, scheduled nighttime voiding.
  • Use nightlights, reward systems, pull-ups or waterproof underwear.
  • Cleanliness training, avoid shaming or punishment.
  • Treat constipation.
  • Referral for behavioral counseling if secondary NE suspected.
  • Combined therapies (alarms + behavioral + pharmacologic) more effective.

ENURESIS ALARMS

  • 66-70% success rate; nightly use 2-4 months.
  • Use until 14 dry nights consecutively.

MEDICATION

First Line

  • Desmopressin (DDAVP): synthetic vasopressin analogue; decreases nocturnal urine.
  • Intranasal (adults only; not recommended in children due to hyponatremia risk).
  • Oral: start 0.2 mg at bedtime; titrate to 0.4 mg if needed.
  • Effect lasts 8-10 hours; success ~60-70%.
  • Side effects: hyponatremia, water intoxication. Restrict evening fluids.

Second Line

  • Anticholinergics: not monotherapy in children; screen for constipation/residual urine first.
  • Oxybutynin: may increase bladder capacity; success 30-50%.
  • Dosage varies by age and formulation; patch options available.
  • Other anticholinergics (tolterodine, fesoterodine, solifenacin) used in adults.
  • Imipramine: tricyclic antidepressant; anticholinergic and antispasmodic; 40% success; high relapse.
  • Monitor ECG before use.

PRECAUTIONS

  • Oxybutynin contraindicated in glaucoma, myasthenia gravis, GI/GU obstruction.
  • Desmopressin avoided in fluid retention risk.
  • Imipramine contraindicated with MAOIs, arrhythmias.

COMBINATION THERAPY

  • DDAVP + oxybutynin more effective than alone.

ISSUES FOR REFERRAL

  • Persistent NE despite therapies.
  • Daytime incontinence or LUT dysfunction.

COMPLEMENTARY & ALTERNATIVE MEDICINE

  • Acupuncture has limited supportive data.

ONGOING CARE

FOLLOW-UP

  • Behavioral: reassess 1-3 months.
  • Alarm: reassess 1-3 weeks.
  • DDAVP: reassess 1-2 weeks, then every 3 months.
  • Imipramine: reassess 1 month (watch for UTI/constipation).

DIET

  • Limit fluid and caffeine 1-2 hrs before sleep.

PATIENT EDUCATION

  • Resources: hypnoticworld.com, wetstop.com, dri-sleeper.com, nitetrain-r.com, bedwettingstore.com
  • Free bedwetting diary apps: My Dryness Tracker, Bedwetting Tracker, HapPee Time.

PROGNOSIS

  • Usually self-limiting in children; 1% persist into adulthood.
  • Evaluate for organic causes if adult onset.

COMPLICATIONS

  • UTI, perineal excoriation, psychological effects (children).

REFERENCES

  1. Kuwertz-Bröking E, von Gontard A. Clinical management of nocturnal enuresis. Pediatr Nephrol. 2018;33(7):1145-1154.
  2. Baird DC, Seehusen DA, Bode DV. Enuresis in children: a case-based approach. Am Fam Physician. 2014;90(8):560-568.

CODES

  • ICD10 N39.44 Nocturnal enuresis
  • ICD10 R32 Unspecified urinary incontinence
  • ICD10 F98.0 Enuresis not due to substance or physiological condition

CLINICAL PEARLS

  • Behavioral and lifestyle changes are first-line for primary monosymptomatic NE.
  • Enuresis alarms and desmopressin are most effective treatments.
  • Secondary enuresis often related to psychosocial factors.