Enuresis, known as bed-wetting, is very common childhood
complaint encountered by pediatricians. Nocturnal enuresis (NE) is
defined as involuntary passage of urine during sleep beyond the age of expected
continence which is 5 years of age. There are two types of NE.
Primary is when a child never stopped wetting for any period, whereas
secondary is acquired after being dry for at least 6 months. Primary
enuresis affects the majority of children with enuresis.
NE is 2-3 times more frequent in boys. Since most NE is due to maturational delay, there is a significant improvement or resolution as the child gets older. Approximately 15% resolve each year. Interestingly, family studies show a strong genetic predisposition for bed-wetting.
Organic causes of enuresis account for less than 5% of all cases; with most being urinary tract infections. Other organic problems include: diabetes, diabetes insipidus, nocturnal seizures, urinary anomalies, nocturnal ADH deficiency, hyposthenuria (constant secretion of urine) associated with sickle cell disease, medications, or emotional stress. Those children need to be identified and treated. Children with severe constipation may compress the bladder and present with bed-wetting. Other theories suggest sleep disturbance or reduced bladder capacity.
The evaluation of NE must exclude any organic causes. A careful history is taken which should include pattern of wetting, fevers, increasing fluid intake due to the sensation of having a dry mouth , excessive or abnormally large production or passage of urine, and prior urinary infections. Questioning about food allergy, sickle cell disease, and constipation is occasionally helpful. Attention should also be paid to stresses and family dynamics that may uncover psychological factors.
There is no treatment modality that is 100% successful so far. Parents should be reminded that a majority of bed-wetting is caused by maturational delay and not under conscious control. Therefore, the important aspects of treatment are reassurance and protection of the child's self esteem. It is important that bed-wetting not be perceived as a bad behavior. because punishment not only lowers the child self esteem, but also does not improve the symptoms. Early education of the caregivers in regards to maturational delay, role of genetics and the importance of a supportive toilet training may ease the difficult period. Remember that there is a 15% spontaneous decrease or disappearance every year so many recommend an approach of watchful waiting and reassurance. Some simple life changes such as improving access to the toilet, avoiding excessive fluid before bed time and emptying the bladder at bed time may be tried initially.
To some families, this conservative approach that requires patience can lead to frustration and suffering. Instead, a wide-ranging method of treatment that includes pharmacologic therapy, bladder training and behavior modification with an alarm system may be implemented.
Treatment can begin with positive reinforcement like keeping a calendar and rewarding dry nights. Another treatment is bladder training composed of different methods such as holding urine as long as possible, then when the child urinates, he/she is suppose to stop and start the urine flow frequently. Another manner is going to the bathroom several times during the night, or having the parents wake the child several times during the night and subsequently increasing the time interval between waking. The goal is to increase the muscle strength of the urethra and give the child confidence that he or she can control urine flow and connect the feeling of a full bladder with the need to go to the bathroom.
Pharmacologic therapy consists of imipramine (tricyclic antidepressants) or desmopressin acetate (DDAVP). Each one has advantages and disadvantages. 10-60% respond to imipramine treatment, but more than 90% relapse. Imipramine is potentially lethal with acute overdose (especially cardiac toxicity). DDAVP is available in two forms, nasal spray and tablets. The oral form is used in children with nasal congestion such as colds and allergies. The drawback is the cost and rare mild side effects of DDAVP. DDAVP is helpful in certain situations such as going to overnight camp. There is a 25-50% success rate with DDAVP, but a relapse rate of 94%.
Enuresis alarms have been shown recently to be the most effective treatment for bed-wetting. Urination acts as a stimulus for the alarm and wakes the child from sleep. The cure rate is 60-80% and the relapse rate is 10-40%. The only drawback is that the child and family must be highly motivated to stay committed to these conditioning methods.
NE is 2-3 times more frequent in boys. Since most NE is due to maturational delay, there is a significant improvement or resolution as the child gets older. Approximately 15% resolve each year. Interestingly, family studies show a strong genetic predisposition for bed-wetting.
Organic causes of enuresis account for less than 5% of all cases; with most being urinary tract infections. Other organic problems include: diabetes, diabetes insipidus, nocturnal seizures, urinary anomalies, nocturnal ADH deficiency, hyposthenuria (constant secretion of urine) associated with sickle cell disease, medications, or emotional stress. Those children need to be identified and treated. Children with severe constipation may compress the bladder and present with bed-wetting. Other theories suggest sleep disturbance or reduced bladder capacity.
The evaluation of NE must exclude any organic causes. A careful history is taken which should include pattern of wetting, fevers, increasing fluid intake due to the sensation of having a dry mouth , excessive or abnormally large production or passage of urine, and prior urinary infections. Questioning about food allergy, sickle cell disease, and constipation is occasionally helpful. Attention should also be paid to stresses and family dynamics that may uncover psychological factors.
There is no treatment modality that is 100% successful so far. Parents should be reminded that a majority of bed-wetting is caused by maturational delay and not under conscious control. Therefore, the important aspects of treatment are reassurance and protection of the child's self esteem. It is important that bed-wetting not be perceived as a bad behavior. because punishment not only lowers the child self esteem, but also does not improve the symptoms. Early education of the caregivers in regards to maturational delay, role of genetics and the importance of a supportive toilet training may ease the difficult period. Remember that there is a 15% spontaneous decrease or disappearance every year so many recommend an approach of watchful waiting and reassurance. Some simple life changes such as improving access to the toilet, avoiding excessive fluid before bed time and emptying the bladder at bed time may be tried initially.
To some families, this conservative approach that requires patience can lead to frustration and suffering. Instead, a wide-ranging method of treatment that includes pharmacologic therapy, bladder training and behavior modification with an alarm system may be implemented.
Treatment can begin with positive reinforcement like keeping a calendar and rewarding dry nights. Another treatment is bladder training composed of different methods such as holding urine as long as possible, then when the child urinates, he/she is suppose to stop and start the urine flow frequently. Another manner is going to the bathroom several times during the night, or having the parents wake the child several times during the night and subsequently increasing the time interval between waking. The goal is to increase the muscle strength of the urethra and give the child confidence that he or she can control urine flow and connect the feeling of a full bladder with the need to go to the bathroom.
Pharmacologic therapy consists of imipramine (tricyclic antidepressants) or desmopressin acetate (DDAVP). Each one has advantages and disadvantages. 10-60% respond to imipramine treatment, but more than 90% relapse. Imipramine is potentially lethal with acute overdose (especially cardiac toxicity). DDAVP is available in two forms, nasal spray and tablets. The oral form is used in children with nasal congestion such as colds and allergies. The drawback is the cost and rare mild side effects of DDAVP. DDAVP is helpful in certain situations such as going to overnight camp. There is a 25-50% success rate with DDAVP, but a relapse rate of 94%.
Enuresis alarms have been shown recently to be the most effective treatment for bed-wetting. Urination acts as a stimulus for the alarm and wakes the child from sleep. The cure rate is 60-80% and the relapse rate is 10-40%. The only drawback is that the child and family must be highly motivated to stay committed to these conditioning methods.
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