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Enuresis
OVERVIEW: Involuntary urination
• Nocturnal enuresis: involuntary urination during sleep more than once a month in girls over 5 and in boys over 6 years of age
• Day-time enuresis: involuntary urination during waking hours
• Primary enuresis: the child who has never been completely continent for an extended (3-6 month) period
• Secondary enuresis: the return of the involuntary loss of urinary control after an extended period of urinary continence.
System(s) affected: Renal/Urologic, Nervous
Genetics: In some families, there appears to be an inheritance which follows an autosomal dominant pattern with a penetrance of 90% and the marker has been identified on chromosome 13q
Incidence/Prevalence in USA: Approximately 10% of children
Predominant age: Occurs in 40% of three year olds, 10% of six year olds, 3% of 12 year olds, and 1% of 18 year olds
Predominant sex: Male > Female
SIGNS AND SYMPTOMS: • Important historical information includes age, primary or secondary incontinence, nocturnal or diurnal or both, voiding pattern (intermittently continent or wet all the time), any delay in developmental milestones, toilet training techniques
• Inability to keep from urinating while asleep at least once per month
• Diurnal enuresis may be associated with frequency, dysuria, or activities that cause an increase in intra-abdominal pressure
• Some children may be withdrawn and shy and some may show aggressive behaviors; both may be secondary to the enuresis and not primary behaviors
• Stress factors such as intrafamilial discord, significant life events, psychosocial or emotional problems may be present
CAUSES: • Primary enuresis
• Some enuretic children lack a normal increase in nocturnal ADH secretion resulting in an amount of urine which exceeds the bladder capacity
• Nocturnal enuresis alone rarely has a psychiatric, neurologic or anatomic basis (reduced bladder capacity is usually functional, not anatomic)
• Reduced bladder capacity (normal capacity is 2 oz at birth and increases 1 oz per year of age up to 12 oz) and/or frequent uninhibited contractions (maturational lag or persistent infantile pattern)
• Recent reports suggest enuretic children have a lower morning level of vasopressin
• Some suggestion that food allergies may influence bladder capacity
• Spinal cord malformations are rarely found
• Most patients are deep sleepers or have a high arousal threshold
• Sleep apnea has been associated with primary nocturnal enuresis
• Secondary enuresis and/or diurnal enuresis
• Bacteriuria
• Inability to concentrate urine due to insufficient antidiuretic hormone or to renal tubular defect
• Glucosuria
• Pelvic mass such as pregnancy
• Spinal cord malformations are still rare but a careful examination of the lower back for signs of spinal dysrhaphia and a thorough neurologic examination of lower extremities and genital area is mandatory
RISK FACTORS: • History of one parent having been enuretic gives 44% occurrence rate in offspring
• History of both parents having been enuretic gives a 77% occurrence rate in their offspring
• First born child
DIAGNOSIS DIFFERENTIAL DIAGNOSIS: • Diabetes insipidus
• Diabetes mellitus
• Renal tubular defects
• Spinal cord malformations or tumors; particularly suggestive in the case of secondary enuresis and with diurnal enuresis
LABORATORY: • Urinalysis including specific gravity, glucose, protein, microscopic exam
• Urine culture
• Tests for pregnancy if history indicates
Drugs that may alter lab results: N/A
Disorders that may alter lab results: N/A
PATHOLOGICAL FINDINGS: Usually none
SPECIAL TESTS: Estimation of bladder size: Have the child hold urine until the urge is unbearable. Then measure urine in a measuring cup.
IMAGING: • Renal ultrasound, intravenous pyelogram, or voiding cystourethrogram are necessary only if urinary tract infections are associated with the enuresis
• Historical information and/or abnormal physical findings may suggest the need for spinal x-rays or imaging studies of the cord
DIAGNOSTIC PROCEDURES: Observation of the child's urinary stream for caliber and projectile force may be helpful
TREATMENT APPROPRIATE HEALTH CARE: Outpatient
GENERAL MEASURES: • Anticipatory guidance relative to toilet training beginning by 18 months
• Counseling and behavior modification
• Treatments which are free from side effects can be started when child is toilet trained
• Secondary or diurnal enuresis needs more investigation and other treatments appropriate to the identified etiology
• Encourage daytime fluids and encourage less frequent urination to help increase bladder size
• Discourage any fluids during the 2 hours prior to bedtime
• Protect the bed from urine by covering the mattress with plastic, have the child wear extra thick underwear (not diapers), and put a towel on the bed in the area of the child's bottom
• Encourage the child to take responsibility for the problem
• Encourage the child to get up to urinate during the night but parents should not awaken the child to urinate
• When enuresis occurs, the child should rinse pajamas and underwear and the towel
• Do not punish the child for wet nights, but act sympathetically
• Heap praise on the child for dry nights. A calendar for gold stars or happy faces can be used as an incentive.
• Bladder stretching exercises may be helpful
• Self-awakening or hypnotherapy programs may be helpful
• Bed-wetting alarms have the greatest rate of success (70%) and the lowest rate of relapse (30%)
SURGICAL MEASURES: N/A
ACTIVITY: No restrictions
DIET: No fluids for 2 hours prior to bedtime
PATIENT EDUCATION: • Inform parents and the patient that most children overcome the problem between ages 6 and 10, and in only a very few cases does the problem persist beyond 16 years of age
• Since enuresis is self-limiting, potential harmful treatments should be avoided
MEDICATIONS DRUG(S) OF CHOICE: • Tricyclic antidepressants - such as imipramine, 1-2 mg/kg q hs to maximum of 50 mg, or desipramine. Initial success is offset by a high relapse rate resulting in an overall success rate after withdrawal of only 40%.
• Desmopressin (DDAVP): An analogue of vasopressin, used in children over 6 years of age has a high success rate and a high relapse rate when discontinued. Initial dose is 20 mcg intranasally qhs, maximum of 40 mcg (or 600 mcg po qhs)
• Oxybutynin (Ditropan) has be used alone and in combination with desmopressin with fair results
Contraindications: Refer to manufacturer's profile of each drug
Precautions:
• Imipramine can cause arrhythmias or conduction blocks. Obtain an ECG prior to starting this drug.
• Imipramine is one of the leading causes of childhood drug-related deaths in the US; usually from accidental overdose
• DDAVP has been associated with hyponatremia (and seizures) due to water intoxication. Prevent this problem by limiting fluids.
Significant possible interactions: Refer to manufacturer's profile of each drug
ALTERNATIVE DRUGS: N/A
FOLLOW UP PATIENT MONITORING: Frequent visits are necessary for support and encouragement
PREVENTION/AVOIDANCE: No preventive measures known
POSSIBLE COMPLICATIONS: Urinary tract infection
EXPECTED COURSE AND PROGNOSIS: • Self-limiting problem
• By age 4-5 years, only 12% of children will not have complete urinary control. These 12% convert to complete control at a rate of 15% per year. By puberty, only 2-3% have not achieved complete control.
MISCELLANEOUS ASSOCIATED CONDITIONS: • Psychosocial problems
• Institutionalization
• Attention-deficit hyperactivity disorder
AGE-RELATED FACTORS:
Pediatric: N/A
Geriatric: N/A
Others: N/A
PREGNANCY: N/A
SYNONYMS: • Bed-wetting
• Primary nocturnal enuresis
ICD-9-CM: 307.6 Enuresis
788.30 Urinary incontinence, unspecified (enuresis)
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