Nocturnal Enuresis

Anne M. Arnhym

I. INTRODUCTION

Nocturnal enuresis is a common condition that affects children of all ethnic backgrounds. It may result from a single factor or a combination of several factors in a given child. In general, treatment is considered straightforward and largely dependent on the motivation of the family and child.

II. DEFINITION

Nocturnal enuresis is defined as the persistence of inappropriate release of urine at night beyond the age of anticipated control.

A. Primary and Secondary

Primary enuretics have never had a dry period of 6 months or more, whereas children with secondary enuresis have had a dry period of at least this length of time prior to wetting again. Approximately 20% of nocturnal enuretics can be classified as secondary. Concern about secondary enuresis suggests a more extensive workup, but in most cases may be treated similar to primary nocturnal enuresis.

III. INCIDENCE

A. Approximately 15% to 25% of 5-year-old children have nocturnal enuresis.

B. There is a spontaneous cure rate of 15% each year. This suggests that a normal developmental process may simply be delayed in kids with primary nocturnal enuresis.

C. Approximately 2% to 3% of older adolescents and 1% to 2% of adults have nocturnal enuresis.

D. Nocturnal enuresis is more common in boys than girls (approximately in the ratio 3:2).

IV. ETIOLOGY

Most evidence suggests that the cause of nocturnal enuresis is multifactorial. Possibilities include the following.

A. Genetic

There is an increased incidence of nocturnal enuresis in children whose parents also had this condition. 1. Incidence is 77% (both parents); 44% (one parent); and 15% (neither).

B. Maturational Delay

Delayed functional maturation of the central nervous system may reduce the child’s ability to inhibit bladder emptying at night.

1. The child’s bladder fills, but the sensory output resulting from bladder expansion is not perceived, or the message fails to reach the brain. Therefore, the bladder contraction is not inhibited.

2. Functional bladder capacity while sleeping is small in some children with nocturnal enuresis.

C. Bowel and Bladder Dysfunction (BBD)

1. Many children with a history of enuresis also present with suboptimal daytime voiding and/or daytime urinary urgency or continence. Stool retention is commonly noted in this population.

2. BBD is often a limiting factor for patients with nocturnal enuresis. Nocturnal enuresis may resolve with treatment of bowel and bladder dysfunction. If not addressed, bedwetting-specific treatment modalities are also less likely effective.

D. Sleep Disorders

Most parents of enuretic children report that their children are deep sleepers. The findings of scientific studies of the sleep patterns of children with and without nocturnal enuresis, however, show wide variations.

E. Upper Airway Obstruction

There are conflicting data that surgical relief of airway obstruction by tonsillectomy, adenoidectomy, or both is associated with resolution of nocturnal enuresis.

F. Psychological Factors

Nocturnal enuresis was once thought to be a psychological problem. In most cases, psychological problems now appear to be a result of nocturnal enuresis rather than the cause.

G. Urinary Tract Infection

Wetting will be the only symptom of urinary tract infection in approximately 1% of children with nocturnal enuresis.

H. Nocturnal Polyuria

1. Nonenuretic children concentrate their urine overnight. This is noted by first morning void with a specific gravity above 1.015. There is a higher rate of poor first void urine concentration in some children with nocturnal enuresis.

2. Children without nocturnal enuresis show a circadian rhythm in the release of antidiuretic hormone (ADH) that increases nocturnally and is associated with lower urine outputs at night.

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