Nocturnal enuresis

    Last updated date: 06-Mar-2023

    Originally Written in English

    Nocturnal enuresis

    Nocturnal enuresis


    Enuresis is the most prevalent urologic complaint in pediatric patients, and it is defined as the involuntary leakage of urine during sleep that happens at least twice a week in children older than 5 years of age (or the developmental equivalent) for at least 3 months.

    Primary enuresis occurs when a kid has not remained dry for at least 6 months, whereas secondary enuresis develops after a period of nocturnal dryness of at least 6 months.

    Enuresis can also be classified as monosymptomatic or non-monosymptomatic, with the latter being associated with daytime incontinence or other lower urinary tract symptoms such as urgency. Enuretic episodes are also termed common if they occur four or more times each week.

    To avoid misunderstanding, the International Children's Continence Society defines enuresis as nighttime wetness, rather than daytime incontinence, which is no longer referred to as diurnal enuresis.

    Nocturnal enuresis is not a benign disorder; it has serious consequences for both the kid and the household. Children are frequently disciplined and are vulnerable to physical and mental abuse. Many youngsters grow socially alienated, have low self-esteem, and do poorly in school. This activity emphasizes a thorough grasp of this extremely prevalent yet sometimes misunderstood condition.


    How common is nocturnal enuresis?

    nocturnal enuresis

    Enuresis occurs at a comparable rate throughout cultures. The prevalence changes with age, with 15% of 7-year-olds, 10% of 10-year-olds, 2% of adolescents, and 0.5 to 1% of adults afflicted by the condition. Enuresis is more prevalent in males than in girls, with a 3 to 1 ratio, however this disparity tends to diminish around the age of 10.

    Furthermore, 20 to 30 % of enuresis patients have at least one psychological, behavioural, or psychiatric disorder, which is double the proportion of the general population. The most prevalent of these comorbidities is attention deficit and hyperactivity disorder, and the hypothesis is that both conditions are linked by a shared sleep disruption. Autism spectrum disorder, oppositional defiant disorder, and mood disorders are among the other comorbid problems in this group.

    There is also a link between sleep-disordered breathing and enuresis. These patients have high levels of atrial natriuretic peptide, which inhibits the renin-angiotensin-aldosterone pathway and increases diuresis; however, other proposed links between the two entities include an inadequate arousal response secondary to sleep fragmentation due to disordered breathing and bladder stimulation from elevated abdominal pressure caused by an increased respiratory effort to compensate for an obstructed airway. Enuresis is usually healed or much reduced following tonsillectomy and adenoidectomy in these individuals.


    Classifications of nocturnal enuresis 

    Classifications of nocturnal enuresis

    There are three elements that influence nocturnal urinary continence: 1) nocturnal urine output, 2) nocturnal bladder function, and 3) sleep and arousal processes. If a kid is not woken by an impending bladder contraction, he or she will suffer from nocturnal enuresis if more urine is generated than can be held in the bladder or if the detrusor is hyperactive.

    Primary nocturnal enuresis:

    The most frequent type of bedwetting is primary nocturnal enuresis. Bedwetting becomes a problem when it persists after the age at which bladder control generally arises (4–7 years) and results in at least two wet nights per week with no lengthy intervals of dryness or when the child is unable to sleep dry without being carried to the toilet by another person.

    According to new research, anti-psychotic medications can cause enuresis as a side effect. It has been demonstrated that nutrition has an effect on enuresis in children. Constipation caused by a poor diet can cause impacted stool in the colon, exerting excessive pressure on the bladder and resulting in bladder control loss (overflow incontinence).

    Some researchers, however, advocate a different age range for commencing. According to this guideline, bedwetting might be deemed a clinical condition if the kid wets the bed on a regular basis beyond the age of seven.

    Secondary nocturnal enuresis:

    Secondary enuresis occurs when a patient has a prolonged period of nighttime dryness (six months or more) and subsequently reverts to nighttime wetting. Emotional stress or a physical problem, such as a bladder infection, can both produce secondary enuresis.


    Mechanism of how nocturnal enuresis develops

    nocturnal enuresis mechanism

    Researchers assume that several factors are involved in the pathophysiology of enuresis, with each patient displaying a unique combination of them, explaining why some people react to certain medications while others do not. As a result, enuresis is generally recognized as a set of disorders rather than a single entity.

    Nocturnal polyuria, bladder dysfunction, and high arousal thresholds are the main pathophysiological mechanisms involved. Nocturnal polyuria may be caused by a lack of vasopressin or changes in its circadian release. Bladder dysfunction is more common in patients who also have incontinence during the day, and it can manifest as decreased functional bladder capacities or abnormal urodynamics, such as nocturnal detrusor hyperactivity, which could be associated with constipation, most likely due to bladder distortion from a full rectum.

    High arousal thresholds are now recognized as either a cause or a result of enuresis, given that disturbed sleep caused by a blocked airway or a contracting bladder can result in this difficult arousal. The maturational delay theory, which is supported by the discovery of a greater incidence of motor clumsiness, perceptual dysfunction, and speech difficulties in children with enuresis, is also worth considering.


    Causes of nocturnal enuresis

    Causes of nocturnal enuresis

    The etiology of nocturnal enuresis is unknown, however three prevalent reasons include high urine volume, inadequate sleep arousal, and bladder spasms. To guide management options, the parent or carer completes a patient history and fluid charts to differentiate the cause.

    There is a major hereditary component to bedwetting. Children whose parents were not enuretic have a 15% chance of bedwetting. When one or both parents are bedwetters, the rates rise to 44% and 77%, respectively.

    These first two reasons are the most prevalent causes of bedwetting, but current medical technology does not allow for straightforward diagnosis for either. There is no test that can confirm that bedwetting is only a developmental delay, and genetic testing is of little or no use. As a result, alternative possibilities must be ruled out. The following reasons are less prevalent, but they are easier to confirm and treat:

    • Individuals who have a history of bedwetting are 2.7 times more likely to be diagnosed with attention deficit hyperactivity disorder.
    • Caffeine stimulates the production of urine.
    • Bedwetting can be caused by chronic constipation. When the bowels are full, the bladder might become strained. Often, such children defecate normally, but a large amount of material remains in the colon, causing bed wetting.
    • Infections and disease have a stronger relationship with secondary nocturnal enuresis and daytime wetness. Infection or disease is responsible for less than 5% of all bedwetting instances, the most prevalent of which is a urinary tract infection.
    • Patients with more severe neurological-developmental disorders are more likely to have bedwetting issues. One study of seven-year-olds found that "handicapped and mentally challenged children" had nearly three times the prevalence of bedwetting as "non-handicapped children" (26.6 % vs. 9.5 %, respectively).
    • Psychological difficulties (e.g., death in the family, sexual abuse, intense bullying) have been identified as a cause of secondary nocturnal enuresis (a return to bedwetting), although they are extremely rare as a cause of PNE-type bedwetting. Bedwetting can also be a sign of PANDAS, a pediatric neuropsychological disorder.
    • Bedwetting has been linked to sleep apnea caused by an upper airway blockage. Snoring and enlarged tonsils or adenoids are symptoms of sleep apnea.
    • Bedwetting can occur as a result of sleepwalking. The sleepwalker may believe he or she is in another room when sleepwalking. When a sleepwalker urinates during a sleepwalking episode, he or she generally believes he or she is in the bathroom and so urinates where they believe the toilet should be.
    • People who return to bedwetting are often stressed. Researchers discovered that relocating to a new place, parent dispute or divorce, the coming of a new baby, or the loss of a loved one or pet may all lead to feelings of insecurity, which can lead to reoccurring bedwetting.
    • Type 1 diabetes mellitus can first manifest as nocturnal enuresis, which might be the presenting symptom. It is traditionally linked with polyuria, polydipsia, and polyphagia, however weight loss, lethargy, and diaper candidiasis may also be present in patients with newly diagnosed disease.


    History and physical exam findings in children with nocturnal enuresis 

    physical examination

    The history and a thorough physical examination are critical in identifying this illness. Obtaining a history is the first step in evaluating nocturnal enuresis. It is critical to ascertain whether the enuresis is primary or secondary, as well as the pattern (number of episodes in one night and number of nights per week), caffeine and nighttime fluid intake.

    It is also critical to rule out nocturnal polyuria (elicited by asking the parents if the enuretic episodes involve huge volumes of pee), polydipsia, dysuria, urgency, frequency, daytime incontinence, irregular urinary stream, and constipation. A child who has several voiding episodes with varying volumes of pee throughout the night is likely to have an overactive bladder or one with a short capacity.

    Other pertinent questions include a family history of enuresis, a history of recurrent urinary tract infections (which may indicate underlying bowel or bladder dysfunction), sleep disorders, snoring or a diagnosis of sleep-disordered breathing, and the use of chronic medications, as some drugs may be associated with secondary enuresis.

    Patients should be screened for psychiatric or behavioral disorders, such as attention deficit hyperactivity disorder and learning difficulties, and a developmental history should be obtained.

    In most afflicted children, the physical examination is unremarkable. Clinicians should check for distended bladder, rectal exam consistent with fecal impaction, phallic or meatal abnormalities in boys and labial adhesions or urethral anomalies in girls, abnormal muscle tone, sensation, or deep tendon reflexes, and skin changes indicative of concealed spinal dysraphism (tuft of hair or sacral dimples).


    How nocturnal enuresis is evaluated?

    Laboratory tests

    Laboratory tests other than a urinalysis are typically unneeded because this test will detect changes in specific gravity in diabetes insipidus, glycosuria in diabetes mellitus, and the presence of nitrites, leukocyte esterase, leukocytes, or bacteria in infection.

    Furthermore, non-monosymptomatic enuresis and a lack of response to medication may necessitate further workups such as renal and bladder ultrasonography, as well as measurements of post-void residual volume, urine flow rate, urodynamics studies, and anorectal manometry.


    Treatment of nocturnal enuresis

    Treatment of nocturnal enuresis

    Bedwetting can be treated in a number of ways. When bedwetting is not caused by a specific medical condition, such as a bladder abnormality or diabetes, the therapies listed below are available. Treatment is recommended when there is a specific medical issue, such as bladder abnormalities, infection, or diabetes.

    It is also considered when a child's self-esteem or relationships with family/friends are compromised as a result of bedwetting. Because only a small percentage of bedwetting is caused by a medical condition, the majority of therapy is driven by concern for the child's emotional well-being. Overall, bedwetting behavioral treatment improves children's self-esteem.

    Punishment is ineffective and can impede therapy. As an initial therapy, simple behavioral strategies are advised. Other ways of therapy include the following:

    • Motivational therapy: The treatment of nocturnal enuresis mostly entails parent and child education. Facts should be used to assuage guilt. Fluids should be limited two hours before bedtime. Before going to bed, the kid should be urged to thoroughly empty his or her bladder. Setting up a journal or chart to track progress and implementing a mechanism to reward the kid for each night that they remain dry can help to start positive reinforcement. As a natural, nonpunitive consequence of wetness, the youngster should help with morning cleanup. This approach is very beneficial in younger children (8 years) and achieves dryness in 15-20% of patients.


    • Waiting: Almost all children outgrow their bedwetting. As a result, urologists and pediatricians usually advise waiting until the child is at least six or seven years old before starting therapy. If doctors believe the disease is affecting the child's self-esteem and/or connections with family/friends, they may start treatment sooner.

    • Bedwetting alarms: Bedwetting alarms, which produce a loud tone when moisture is detected, are also regularly recommended by doctors. This can assist train the child to wake up when he or she feels a full bladder. These alerts are thought to be more successful than no therapy and may have a reduced risk of bad outcomes than certain medical medications, but it is unclear if they are more effective than other treatments. Because of the possibility of a recurrence rate ranging from 29% to 69%, the therapy may need to be repeated.


    Other pharmacological therapies have been indicated:

    • DDAVP (desmopressin): These pills are a synthetic substitute for antidiuretic hormone, a hormone that decreases urine output while sleeping. Desmopressin acetate, DDAVP, is the most often utilized type of desmopressin. Patients who use DDAVP are 4.5 times more likely to remain dry than those who take a placebo. The medicine substitutes the hormone for that night alone, with no long-term effects. Because the oral version is regarded safer, US drug authorities have prohibited the use of desmopressin nasal sprays for treating bedwetting.

    DDAVP is most effective in children who have nocturnal polyuria (nocturnal urine output that exceeds 130 % of anticipated bladder capacity for age) and normal bladder reservoir function (maximum voided volume greater than 70 % of expected bladder capacity for age). Other children who are potential candidates for desmopressin treatment include those whose alarm therapy has failed or who are thought to be unlikely to cooperate with alarm therapy. It can be especially effective for preventing enuresis at summer camp and sleepovers.


    • Tricyclic antidepressants: Tricyclic antidepressant prescription drugs with anti-muscarinic qualities have been shown to be effective in treating bedwetting, but they also have a higher risk of side effects, including death from overdose. Amitriptyline, imipramine, and nortriptyline are examples of these medications. According to studies, people who use these medications are 4.2 times more likely to keep dry than those who take a placebo. The recurrence rate after discontinuing the medications is close to 50%.


    Outcome of nocturnal enuresis 

    Outcome of nocturnal enuresis 

    Enuresis tends to resolve on its own, with 15% of afflicted persons becoming continent each year. The disorder, however, is accompanied with significant morbidity. Children are vulnerable to both mental and physical abuse. The child frequently has low self-esteem and does poorly in school.

    Alarm therapy and treatment with imipramine and desmopressin have the best effectiveness rate of all therapies. However, the reaction is gradual, and up to 20% of individuals will continue to develop enuresis.



    Nocturnal enuresis

    Nocturnal enuresis, often known as bedwetting, is the uncontrollable urinating while sleeping that occurs after the age at which bladder control normally begins. Bedwetting in both toddlers and adults can cause mental distress. Urinary tract infections are one type of complication.

    The majority of bedwetting is caused by a developmental delay rather than an emotional or physical disease. Only a tiny minority of bedwetting instances (5 to 10%) have a clear medical reason. Bedwetting is frequently linked to a family history of the disorder. When a youngster has not been dry for an extended amount of time, he or she is said to have primary nocturnal enuresis. Secondary nocturnal enuresis occurs when a kid or adult begins wetting again after being dry for an extended period of time.

    Treatment options include behavioral counseling, such as bedwetting alarms, medication, such as hormone replacement, and surgery, such as urethral dilatation. Most treatment approaches try to safeguard or promote self-esteem because most bedwetting is merely a developmental delay. 

    Treatment recommendations indicate that the physician advise the parents, advising them about the psychological implications of putting pressure, humiliating, or punishing a kid for a condition over which the child has no control.