Enuresis
Enuresis is defined as involuntary passage of urine while an individual is asleep. The passing of
urine could be into bed or clothes by a person older than 5 years occurring at least twice weekly
for 3 consecutive months that causes significant distress for person and hampers his/her
functioning (e.g. school). The existence of passing urine day time is suggestive of kidney or
bladder problem. Nocturnal enuresis is one of the most frequent problems of childhood, affecting
up to 15% of children from 5 to 7 years. It is a common psychosomatic symptom that presents
both alone and in conjunction with other disorders in children and adolescents.(1), (3)
Etiology:
It is a symptom with a number of possible etiologies. There clearly is a genetic basis at the origin
of these phenomena, and the difficulty in waking up when the bladder is full is a sign of problems
in the maturation of the central nervous system. Developmental immaturity, sleep disorder,
psychological factors such as parental separation, child neglect, school trauma, sexual abuse, or
hospitalization etc is some of the factors involved in secondary type.(1)(3)
Classification:
Enuresis is subdivided into primary and secondary forms:
1. Primary enuresis occurs in children who have never been consistently dry through the night.
2. Secondary enuresis refers to the resumption of wetting after at least 6 months of dryness.(3)
Clinical features:
Urinary continence is obtained in three sequential steps:
 Enlargement of the bladder capacity,
 Voluntary control of the sphincter muscles, and
 Voluntary control of the micturition reflex.
There is a consistent sequence of attainment of continence in children. Bowel control during sleep
is attained first. This usually is followed by bladder and bowel control during wakefulness and,
last, bladder control at night. Girls typically achieve each of these milestones before boys. Most
early studies of children with enuresis revealed reduced functional bladder capacity, although
recent studies have shown normal nocturnal bladder capacity in children with enuresis.
Most people (80%) who wet their beds, wet only at night. They tend to have no other symptoms
other than wetting the bed at night. Other symptoms could suggest psychological causes or
problems with the nervous system or kidneys and should alert the family or health-care provider
that this may be more than routine bedwetting.(1),(3)
Diagnosis:
When enuresis is identified, either as the chief complaint or as an incidental part of an evaluation
for another problem, the assessment must be expanded to include enuresis-specific elements. In
every instance, both the parents and the child should be interviewed, and sensitivity to the
emotional consequences of the symptom should be high. The enuresis specific history should
explore every aspect of urinary incontinence, with a thorough review of the genitourinary and
neurologic systems. A thorough physical examination is essential; enlarged adenoids or tonsils,
bladder distention, fecal impaction, genital abnormalities, spinal cord anomaly, and neurologic
signs should be noted. Routine laboratory tests need only include urinalysis and possibly urine
culture; more invasive tests are pursued only with specific indications.
Differential diagnosis: cystitis, seizure disorder, sleep disorder, low nocturnal bladder capacity,
overactive bladder, constipation, neurogenic bladder, urethral obstruction and diabetes.(2)(3)
Prevention:
Relapse of the enuresis is the most common complication and requires restarting the treatment
that resulted in an improvement or cure of the condition. Bedwetting can damage the child's selfimage and confidence. The best way to prevent this is to be supportive. Parents should reassure
the child that bedwetting is a common problem and that they, the parents, are confident that the
child will overcome the problem. The emotional impact of enuresis on a child and family can be
considerable. Children with enuresis are commonly punished and are at significant risk of
emotional and physical abuse. Numerous studies report feelings of embarrassment and anxiety in
children with enuresis; loss of self-esteem; and effects on self-perception, interpersonal
relationships, quality of life, and school performance. (3)
Treatment:
Commonly prescribe medicines for enuresis are Imipramine and desmopressin which are not in
the essential medicines list MoPH instead them Amitriptyline, which is from the same drug class
and it is included in the essential medicines list but it cause more sedition and the dose of it is 10
mg at once at night for few Weeks
The most important reason to treat children with enuresis is to improve the loss of self-esteem and
other secondary psychological or behavioral. Improvement in self-esteem is noted with all
therapies and to. Bedwetting is typically seen more as a social disturbance than a medical disease.
It creates embarrassment and anxiety in the child and sometimes conflict with parents. The single
most important thing parents can and should do is to be supportive and reassuring rather than
blaming and punishing. Primary nocturnal enuresis has a very high rate of spontaneous resolution
of approximately 15% per year. Treatment is based on the findings of the assessment. Positive
findings on history, physical examination, or laboratory tests are indications for specific
treatments.
Both pharmacological and behavioral treatments are currently available for enuresis. Enuresis can
be assumed to be of psychological origin when a previously dry child begins wetting during a
period of stress (e.g., parental separation, out-of-home placement, problem in school, abuse,
hospitalization). Supportive approaches should always include education, demystification, and
ensuring that parents do not punish the child for enuretic episodes.
Journal keeping, fluid restriction and night awakening may also fit in the category of nonspecific
supportive approaches. Conditioning, using a modern, portable and battery operated alarm makes
behavioral treatment highly effective as the first line of treatment with cooperative, motivated
families. Alarm therapy offers the possibility of sustained improvement of enuresis and should be
considered for every patient. Alarm therapy is reported to improve bedwetting by increasing
nocturnal bladder capacity or by enhanced arousal. Alarm therapy does not reduce nocturnal urine
output.
A number of commonsense approaches to enuresis have evolved over time and can be considered
supportive, they include the following:
1. Educate parents about enuresis (to reduce their guilt), the relatively high spontaneous cure rate
(to encourage hope), and the nonvolitional nature of the symptom (to avoid a punitive response or
the development of a control struggle).
2. Encourage the keeping of a journal or a dry bed chart by the child Involving the child in
changing the bed also serves this purpose.
3. Reduce fluids, and especially caffeinated beverages, before bedtime.
4. Awaken the child to void during the night this does not lead to significant sleep disruption.
Psychosocial intervention is indicated when a specific psychological issue associated with the
onset of the symptom (in secondary enuresis) is identified or a control struggle between parent
and child is maintaining the symptom.
Bladder training, in which daily stretching by retaining urine is intended to increase the functional
bladder capacity, has been reported to be effective. The effort not to void despite considerable
urgency is unpleasant for both the child and the family, making it a less desirable approach.
Two medications, imipramine and DDAVP (Desmopressin), have proven efficacy in the
treatment of enuresis. Imipramine in a single bedtime dose of 1.0 to 2.5 mg/kg has been used for
many years if conditioning treatment fails or is not feasible.(1), (2), (3)
Referral:
Daytime wetting, abnormal voiding (unusual posturing, discomfort, straining, or a poor urine
stream), a history of urinary tract infections or evidence of infection on urinalysis or culture, and
genital abnormalities are indications for urologic referral and treatment. Presence of
psychological problems and family conflicts including low self esteem needs referral for
psychosocial counseling. Referral to a pediatric specialist may be appropriate if obstructive sleep
apnea is suspected.(4)
References:
1. Standard treatment protocol for Mental Disorders, MOPH, 2003
2. Mental Health in Primary Care, Training Manual for health workers; Based on the WHO
Primary Care Guidelines, 2010.
3. KAPLAN & SADOCK’S/Synopsis of Psychiatry eight edition 1998 Baltimore, Maryland
USA /LIPPINCOTT WILLIAMS &WILKINS Pages 1226-1228
4. Mental health promotion for school children, a manual for scholl teachers and school
health workers , WHO Regional Office for eastern Mediterranean, Alexandria,
Egypt,1998