 The word enuresis is derived from a Greek word that
means "to make water." In North America, the term is
used to refer to wetting by night or day.
 Enuresis can be divided into primary enuresis (PE) and
secondary enuresis (SE). A child who has experienced
a minimum 6-month period of continence before the
onset of the bedwetting is considered to have SE. A
recent study suggests that the pathogenesis of PE and
SE might be similar.
Robson WL, Leung AK, Van Howe R. Primary and secondary nocturnal enuresis: similarities
in presentation. Pediatrics. Apr 2005;115(4):956-9.
 Dryness at night usually follows achievement of
continence by day.
 During the second year of life, children start to develop
the ability to voluntarily relax the external urethral
sphincter and initiate voiding, even in the absence of
the desire to void.
 By approximately age 4 years, all children with normal
bladder function should have acquired this ability.
Genetics:
Enuresis is reported in 43% of children of enuretic
fathers, 44% of children of enuretic mothers, and 77% of
children when both the mother and father had enuresis. A
family history of bedwetting is found in approximately 50%
of children with SE.
Enuresis is usually transmitted in an autosomal
dominant fashion. Chromosome 22 was identified as the
site of enuresis locus in a Danish family in
1995.[3] Subsequent reports link enuresis in other families to
loci chromosomes 8, 12, and 16.
von Gontard A, Eiberg H, Hollmann E, et al. Molecular genetics of nocturnal
enuresis: linkage to a locus on chromosome 22. Scand J Urol Nephrol Suppl.
1999;202:76-80.
 Enuresis is more common in males.
 The reported prevalence of enuresis in boys aged 7 and
10 years is 9% and 7%, respectively, compared with 6%
and 3%, respectively, in girls.
Presence of common underlying
problems is indicated by the following:
 Patients with overactive bladder or dysfunctional voiding usually
present with frequency, urgency, squatting behavior, and daytime
and nighttime wetting. Constipation and cystitis are common
associated problems in patients with overactive bladder or
dysfunctional voiding.
 Symptoms of cystitis include dysuria; cloudy, foul-smelling urine;
visible blood in the urine; frequency; urgency; and day and
nighttime wetting. Symptoms of cystitis can be very subtle in
some children.
 Constipation manifests as infrequent and painful passage of hard
wide stool, encopresis, and colicky periumbilical pain.
 Bowel-related problems and gait abnormalities are often present
in patients with neurogenic bladder.
 Symptoms of sleep disordered breathing (SDB) include
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snoring, mouth breathing, lack of restful sleep, and
tiredness the following morning.
The hallmark symptoms of urethral obstruction are the
need to wait or push to initiate voiding and a weak or
interrupted stream.
When bedwetting is a feature of a major motor seizure,
parents may hear nocturnal sounds associated with
abnormal muscle movements.
Girls with ectopic ureter are "always" wet.
Symptoms of diabetes mellitus include polyuria,
polydipsia, and weight loss
Patients with diabetes insipidus present with polyuria,
polydipsia, and symptoms related to the underlying
hypothalamic or renal causes.
Causes:
1. Nocturnal polyuria which may be due to fluid ingestion
before bedtime, food consumption before bedtime, low
nocturnal secretion of ADH, increased nocturnal solute
excretion & excess intake of caffeine
Although nocturnal polyuria is important in the
pathophysiology of enuresis, it does’t explain why children
with enuresis do not wake up to the sensation of a full or
contracting bladder or enuresis that occurs during daytime
naps.
2. Overactive bladder/dysfunctional voiding is more common
in preschool- and elementary school–aged girls and usually
presents with urinary frequency, urgency, squatting behavior,
daytime wetting, and enuresis.
3. Cystitis which causes uninhibited detrusor contractions that
can lead to episodes of day and nighttime wetting.
4. Psychological causes including birth of a new sibling,
parental divorce or separation, a death in the family, child
abuse, or any other cause of social dysfunction at home or
school.
Stressful life events and psychiatric diagnoses are reported
to precede the diagnosis of SE.
The later the onset of SE, the more likely the possibility of
preceding psychological stress.
5. Seizure disorder
SE may be a symptom of an unobserved overnight
major motor convulsion in a child with a known seizure
disorder.
But new-onset seizures rarely occur only at night, and
bedwetting is, therefore, a rare manifestation.
6.
Diabetes insipidus is an uncommon cause of
enuresis. Although nocturnal polyuria is often
presumed to be the cause of bedwetting, a disorder of
arousal may also be present.
7. Diabetes mellitus
Enuresis is usually not the presenting complaint in a
child with new-onset diabetes mellitus. Conventional
symptoms of insulin deficiency usually overshadow the
presence of bedwetting.
SE in a child with established diabetes mellitus may be
a symptom of suboptimal control with nocturnal polyuria
due to hyperglycemia. Although nocturnal polyuria is
presumed to be the cause of the bedwetting, a disorder of
arousal is also likely present because most school-aged
patients develop nocturia but maintain a dry bed.
Diabetes mellitus is also associated with abnormalities
in the afferent sensory pathways to the bladder, which may
contribute to enuresis.
8. Ectopic ureter which is a rare congenital abnormality,
enuresis results when the insertion is distal to the
external urethral sphincter.
9. Urethral obstruction can be congenital, such as
with posterior urethral valves, congenital stricture,
or urethral diverticula, or acquired because of a traumatic
or infectious stricture.
Traumatic strictures may develop after a traumatic
urethral catheterization, a foreign body in the urethra, or
pelvic trauma.
10. Constipation can cause both PE and SE and is a
common aggravating factor that should be considered
when other causes are present.
Although the mechanism is not clear, the pressure
effect of stool in the descending or sigmoid colon likely
compromises bladder capacity, and colonic movements at
night might trigger an uninhibited detrusor contraction.
Constipation is usually present in children with neurogenic
bladder and is more common in those with overactive
bladder and dysfunctional voiding.
Investigations:
1. Urinalysis is the most important screening test in a child
with enuresis.
 Children with cystitis usually have WBCs or bacteria evident
in the microscopic urinalysis.
 Children with overactive bladder or dysfunctional voiding,
urethral obstruction, neurogenic bladder, ectopic ureter, or
diabetes mellitus are predisposed to cystitis.
 Urethral obstruction may be associated with RBCs in the
urine.
 The presence of glucose suggests diabetes mellitus.
 A random or first-morning specific gravity greater than
1.020 excludes diabetes insipidus.
2. Ultrasonography of the kidneys and bladder (prevoiding
and postvoiding)
Failure to empty the bladder is a significant risk factor
for cystitis and is common in patients with overactive
bladder, dysfunctional voiding, neurogenic bladder, and
urethral obstruction. The residual volume of urine is
normally less than 5 mL.
3. Urodynamic studies help to clarify the diagnosis of
neurogenic bladder.
4. Uroflowmetry is a simple, noninvasive measurement of
urine flow that is helpful to screen patients for neurogenic
bladder and urethral obstruction.
5.
MRI of the spine is indicated in any patient with an
abnormal neurologic examination finding of the lower
extremities; a visible defect in the lumbosacral spine; or
the triad of encopresis, gait abnormality, and daytime
symptoms.
Treatment:
The most important reason to treat enuresis is to
minimize the embarrassment and anxiety of the child and
the frustration experienced by the parents.
Most children with enuresis feel very much alone with
their problem.
Doctors consider treatment when there is a
specific medical condition such
as bladder abnormalities, infection, or diabetes.
Physicians also treat bedwetting when it may harm the
child's self-esteem or relationships with family/friends.
Only a small percentage of bedwetting is caused by a
specific medical condition, so most treatment is
prompted by concern for the child's emotional welfare.
Behavioral treatment of bedwetting overall tends to show
increased self esteem for children
Parents become concerned much earlier than doctors. A
study in 1980 asked parents and physicians the age that
children should stay dry at night. The average parent
response was 2.75 years old, while the average physician
response was 5.13 years old.
Punishment is not effective and can interfere with
treatment.
Shelov SP, Gundy J, Weiss JC, et al. (May 1981). "Enuresis: a contrast of
attitudes of parents and physicians". Pediatrics 67 (5): 707–10
1. Waiting
Almost all children will outgrow bedwetting. For this
reason, urologists and pediatricians frequently
recommend delaying treatment until the child is at least
six or seven years old.
Physicians may begin treatment earlier if they
perceive the condition is damaging the child's selfesteem and/or relationships with family/friends.
2. Desmopressin acetate therapy
DDAVP tablets or oral disintegrating tablets should
be administered 1 hour before bedtime. The
recommended starting dose for the tablet is 0.2 mg, and
the drug can be titrated as necessary to a maximum of
0.6 mg. The equivalent starting dosage for the melt is 120
mcg and the maximum dose is 360 mcg.
3. An anticholinergic medication may be helpful in some
patients, especially those with overactive bladder,
dysfunctional voiding, or neurogenic bladder.
The combination of DDAVP and oxybutynin chloride
may be effective in children with overactive bladder or
dysfunctional voiding who respond to anticholinergic
therapy with improved daytime symptoms but who
continue to wet at night.
4. Physicians also frequently suggest bedwetting
alarms which sound a loud tone when they sense
moisture. This can help condition the child to wake at the
sensation of a fullbladder.
5 . Star chart
A star chart allows a child and parents to track dry
nights, as a record and/or as part of a reward program.
This can be done either alone or with other treatments.
There is no research to show effectiveness, either in
reducing bedwetting or in helping self-esteem.
Some psychologists, however, recommend star charts as
a way to celebrate successes and help a child's self-esteem
Mortality/Morbidity:
 Mortality attributable directly to enuresis has not been
reported, but children with enuresis have been fatally abused
by parents and other caregivers, and bedwetting was
considered a "trigger" for the abuse in some situations.
 The morbidity, in terms of psychosocial stress, has been
recognized in the psychiatric literature. Enuresis can also be
associated with significant family stress. Punishment should
be considered a potential morbid consequence of enuresis.
 A study was done to To determine whether occult megarectum
remains a commonly unrecognized cause of enuresis and whether
treating it will cure enuresis in most children. A landmark study
proved constipation was a commonly unrecognized cause of
enuresis in which constipation was defined as abnormal rectal
distension. However, modern recommendations have focused on
signs of functional constipation, such as hard or rare stools.
 All patients demonstrated rectal distension according to the
rectal/pelvic outlet ratio, and 80% were constipated according to
the Leech criteria. Only 10% of the patient or families reported
clinical symptoms of constipation. All the adolescent patients in
our study and 80% of the younger patients were cured of enuresis
with laxative therapy.
 Occult megarectum remains a commonly undiagnosed cause of
nocturnal enuresis. Abdominal radiographs represent a simple,
noninvasive method to diagnose megarectum and might improve
the treatment of nocturnal enuresis.
Urology. 2012 Feb;79(2):421-4.
NOCTURNAL ENURESIS AMONG CHILDREN ATTENDING KIFAN
PRIMARY HEALTH CARE CENTRE IN KUWAIT
Objective:
This study aimed at describing the general profile
of nocturnal enuresis in Kuwaiti children 5-15 years old
attending primary health care centers and identifying
factors associated with the condition.
Methods:
The study design is a case control one conducted in
Kifan health center, Capital health region, Kuwait during
September 2006 - March 2007.
118 children with nocturnal enuresis 5-15 years old as
cases and 118 controls in the same age groups were
included.
Data collection form included personal and family
characteristics as well as data regarding child development
and psychosocial characteristics. Data were analyzed using
univariate and multiple logistic regression analyses.
Results:
The final analyses revealed that children pertaining to
large families with positive history of nocturnal enuresis
were at higher risk of nocturnal enuresis
Higher social class as indicated by mother education
and high income was proved to be a protective factor
against this condition.
Children suffering from nocturnal enuresis were
proved to be sad and more fitful.
Conclusions:
Children from large, low income families with positive
family history of nocturnal enuresis were at higher risk
of enuresis and seemed to be sad and more fitful.
Thank you