Enuresis Disease

BASICS

DESCRIPTION

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Some children may be withdrawn and shy and some may show aggressive behaviors; both may be secondary to the enuresis and not primary behaviors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

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

FOLLOW UP

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

OTHER NOTES

N/A

ABBREVIATIONS

N/A

Clinical Investigations

ROLE OF HOMOEOPATHY

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