Enuresis



Enuresis


Nina Sand-Loud

Leonard A. Rappaport



Enuresis refers to the involuntary discharge of urine beyond the age of expected continence. Daytime wetting, or diurnal enuresis, is considered abnormal after 4 years of age, and nighttime wetting, or nocturnal enuresis, is considered abnormal after 6 years of age. Enuresis can be primary, which refers to having never been dry for a period of 6 months, or secondary, which occurs after a dry interval of at least 6 months. Uncomplicated nocturnal enuresis is primary and monosymptomatic, meaning occurring just at night time, with a normal examination and often a family history of enuresis. Complicated enuresis is more likely to be secondary with diurnal symptoms and a history of constipation and urinary tract infections (UTIs) as well as an abnormal physical examination.

Only 10% of children with enuresis have an underlying disease process causing their enuresis; all the rest remain unexplained. The differential diagnosis of both nocturnal and diurnal enuresis can be divided into four main categories (Table 111.1). When a child initially presents with secondary enuresis, it is always important to consider the possibility of sexual or physical abuse, although this is a very rare cause.


NOCTURNAL ENURESIS


Epidemiology

Although 15% of 5-year-olds have nocturnal enuresis, this number is reduced to 5% of 10-year-olds and then 1% of adolescents, with 15% of children spontaneously resolving per year. The ratio of males to females is 3:2. There are adults who have primary nocturnal enuresis.


Pathology

Hypothesized causes of nocturnal enuresis include high nocturnal urine production, poor arousal from sleep to a full bladder, and a small functional bladder capacity. Family histories and recent genetic studies have also suggested a genetic basis to nocturnal enuresis with linkage on chromosomes 13q, 12q, 22q, and 8q, although heterogeneity exists. However, it has long been observed that nocturnal enuresis tends to cluster in families, with 44% of children wetting the bed if one parent wet the bed and 70% wetting the bed if both parents have a history of
bedwetting. There is also evidence for children with developmental difficulties having an increased incidence of nocturnal enuresis. Lastly, there is no evidence that children with primary nocturnal enuresis have a psychological cause for their bedwetting but rather that bedwetting may cause psychological difficulties for the child.








TABLE 111.1. DIFFERENTIAL DIAGNOSIS OF ENURESIS

















Diagnostic Categories of Differential Diagnosis Examples
Increased urinary output Diabetes mellitus, diabetes insipidus, sickle cell disease, excessive water intake
Increased bladder irritability Urinary tract infection, constipation, pregnancy, bladder spasm
Structural problems Ectopic ureter, epispadius (females), partial urethral valves and thickened bladder wall (males)
Abnormal sphincter control Spinal cord abnormalities, sphincter weakness, neurogenic bladder








TABLE 111.2. BEHAVIORAL INTERVENTIONS


























Intervention Description Success Rate
Motivational therapies Include positive reinforcement systems such as placing a sticker on a chart for a dry night or responsibility training, which would include giving children increased age-appropriate responsibility in nonpunitive ways 25% (although a reported 70% of children show some improvement)
Bladder stretching exercises or retention control Involves practicing to hold urine for progressively longer periods during the day 35%
Fluid intake programs Restriction of fluid intake in the evenings (important to ensure that not overly restrictive) 15% (close to the spontaneous cure rate)
Hypnotherapy, biofeedback Similar to such methods when used with other problems Data unclear but 60% success reported in limited trials
Behavioral conditioning (e.g., alarm/arousal systems) Association of bedwetting with a consequence (in this case, waking from sleep) 70%–80%

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Jul 24, 2016 | Posted by in PEDIATRICS | Comments Off on Enuresis

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