ENURESIS: AND IT’S
Enuresis refers to a repeated inability to control urination/bed wetting.
It is most common in children. Nocturnal enuresis, or bed-wetting at night, is the most
common type of elimination disorder. Daytime wetting is called diurnal
enuresis. Some children experience either or a combination of both. this problem affects about 1-2 out of every 100 teens. At age 4½, 30% of children still wet
the bed, 21% infrequently and 8% of these more frequently. At the age of 7½ years
it was 2.6% wet their bed on two or more nights a week. Nocturnal enuresis
found .52% in adults
While bedwetting is an
extremely common condition, children are generally expected to no longer wet
the bed (to be "dry") by a developmental age of five. Historically it
has been common practice to only consider treating children for their
bedwetting when they reach seven years.
However, in a change to
current clinical practice, the National Institute for Health and Care
Excellence (NICE) has not specified a minimum age limit in its new clinical
guideline on the assessment and management of this condition. This means that
healthcare professionals are now more likely to consider whether children under
seven years may benefit from appropriate advice and treatments currently
available on the NHS.Enuresis is a repetitive voiding
of urine, either during the day or night, at inappropriate places. This state
of affairs is normal in infancy.
can be either of (1) primary type or (2) secondary type.
Primary type: where bladder control
has never been achieved or,
type: where enuresis emerges after a period of bladder control (at least 1
may also be classified as (1) Nocturnal only (2) Diurnal only or (3) Nocturnal
Nocturnal only: Passage of urine only
during nighttime sleep
Diurnal type: Passage of urine
during working hours
Nocturnal and Diurnal: a combination of the 2
The diurnal only subtype
may be referred to simply as urinary incontinence. Individuals with this
subtype may further be divided into 2 groups: (1) Individuals with urge incontinence:
individuals have sudden urge symtoms (2) Detrusor
Instability: Individuals with “voiding postponement” consciously defer
micturition urges until incontinence occurs.
About 85% of children
with enuresis have primary enuresis.The majority of
children (about 80%) with enuresis have nocturnal bedwetting only. Non organic
enuresis is more common in males (about 2 times).1Numbers show that
diurnal enuresis is much less common. Overall, about 60% of those suffering are
males. However, this too depends on age. From ages 4 to 6 years, the number of
boys and girls is about equal. However, the ratio changes so that by 11 years
of age, there are twice as many boys as girls.
Incidence varies with
social class with more incidences among those with low socioeconomic status. Studies
conducted in the United
States show a varying prevalence with age:
33% of 5 years old, 25% of 7 years old, 15% of 9 years old, 8% of 11 years old,
4% of 13 years old and 3% of 15 to 17 years old. Most school based
epidemiological studies on child and adolescent psychiatric disorders in India have
focused on disorders of concern like learning disability, mental retardation
and attention deficit hyperactive disorder with little or no reference to
Environmental: Delayed or lax toilet
training & psychosocial stressor/s. Latter include fights between parents,
unfamiliar social situations and overwhelming family events such as the birth
of a sibling.
Genetics Nocturnal Enuresis is a
genetically heterogeneous disorder. In
1995, Danish researchers announced that they had found a site on human
chromosome 13 that is responsible, at least in part, for nocturnal enuresis. If
both parents were enuretic, 77% of their children
would be enuretic also; if only one parent was enuretic, then 44% of their offspring would be also.
Physiological Nocturnal enuresis has
been associated with delays in the development of normal circadian rhythms of
urine production. The body normally produces more ADH during sleep so that the
need to urinate is lower at night. If ADH is not sufficiently produced at
night, the making of urine may not be slowed down, leading to bladder
overfilling. If a child does not sense the bladder overfilling, and is not awaken to urinate, wetting occurs.
Structural problems A blocked bladder or
urethra may cause the bladder to overfill and leak. Nerve damage associated
with the birth defect spina bifida can cause
incontinence. An ectopic ureter can commonly cause incontinence. In these
cases, the incontinence can appear as a constant dribbling of urine.
Obstructive sleep apnoea Nocturnal enuresis may
be one sign of another condition called obstructive sleep apnoea,
in which the child’s breathing is interrupted during sleep, often because of
inflamed or enlarged tonsils or adenoids. Other symptoms of this condition
include snoring, mouth breathing, frequent ear and sinus infections, sore
throat, choking and daytime drowsiness. In some cases, successful treatment of
this condition may also resolve the associated nighttime incontinence.
Infrequent voiding When the child
voluntarily holds urine for prolonged intervals, the
bladder overfills and leaks urine. For example, a child may not want to use toilets
at school or may not want to interrupt enjoyable activities, so that he or she
ignores the body’s signal of a full bladder.
An overactive bladder This occurs when the
bladder contracts strongly and the muscles surrounding theurethra
may not be able to keep urine from passing. This often happens as a consequence
of urinary tract infection and is more common in girls.
Other causes A small bladder
capacity, constipation and food containing caffeine,chocolate or artificialcolouring.Sometimes,
overly strenuous toilet training may make the child unable to relax the
sphincter and pelvic floor to completely empty the bladder. Incomplete bladder
emptying sets the stage for urinary tract infections.
condition PANDAS ( Pediatric autoimmune neuropsychiatric disorders associated
with streptococcal infections) has been used to describe a set of children who
have a rapid onset of OCD and/or tic disorders following a streptococcal
infection, with a link to other symptoms such as enuresis.2
classification of this hypothesis , PANS (Pediatric acute onset
neuropsychiatric syndrome) has been proposed which states that some patients
suffer from these symptoms in response to mycoplasma or lyme
disease or even viruses rather than streptococcal. This hypothesis describes children who have
abrupt, dramatic onset of OCD or Anorexia Nervosa coincident with the presence
of 2 or more neuropsychiatric symptoms. It is believed that these children
experience a rise in dopamine levels as a result of cross-reactive
anti-neuronal nqnantibodies. The rise in dopamine can
cause such side effects as enuresis, bedwetting and urinary urgency.3
Diagnostic Features (DSM-V)
feature is repeated voiding of urine during the day or at night into bed or
clothes. Most often the voiding is involuntary, but occasionally it may be
▪The voiding of
urine must occur at least twice a week for at least 3 consecutive months or
cause clinically significant distress or impairment in social, academic or
other important areas of functioning.
The individual must have reached an age at
which continence is expected (at least 5 years chronological age or for
children with developmental delays, a mental age of at least 5 years).
Urinary incontinence is not attributable to
the physiological effects of a substance (eg
diuretic, an antipsychotic medication) or another medical condition (diabetes, spina bifida, a seizure disorder).
of fluid intake after 8 pm in nocturnal enuresis
are encouraged to enforce frequent waking up of the child for trips to the
bathroom during the night and to develop a cleanup routine for the child, with
positive reinforcement for dry nights.
training during daytime: Parents can be instructed to have their child drink
more and more fluids during the day and delay urination for longer periods of
time, attempting to strengthen bladder control.
healthy urination such as relaxing bladder muscles & taking required time.
devices, which cause an alarm to sound as soon as the voided urine touches the
bed sheet. It is important to check the child’s hearing before starting
treatment. The alarm causes inhibition of further micturition and the child
awakens. If properly used, it is an effective method of therapy. Bed wetting
alarms have been around since 1938, when O.H Mowrer
and W.M Mowrer first invented the bell and pad. This behavioural training is one of the safest and more effective
treatments. By 12 weeks, the child will most likely have mastered his nighttime
recommends the following in its new guidelines regarding nocturnal enuresis
•Not to exclude under-7s
from the management of bedwetting on the basis of age alone.
•Inform the child and
their parents or carers that bedwetting is not the
child's fault and so punitive measures should not be used.
•Encourage parents to
reward their children for agreed behaviour rather
than for dry nights, e.g. for drinking the recommended levels during the day,
going to the toilet before sleep, taking medications, or for helping to change
•Discuss with the
child's parents or carers whether they need support,
particularly if they are having difficulty coping with the bedwetting, or if
they are expressing anger, negativity or blame towards the child.
•Address excessive or
insufficient fluid intake or abnormal toileting patterns before starting other
treatment for bedwetting in children.
•Refer children who have
not responded to courses of treatment with an alarm and/or desmopressin
(a medication that slows down urine production at night) to a relevant
specialist, so that they can be assessed for factors that may be associated
with a poor response, e.g. an overactive bladder, an underlying disease, or
social and emotional factors.
Drug treatment is
usually not a preferred option for the treatment of enuresis.
The drug of choice in
those who need pharmacotherapy has traditionally been a tricyclic antidepressant,
usually imipramine (25-75 mg/dl). It probably acts by its anticholinergic
effect as well as by decreasing the deep sleep (stage 4 NREM-sleep) period.
However, there is a risk of sudden death in some children with the use of tricyclics; it should never be used for children under the
age of 6 years.
Intranasal desmopressin has been found useful in some patients and it
is a good alternative. There is difficulty in keeping the bed dry after the
medication is stopped, with as high as an 80% relapse rate.
anticholinergic may be prescribed to control bladder muscle spasms in case of
an overactive bladder.
NICE GUIDELINES RECOMMEND
An alarm is offered as
initial treatment for children and young people whose bedwetting has not
responded to advice on fluids, toileting, or an appropriate reward system
child, young person, parents, or carers do not want
to try it or
treating doctor thinks it is unsuitable for the child, young person, parents,
Alarms may not be
suitable if the child or young person wets the bed infrequently (only once or
twice a week), if the parents or carers are having
emotional difficulty coping with the burden of bedwetting or are expressing
anger, negativity, or blame towards the child or young person, or if the
priority is for fast or short term improvement.
If alarm treatment is
Desmopressin (a synthetic analogue of
antidiuretic hormone) is offered desmopressin as well as use of
alarm. Alternatively, if the parents,
carers, child, or young person no longer want to use
an alarm, offer
Desmopressin is offered as first
line of treatment if:
1-The child, young
person, parents, or carers do not want to try an
2-The healthcare team
decides that an alarm is not suitable
3-Fast acting, short
term improvement is the priority.
4-If the bedwetting
stopped when using an alarm but has started again after treatment ended, offer
an alarm again. If bedwetting then recurs, offer desmopressin
as well as using the alarm.
5-If alarm and/or
treatment with desmopressin are not successful, refer for further review and assessment by a
5-After such assessment
consider offering an anticholinergic drug such as tolterodine
or oxybutynin to take with desmopressin.Study
findings have shown that starting with a low dose of 2.5mg tds,
a positive result with fewer side effects is achieved.9
Side effects: blurred
vision, dryness of eyes & mouth & throat, drowsiness, irregular heart
6- If no other treatment
has been successful consider offering imipramine. Do not offer this in
combination with an anticholinergic.
Until now, children have
not been offered treatment until age 7 years. However, NICE guideline includes
treatment options (such as advice, drugs, and alarms) for children aged 5-7
years. If a 4 month course with an enuretic alarm is
unsuccessful, rather than using desmopressin, the
alarm should be continued with relearning and consideration given to additional
use of the dry bed training technique.4
Enuresis. Ahuja –A short textbook of Psychiatry (7th
LA and Swedo SE. Pandas:current status and directions for research.
Molecular Psychiatry 2004; 9:900-907.
Swedo SE, Leckman JF, Rose
NR. From Research Subgroup to Clinical Syndrome: Modifying the PANDAS Criteria
to describe PANS. Pediatr Therapeut
R1, Morton R, Uing A, Williams C. Nocturnal
enuresis and the use of desmopressin: is it helpful? Child
Care Health Dev 1996;22(2):73-84.
H C Evans. Evidence based management of nocturnal enuresis. BMJ 2001;323:1167–9.
Herzeele V. Desmopressin
improves sleep pattern and psychological functioning in patients with monosymptomatic nocturnal enuresis. European Society for Paediatric Urology Congress 2014, 7-10 May, Innsbruck, Austria.
et al. Nocturnal Enuresis in children. Behav Psychother 1986;78:884-90.
Yeung CK et al. Nocturnal Enuresis in children. BJU Int 2006;97:1069-1073
BL, Kiemeney LA, Debruyne
FM. Low dose oxybutynin for the treatment of urge incontinence: good efficacy
and few side effects. Eur Urol
2000; 37(6): 709-13.