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MikaVenhola

Enuresis in a Child

Essentials

  • Examination and treatment of nocturnal enuresis are the responsibility of primary health care.
  • It is normally no use treating nocturnal enuresis in a child below 5 or 6 years of age.
  • An alarm device and desmopressin are alternative forms of treatment.
  • Daytime enuresis is usually treated in specialized care.

General

  • There is great individual variation in learning to be dry. Nevertheless, it can be assumed that, on an average:
    • below the age of 1 year the bladder will empty automatically
    • at the age of about 2 years the child will begin to distinguish between the needs to defecate and to urinate
    • by the age of about 3 to 4 years, 2 children in 3 have learned to be dry
    • at the age of about 4 to 6 years, they can begin to urinate and interrupt urine flow when they so wish.
  • Slightly more than 10% of children who have started junior school have enuresis, about 5% regularly.
  • Slightly less than 1% of teenagers continue to have enuresis, and in about 0.5% this persists into adulthood.

Significance of enuresis

  • Enuresis may represent a harmless variation in individual development or signify a serious disease.
  • Even though enuresis often does not represent a disease it may be difficult to tolerate.
  • Enuresis is not a conduct disorder but may, at worst, lead to one.
  • In most cases, the child cannot be blamed for enuresis but may still wrongly be punished.

Terminology

  • Incontinence means inability to control urination for neurological or organic reasons.
  • Enuresis means involuntary urination due to delayed development.
  • Enuresis can be divided into daytime enuresis (enuresis diurna), nocturnal enuresis (enuresis nocturna) and mixed enuresis (with both nocturnal and daytime symptoms).
  • Primary enuresis means that the child has never had a dry period of more than 6 months.
  • Secondary enuresis means enuresis recurring after the child has at some point been dry for more than 6 months.

Nocturnal diuresis (enuresis nocturna)

  • The causes of nocturnal diuresis are multifactorial, and not all of them are known.
  • Nocturnal enuresis and its end in due course are commonly considered to depend on physical development.

Background

  • People with nocturnal enuresis often have common features.
    • Abundant nocturnal production of urine
      • Considered to be due to insufficient antidiuretic hormone secretion
      • Not everyone with nocturnal enuresis is polyuric, and not everyone with polyuria has nocturnal enuresis.
      • Polyuria does not explain, either, why people with nocturnal enuresis do not wake up when their bladder feels full.
    • Sound sleeping
      • Many people with nocturnal diuresis are difficult to wake up, and many of them sleep quite long nights.
      • In brain activity measurements, people with nocturnal enuresis have been found to have a higher than usual waking response.
      • Not all sound sleepers wet their beds, and not all people who wet their beds are sound sleepers.
  • Heredity
    • About half of those with nocturnal enuresis have at least one parent who had nocturnal enuresis.
    • If both parents had nocturnal enuresis, the probability that their children will, too, is about 80%.
    • The tendency has been linked to various chromosomes (8q, 12q and 13q, at least) but not yet conclusively.

Workup

  • Examination and treatment of nocturnal enuresis are the responsibility of primary health care.
  • If the patient has no other symptoms, no further examinations or referral to specialized care are needed.
  • At the first visit take the patient history (table T1) and do chemical screening of urine (glucose, albumin, inflammatory markers).

History of a patient with nocturnal enuresis

Information to be obtainedSignificance or interpretation
Growth data: weight and heightFailure to thrive may be associated with a renal problem.
How often does the patient wet the bed?The prognosis is better if there are dry nights.
Was the patient previously dry?Patients with secondary enuresis often have daytime symptoms, as well.
Daytime symptoms?Treat daytime enuresis first, particularly if the patient has symptoms of overactive bladder.
Voiding symptoms (pain, weak stream, insufficient emptying of the bladder)?Significant symptom, refer for further examination
Urinary tract infections?Significant symptom, refer for further examination
Thirst, copious drinking?Renal problem, diabetes, polydipsia?
Constipation?Constipation provokes enuresis, so it should be treated first.
Soiling?This is almost certainly due to constipation; the treatment of constipation is of primary importance.
Conduct disorders?Cause or consequence? Consult a specialist, as necessary.
What is the child's experience of nocturnal enuresis?Motivation for treatment, choice of treatment

Treatment

  • Nocturnal enuresis need not be treated if the child is unmotivated or very young (below 5 or 6 years, for example).
  • If the child has significant daytime symptoms, treatment of these should be started first.
  • Treatment of nocturnal enuresis may not be worthwhile if there are more dry than wet nights.
  • Nocturnal enuresis should not be treated by punishment, toughening up, homeopathy, acupuncture, zone therapy, hypnosis, psychotherapy or fluid restriction. None of these are better than a placebo.
  • An alarm device and desmopressin have been shown to be effective for nocturnal enuresis. Combining the two will not add to the efficacy.
  • Alarm device Alarm Interventions for Nocturnal Enuresis in Children
    • An alarm device helps about 2 children in 3, and half of those who become dry remain dry after the treatment.
    • This should be chosen as the method of treatment if you wish to have a permanent effect and if the motivation for treatment and the family situation are suitable for such a form of treatment.
    • Commitment to the treatment is needed for 6 weeks, at least, with no days off or free weekends.
    • Alarm device sensors placed in the child's underwear are most sensible even though sensors placed under the bedsheets are still available, too.
    • The best results are obtained with one parent sleeping in the same room with the child and, as the alarm goes off, immediately taking the child to the toilet. The sensor and the clothes should then be changed and sleeping continued. The alarm may go off several times during the night.
    • As the treatment works, the quality of the child's sleep will change and they will 'learn' to wake up when they feel that their bladder is getting full, before wetting their bed.
    • This method of treatment requires frequent follow-up visits, the first after 1 to 2 weeks to repeat the instructions and to support the family in the treatment.
    • The treatment should be withdrawn if no results are obtained in 6 weeks. If no result was obtained the first time, the treatment can be repeated in about 4 to 6 months.
    • The treatment has no adverse effects but as the loud noise of the alarm device will probably wake up the rest of the family, too, not all families like this form of treatment.
  • DesmopressinDesmopressin for Nocturnal Enuresis in Children
    • The treatment helps about 2 children in 3. It is symptomatic and will not speed up becoming dry. After the treatment, bed-wetting will continue unless the child has become physically sufficiently mature during the treatment to remain dry at night.
    • On the positive side, a response is seen quickly and the treatment can be used in many ways.
    • The treatment should be started with a trial of using the maximum dose (240 µg) for 2 weeks. If this doesn't help, the trial should not be continued. The trial can be repeated 4 to 6 months later.
    • If the medication is helpful, the decision about continuing it is made with the family.
    • The continuation may be
      • continuos treatment with a pause every 3-4 months to see whether the medication is needed anymore. The dose may be halved as a trial.
      • treatment given when necessary, e.g. during overnight visits away from home and summer camps, when enuresis is especially troublesome.
    • Hyponatraemia has been described as a severe adverse effect associated with the treatment. The risk is notably low but excessive drinking should still be avoided after taking the drug.
    • As blood levels of the drug remain effective for about 8 hours, the drug should be taken just before going to bed to make sure that the levels stay therapeutic until the morning.

Daytime enuresis (enuresis diurna)

  • Children usually become capable of controlling their bladder at the age of 4 to 6 years but there is great variation here. It is not known precisely how this happens and what the mechanism behind voluntary control is.
  • The treatment of daytime enuresis in a child represents a diagnostic and therapeutic challenge. Treatment should be started in primary health care only by those with sufficient expertise. Otherwise, it is best to write a non-emergency referral to specialized care.
  • A referral to specialized care should include at least the information listed in table T2.
  • Physical examination of a child with daytime enuresis
    • Often there are no abnormal clinical findings.
    • Growth retardation or elevated blood pressure may be suggestive of a kidney disease.
    • Pharynx: large tonsils may cause sleep apnoea.
    • Abdomen: an abnormal finding may suggest constipation or an obstruction of the urine flow.
    • Back: signs of malformation in the spinal area?
    • Neurological status: sensation and reflexes in the lower extremities
    • Anus and vulvar area: pinworms?
    • Skin: irritation of skin in the genital area in association with enuresis?
  • In specialized care, urinary tract ultrasonography will be done once and other special examinations as necessary. Urodynamic testing is rarely helpful when investigating daytime enuresis.

Data to be included in the referral of a patient with daytime enuresis

Information to be obtainedFurther information
Inflammation history, recent chemical screening of urineInflammation, glucose, albumin?
Bowel functionConstipation, soiling?
Wetting volumeDribbling, wet underpants, soaking wet?
Recurrence of wettingDry days? Wetting at school?
Voiding habitsInfrequent? Frequent?
VoidingPain or other symptoms?
Urgency or urge incontinenceSuggest an overactive bladder
Symptoms associated with control of urinationSuggest an overactive bladder

Pseudoincontinence

  • A special case of daytime enuresis that appears as slight dribbling into the underpants soon after going to the toilet.
  • In boys, this is usually due to "tight flies", i.e. to taking the penis out by lowering the waistband or by opening the flies only partly. The urethra is then partly compressed and at the end of voiding some urine remains in its proximal end. As the penis is returned to the underpants, the remaining urine soon drips out. This can be treated by instructing patients to sit down or to pull their pants down to their thighs to urinate.
  • In girls, this is due to urine ending up in the vagina. In prepubertal girls, the vaginal and urethral openings are anatomically quite close together. In some girls, the hymen reaches quite far anteriorly, which may increase the risk of urine ending up in the vagina. As a girl sits on a toilet seat, her pelvis tilts down and back, and any urine that gets into the vagina will remain in the vaginal fornix. As the girl stands up, the position of her vagina changes and the urine flows out. The girl should be instructed to do final wiping in the standing position, so that the small amount of urine flowing out from her vagina will be absorbed in toilet paper and not flow into her pants.

Giggle incontinence

  • Wetting associated with laughing. The cause is unknown, and there is no effective treatment. However, this phenomenon usually decreases or ends by puberty.
  • The wetting is abundant and only associated with laughing.

Disability allowance

  • The right to receive a disability allowance due to enuresis in a child varies from country to country. In Finland, to get such an allowance, enuresis must have been diagnosed, the symptoms must have continued for more than 6 months, and the child must be undergoing medical treatment in the form of either an alarm device or desmopressin. The allowance cannot be granted before the age of 5 years.

    References

    • Chan IHY, Wong KKY. Common urological problems in children: primary nocturnal enuresis. Hong Kong Med J 2019;25(4):305-11. [PubMed]
    • Gontard AV, Kuwertz-Br�king E. The Diagnosis and Treatment of Enuresis and Functional Daytime Urinary Incontinence. Dtsch Arztebl Int 2019;116(16):279-285. [PubMed]