Pediatric Urology

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Overview

Nocturnal enuresis is a condition in which a person who has bladder control while awake urinates while asleep. The condition is commonly called bedwetting and it often has a psychological impact on children and their families. Children with the condition often have low self-esteem and their interpersonal relationships, quality of life, and school performance are affected.

Children achieve bladder control (continence) at different ages and usually achieve daytime continence before nighttime dryness. Most children are continent by the age of 4 or 5. Nocturnal enuresis is common and usually does not require treatment in children of preschool age who have achieved continence during the day.

Nocturnal enuresis is classified as primary (PNE) or secondary(SNE). In primary nocturnal enuresis, the child has never been consistently dry at night. If the child has experienced at least 6 months of dryness at night and then begins bedwetting, the condition is referred to as secondary nocturnal enuresis. Psychological issues and acquired medical conditions cause the development of SNE.

Incidence and Prevalence
Nocturnal enuresis is more common in males and prevalence of the condition gradually declines during childhood. Approximately 23% of 5-year olds, 20% of 7-year olds, 4% of 10-year olds, and 1–2% of those aged 18 and older experience bedwetting. Secondary nocturnal enuresis accounts for approximately 25% of cases.

Risk Factors and Causes

There are a number of causes for nocturnal enuresis. Primary nocturnal enuresis is often caused by a chromosomal abnormality and there is a strong genetic link associated with the condition. Children whose parents or siblings experienced bedwetting are at increased risk. If one parent had the condition, the risk is approximately 45% and if both parents had the condition, the risk is approximately 75%.

Other causes of PNE include the following:

• Abnormally positioned ureter (ectopic ureter; more common in females)
• Constipation
• Excessive urine output (polyuria; may result from excessive fluid intake)
• Heart condition that causes an irregular heartbeat (heart block)
• Neurological disorders (e.g., cerebral palsy, spinal cord disorders, neurogenic bladder)
• Sleep arousal disorder (e.g., not awaking in response to sensory signals)
• Urinary tract infection (UTI; e.g., cystitis)
• Urethral obstruction (congenital or acquired as a result of trauma or infection)

Secondary nocturnal enuresis may be caused by psychological issues (e.g., death in the family, sexual abuse, extreme bullying) and is often associated with stress. It may also result from an acquired condition such as diabetes, overproduction of hormone by the thyroid gland (hyperthyroidism), seizure disorder (e.g., epilepsy), and obstructive sleep apnea (OSA).

Signs and Symptoms

Nocturnal enuresis causes regular involuntary bedwetting during sleep.

Diagnosis

Diagnosis of nocturnal enuresis is made when involuntary urination regularly occurs during sleep in a person who is continent while awake. Determining the cause for the condition requires a detailed medical history and a comprehensive physical examination.

Medical history includes the following:

• Assessment of psychological and emotional issues
• Fluid and dietary intake (especially late in the day)
• Daytime voiding frequency and volume
• Sleep history (i.e., time the child goes to bed, falls asleep, and awakens; depth of sleep; timing of bedwetting; snoring; nightmares)
• Periods of nighttime dryness and the circumstances

Physical examination includes the following:

• Blood pressure
• Examination of the genitals
• Palpitation of the kidneys, bladder, and lower spine
• Neurological examination of the lower body including gait, muscle strength and tone, reflexes, and sensation

Various diagnostic tests may also be performed to determine the cause of bedwetting. These tests are reserved for patients in whom physical abnormality or obstruction are suspected. Urinalysis is performed to detect cystitis, UTI, urethral obstruction, diabetes, and other possible physical causes.

Imaging or other tests used to detect abnormalities may include the following:

• Cystometrogram (measures bladder pressure at various stages of filling)
• Cystoscopy (examination of the bladder using a cystoscope)
• Magnetic resonance imaging (MRI scan)
• Ultrasound
• Voiding cystourethrogram (VCUG; used to observe the urinary tract before, during, and after urination)

Other urodynamic studies, which measure the storage and rate of movement of urine from the bladder, and uroflowmetry, which measures urine flow, may also be performed.

Treatment

The goals of treatment are to reduce the social and psychological impact of the condition and to eliminate the underlying cause. Treatments include the following:

• Behavior modification (e.g. positive reinforcement, periodic waking, restricted fluid intake, alarm therapy)
• Medication
• Surgery (in cases of obstructive sleep apnea, ectopic ureter, heart block)

Behavior Modification
It is important to manage nocturnal enuresis in a way that reduces the child's embarrassment and the anxiety within the family. Family members who have outgrown the condition can share their experience with the child to reduce feelings of isolation. Parents should use patience and caring while waiting for the child to outgrow bedwetting. Behavior modifications often improve nighttime dryness within 1 month.

Positive reinforcement (e.g., keeping a chart with gold stars awarded for dry nights) is sometimes beneficial, as is periodically waking the child at night to use the bathroom. An alarm clock set to go off a few hours after the child goes to bed can be used to wake the child or the parent can wake the child before retiring for the night.

Restricting the intake of fluids late in the day and encouraging voiding at regular intervals throughout the day may also be helpful. The child should be encouraged to use the bathroom every 1–2 hours during the day and immediately before bed. The restriction of fluids should not be demanded in a way that suggests punishment and should be implemented carefully in children who are physically active and in warm weather to reduce the risk for dehydration.

Alarm therapy has a success rate of approximately 70%, works best in older children who are well motivated, and requires commitment from all household members who may be awakened by the alarm. It takes from 2 weeks to several months to produce improvement, and if the child is not dry after 3 consecutive months of use, therapy should be discontinued until the child is older.

The alarm is positioned to sense wetness promptly and although most children sleep through the alarm, they stop voiding when it sounds. A parent then helps the child to the bathroom to finish voiding; changes wet sheets and pajamas; resets the alarm; and takes the child back to bed. Some children who achieve success with this type of therapy are able to sleep through the night without voiding, but others may continue to get up during the night to use the bathroom (nocturia).

Medication

Drug therapy usually is reserved for children who have had no success with nonpharmacological treatments. Medications used to treat nocturnal enuresis include the following:

• Desmopressin acetate (DDAVP®)
• Oxybutynin chloride (Ditropan®)
• Hyoscyamine sulphate (Levsin®)
• Imipramine (Tofranil®)

Desmopressin (DDAVP®) is an antidiuretic that is used to treat primary nocturnal enuresis. DDAVP® is available in a nasal spray (10–40 mcg, at bedtime) or oral form (0.2-0.6mg, at bedtime) and is up to 55% effective. It may also be combined with alarm therapy. Side effects of the nasal spray include nasal discomfort, nosebleed, abdominal pain, and headache. It is important to reduce fluid intake when taking DDAVP. If fluids are not restricted, water intoxication may occur. This condition requires immediate medical attention. Symptoms of water intoxication include headache, nausea, vomiting, and seizure.

Ditropan® and Levsin® are anticholinergic medications that reduce muscle contractions in the bladder. The usual dose is 2.5–5 mg taken at bedtime. Side effects include blurred vision, constipation, dizziness, dry mouth, facial flushing, and fluctuations in mood.

Tofranil® may be prescribed in doses of 25 mg in children 6 to 8 years old and 50–75 mg in older children, taken 1 to 2 hours before bed. This antidepressant effectively treats primary nocturnal enuresis without organic causes in as many as 40% of cases when used as a temporary adjuvant therapy.

Side effects include the following:

• Constipation
• Difficulty voiding
• Drowsiness
• Nervousness
• Mood changes
• Sleep disorders

Overdose can be fatal and the World Health Organization (WHO) does not recommend using this drug for nocturnal enuresis.

Oral antibiotics (e.g., Bactrim®, amoxicillan, Macrobid®, Levaquin®) are used to treat UTIs that cause bedwetting.

Surgery
Structural abnormalities in the urinary system (e.g., ectopic ureter) and other conditions, such as obstructive sleep apnea and heart block, may require surgery. Surgery to correct these conditions often eliminates nocturnal enuresis.

Prognosis

The prognosis for children who experience nocturnal enuresis depends on the cause. Almost all children outgrow bedwetting, even without treatment.

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