Enuresis

Epidemiology

Up to 10% prevalence among 5 year olds
Approximately 1% among individuals 15 years and older
At age 3 to 4 years, maturation of function and control over the external urinary sphincter AND control over bladder-sphincter unit so child can voluntary initiate and inhibit micturition occurs.
Key point 1: Provide reassurance to families and let the child know how common and normal it may be to still be wetting the bed.
Key point 2: The longer enuresis persists, the lower probability of spontaneous resolution (i.e. older children with enuresis requires more attention and treatment)

Definitions:

Enuresis - Intermittent incontinence while asleep in a child >= 5 years of age
Primary enuresis - nighttime wetting in a child who has not been dry for at least 6 months
Secondary enuresis - return of nighttime wetting after a child has been dry for at least 6 months
Monosymptomatic enuresis - Enuresis with no other lower urinary tract symptoms (LUTS) and limited to nighttime enuresis
Non-monosymptomatic enuresis - Enuresis with other, mainly daytime, LUTS
Nocturia - Nighttime awakening to void
Nocturnal enuresis - nighttime incontinence

History

Day vs nocturnal enuresis
# episodes bedwetting per week
Fluid intake (especially in the evening or night)
Juice, caffeine, or alcohol intake (especially soda, teas, and energy drinks!)
Constipation
Fecal incontinence - not due to insufficient wiping of the bottom

Red Flag History***

Presence of one or more suggestive for underlying bladder dysfunction (consider sending straight to Urology)

Leakages of urine during the day
Intermittent or continuous leakage
Urinary frequency (>= 8x/day)
Sudden and urgent need to urinate
Holding maneuvers observed (e.g. Vincent's curtsey - pressing heel into perineum, leg crossing, standing on tiptoes)
Straining to urinate
Interrupted urinary stream or several voids, one after another
History of recurrent urinary tract infections
Associated neurologic symptoms

Physical Exam

Goal: 1) Confirm normal anatomy 2) look for anatomic abnormalities 3) look for neurologic abnormalities

Genital Exam

Check underwear - signs of fecal incontinence
Physical abnormalities (e.g. phimosis, labial adhesions)

Back Exam

Spinal dysraphism (e.g. dimple, hemangioma, lipoma, patch of hair, sacral agenesis)
Scoliosis (another potential sign of spinal dysraphism)

Neuro Exam

Muscle atrophy
Abnormal gait
Lower extremity weakness

MSK Exam

Foot deformities (high arch, hammer toes, clubfoot/equinovarus, limb-length discrepancies)
Tight heel cords (can be sign of spasticity)

Labs/Tests

Urinalysis (assess for glycosuria or signs of infection)
+/- Urine culture

Management

If non-monosymptomatic enuresis and/or signs of LUTS, refer to Urology!

Monosymptomatic enuresis can be treated by a general practitioner using:

1) Treat any coexisting constipation FIRST

2) Restriction of fluid and diuretic intake around bedtime (no fluids after dinner or limit no more than 1 glass before bedtime)

3) Bedwetting alarm

Consistence is KEY
Trial for 6-8 weeks DAILY

4) Desmopressin acetate

Recommended starting dose 0.2 mg PO administered 1 hours prior to bedtime
Titrate up to 0.4 mg-0.6 mg daily based upon clinical response (dosage is individualized for each patient)
Limit fluid intake to a minimum from 1 hour before administration (no fluids after dinner), and until the next morning, or at least 8 hours after administration
Precaution: Hyponatremia from antidiuretic effect of desmopressin which may lead to water intoxication and potential seizures and fatality.
Do not administer Desmopressin for patients during acute illnesses due to risk of fluid and/or electrolyte imbalance, or under conditions that increases water intake (exercise or hot weather)

Follow-up

If there is non-response to the alarm or desmopressin therapy, the actual diagnosis may be non-monosymptomatic enuresis and non monosymptomatic enuresis. Assess upon re-evaluation. If any suspicion for non-monosymptomatic enuresis, refer to the appropriate specialist.

Constipation is a high risk factor for enuresis and treatment resistance; it should be treated prior to managing enuresis.

Potential Reasons for Treatment Failure

Differential Reasons for Enuresis in Children

1) Monosymptomatic enuresis

Polyuria
Arousal disorder (e.g. sleep disorders)
Nocturnal detrusor overactivity (e.g. diuretics, caffeine, alcohol)

2) Non-monosymptomatic enuresis (See why you would refer to Urology?)

Functional incontinence

Dysfunctional voiding
Giggle incontinence
vaginal entrapment (e.g. vaginal prolapse)
Detrusor overactivity

Neurogenic bladder

Spina bifida
Tethered cord
Sacral malformation
Cerebral palsy
Spinal cord tumors
Imperforate anus
Trauma

Anatomic abnormalities

Exstrophy epispadias complex
Ectopic ureter and ureterocele
Cloacal malformations
Urethral valve abnormalities
Syringocele

Parental Handouts

CHOP Voiding Chart for tracking voiding

https://www.chop.edu/sites/default/files/urology-voiding-chart-2.pdf

Information about bedwetting:

https://www.healthychildren.org/English/health-issues/conditions/genitourinary-tract/Pages/Nocturnal-Enuresis-in-Teens.aspx?gad_source=1&gad_campaignid=69654055&gbraid=0AAAAADyMpZF-tbkbYisFeuWsGfrYiZ0wn&gclid=CjwKCAjw-J3OBhBuEiwAwqZ_h3wiBjcny9jei8xpQiThC4qnVtMkNUaHkH3-61BdEtIS7KNe3qRKDxoCCbgQAvD_BwE

Information about bedwetting alarms and how to use them:

https://www.kidney.org/directions-your-child-when-using-bed-wetting-alarm

References

Jonathan Apostol Guzman, Lane S. Palmer; Nocturnal Enuresis. Pediatr Rev August 2024; 45 (8): 479–481. https://doi.org/10.1542/pir.2023-006166
https://www.ics.org/Publications/ICI_4/files-book/Comite-9.pdf
Aaron P. Bayne, Steven J. Skoog; Nocturnal Enuresis: An Approach to Assessment and Treatment. Pediatr Rev August 2014; 35 (8): 327–335. https://doi.org/10.1542/pir.35-8-327
https://www.accessdata.fda.gov/drugsatfda_docs/label/2019/021795s006lbl.pdf