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Nocturnal enuresis

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Kristy is a 5-year old girl; her mother has brought her in due to her having started kindie. She has been invited to have a sleepover at a family friends house however she still wets the bed most nights of the week and is wondering about how to manage this.

 

Attaining continence – both daytime and nighttime – is a developmental milestone with a significant normal variation which is affected by both genetic and environmental factors.

At 5 years of age, approximately 15% of children continue to experience nocturnal enuresis (more commonly known as bedwetting). Every year beyond this, there is spontaneous resolution in ~15% of affected children (although it should be noted that the longer duration of NE, the lower the likelihood of spontaneous resolution).

Boys are more commonly affected than girls (2:1) and there is a strong family predisposition (both parents = 77%, single parent = 43%). Only one-third of those affected will seek medical attention.

 

What is nocturnal enuresis?

Nocturnal enuresis is episodes of urinary incontinence during sleep in children ≥5 years of age. It may be further subdivided into monosymptomatic (aka uncomplicated) and non-monosymptomatic (aka complicated or polysymptomatic).

  • Monosymptomatic: incontinence is present without other symptoms of lower urinary tract/gastrointestinal tract
  • Non-monosymptomatic: incontinence associated with other symptoms including but not limited to
    • Polyuria/oliguria (8/3 times per day respectively)
    • Urgency, hesitancy, intermittency
    • Straining/holding manoeuvres
    • Weak stream, dribbling
    • A feeling of incomplete emptying
    • Pain

When episodes additionally occur during the day, it is more appropriately referred to as diurnal enuresis/incontinence.

Incontinence should be classified as primary or secondary.

  • Primary: the child has never been dry
  • Secondary: the child has been dry for a period of at least 6 months

 

Why does nocturnal enuresis occur?

Nocturnal enuresis is the result of inappropriate emptying of the bladder by the child and is the result of a mismatch between the neurones of the bladder and the conscious state of the child. This may be due to a multitude of factors including:

  • Maturation delay
  • Genetic factors
  • Nocturnal polyuria – this may be due to fluid intake, reduced response to antidiuretic hormone (ADH) and/or reduced production of ADH
  • Disturbed sleep in the child (controversial)
  • Small bladder capacity
  • Detrusor overactivity

These factors may be primary to the child (eg. genetic factors) or secondary to an underlying condition (eg. polyuria secondary to undiagnosed diabetes insipidus)

 

 


How to evaluate a child with nocturnal enuresis?

It’s almost all in the history – search for red flags!

History:

  • Onset
  • Previously dry?
  • Daytime symptoms (non-monosymptomatic NE)
  • Frequency, amount
  • Response to episodes
  • Fluid habits
  • Bowel habits
  • Sleep routines

 

Examination:

  • Height/weight
  • BP
  • Tonsillar hypertrophy/adenoidal facies
  • Abdomen (distended bladder, faecal mass)
  • Spine
  • Lower limb neurology
  • Perianal/vulval inflammation (pinworms)

 

Do you need to do investigations?

Investigations are not necessary for all patients and should be guided by history and examination. Consider:

  • Blood sugar level (fingerprick)
  • Urinalysis (m/c/s, electrolytes)

Imaging and blood tests are not routinely indicated.

 

What are the treatment options?

 

Important things to remember in treatment:

  • Tricyclic medications are not recommended as they are less effective and have a higher risk of adverse effects
  • Intranasal desmopressin is not recommended due to the risk of hyponatraemia
  • There are high rates of relapse when desmopressin is discontinued (60 – 70%) therefore best used as a short term measure (eg. for going to camp) whilst awaiting spontaneous resolution
  • Desmopressin should not be used in those who are unable to adhere to fluid restrictions (due to risk of hyponatraemia)
  • Treatments with weak evidence include elimination diet, hypnosis, retention control (holding urine for progressively longer periods), biofeedback, acupuncture, scheduled awakenings, caffeine restriction

 

Take-home messages

  • It doesn’t require treatment in those under the age of 6
  • It is common  although undertreated despite treatment options (and families potentially being eligible for funding)
  • It is usually a primary disorder rather than secondary to an underlying medical condition (although maybe particularly exacerbated by constipation)
  • Investigations are not routinely required
  • Treatment requires a motivated family, with behavioural measures and bedwetting alarms being the first line of treatment.

 

Selected references

Tu, Baskin, Arnhym et al (2019) “Nocturnal Enuresis in Childre: Etiology and Evaluation”. UpToDate.

Tu, Baskin, FAAP (2019). “Nocturnal Enuresis in Children: Management”. UpToDate.

The Royal Childrens Hospital. (2019). “Enuresis – Bedwetting and Monosymptomatic Enuresis.” Melbourne. Retrieved from: https://www.rch.org.au/clinicalguide/guideline_index/Enuresis_-_Bed_wetting_and_Monosymptomatic_Enuresis/

Thiedke C. “Nocturnal Enuresis”. American Family Physician (2003); April 1; 67(7): 1499 – 1506

Ramakrishnan K. “Evaluation and treatment of enuresis”. American Family Physician (2008); August 15; 78(4): 489 – 496.

About the authors

  • Mary is an advanced trainee in General Paediatrics/Community and Developmental Paediatrics. Has called Townsville home for the last decade. Outside of work, she enjoys eating and Crossfit (one of 'those people'!)

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