Approximately 10% of six to seven year-olds around the world who experience enuresis. 15% to 20% of 5‐year‐old children experience nocturnal enuresis which usually goes away as they grow older. Approximately 2% to 5% of young adults experience nocturnal enuresis.
Causes
Enuresis can be caused by one or more of the following:
The inability to control the detrusor muscle has been theorized as a possible pathophysiological cause of enuresis, which may explain why anticholinergic drugs are effective as medication therapy, since they act on the detrusor muscles. Enuresis is also theorized to be a hereditary condition based on epidemiological and genetic studies. Although several genes are considered of interest in relation to enuresis, lack of a single gene that may cause enuresis means that individuals of a family may have differing genetic mechanisms resulting in the condition.
Signs and symptoms
Nocturnal enuresis usually presents with voiding of urine during sleep in a child in whom it is difficult to wake. It may be accompanied by bladder dysfunction during the day which is termed non-mono symptomatic enuresis. Day time enuresis, also known as urinary incontinence, may also be accompanied by bladder dysfunction. The symptoms of bladder dysfunction include:
Voiding postponement - delaying urination in certain situations such as school
Stress incontinence - incontinence that occurs in situations when increased intra-abdominal pressure occurs such as coughing.
Giggling incontinence - incontinence that occurs when laughing.
Secondary incontinence usually occurs in the context of a new life event that is stressful such as abuse or parental divorce.
Diagnosis
Clinical definition of enuresis is urinary incontinence beyond age of 4 years for daytime and beyond 6 years for nighttime, or loss of continence after three months of dryness. Current DSM-IV-TR criteria:
Repeated voiding of urine into bed or clothes
Behavior must be clinically significant as manifested by either a frequency of twice a week for at least three consecutive months or the presence of clinically significant distress or impairment in social, academic, or other important areas of functioning.
Chronological age is at least 5 years of age.
The behavior is not due exclusively to the direct physiological effect of a substance or a general medical condition.
All these criteria must be met in order to diagnose an individual.
Classification
Primary enuresis refers to children who have never been successfully trained to control urination.
Secondary enuresis refers to children who have been successfully trained and are continent for at least 6 months but revert to wetting in a response to some sort of stressful situation.
There are 2 categories of enuresis:
Monosymptomatic enuresis - Does not include bladder dysfunction during daytime.
Nonmonosymptomatic enuresis - Includes bladder dysfunction during daytime. Involves bladder dysfunction causing daytime incontinence this is frequent and urgent.
Management
There are a number of management options for enuresis. Management of enuresis, both nocturnal and daytime, can include behavioral therapy, drug therapy, and traditional Chinese medicine alternatives. Treatment of enuresis for children under 5 years old is not recommended.
Behavioral Therapy
Simple behavioral interventions may prove to be superior in comparison to no ongoing form of treatment and are recommended as initial treatment.
Nighttime fluid limitation
Enuresis alarm - includes sleeping mats with electrical circuits; alarms with sensors placed in child's underwear; alarms that are wired or wireless and produce noise, vibration, or light; and alarm clocks or mobile phones for older individuals
Lifting - carrying the child, who is still asleep, away from the bed to an appropriate place to urinate
Neurostimulation
Evidence suggests that neurostimulation therapy may be an efficacious and safe form of treatment of pediatric primary enuresis, also known as bedwetting.
Traditional Chinese medicine utilizes the patients' history and pattern of disease to formulate treatment regimens. Patterns of enuresis in TCM are divided into vacuity and repletion patterns with kidney qi vacuity and spleen-lung qi vacuity patterns being the two main patterns of enuresis. Depending on the vacuity pattern of the patient's enuresis, there are different guiding formulas and acupuncture therapies for treatment. Guiding formulas include ready-made pills or medicinal liquid of indicated Chinese herbs, while acupuncture therapy aims to balance the flow of energy, also known as qi, at specific points on the body. It should be noted that efficacy of acupuncture in children with nocturnal enuresis may improve clinical efficacy but more high quality studies are needed to confirm this claim.
Medications
Nighttime incontinence may be treated by increasing antidiuretic hormone levels. The hormone can be boosted by a synthetic version known as desmopressin, or DDAVP. Desmopressin is approved by the United States Food & Drug Administration for use in children 6 years and older with primary nocturnal enuresis and is available in both spray and tablet formulations. There is good short-term success rate; however, there is difficulty in keeping the bed dry after medication is stopped. In children whose enuresis symptoms do not resolve with desmopressin, anticholinergic drugs may be effective as a second-line therapy or as an add-on drug with desmopressin. However currently only oxybutynin has an FDA-approved labeled indication in children aged 6 and older. An additional third-line alternative shown to be effective is the tricylic antidepressantimipramine, however the use of tricylic antidepressants carries the risk of cardiotoxicity and is not recommended to be given without evaluating a person's risk factors for certain heart diseases.
Impact
Children with nocturnal enuresis are found to have lower quality of life, but it is not clear which domain is most affected.
History
Enuresis was first documented in Ebers Papyrus in 1550BC. Roman author Gaius Plinius Secundus documents nocturnal enuresis in his work, 'Natural History' by stating that "the incontinence of urine in infants is checked by giving boiled mice in their food." Furthermore, in the eighteenth century, children with enuresis was subjected to a variety of chemical and mechanical treatments including fluid restriction, enemata, the use of an alarm clock, cold baths, warm baths, cold dashes to the perineum and douches to the lower spine.
