Enuresis
Basics
Description
- Classification
- Primary nocturnal enuresis (NE): 80% of all cases; person who has never established urinary continence on consecutive nights for a period of ≥6 months
- Secondary NE: 20% of cases; resumption of enuresis after at least 6 months of urinary continence
- NE: intermittent nocturnal incontinence after the anticipated age of bladder control (age 5 years)
- Primary monosymptomatic NE (PMNE): bed-wetting with no history of bladder dysfunction or other lower urinary tract (LUT) symptoms
- Nonmonosymptomatic NE (NMNE): bed-wetting with LUT symptoms such as frequency, urgency, daytime wetting, hesitancy, straining, weak or intermittent stream, post-urination dribbling, lower abdominal or genital discomfort, or sensation of incomplete emptyingALERT
Adult-onset NE with absent daytime incontinence is a serious symptom; complete urologic evaluation and therapy are warranted.
- System(s) affected: nervous, renal/urologic
- Synonym(s): bed-wetting; sleep enuresis; nocturnal incontinence; primary NE
Epidemiology
Incidence
- Depends on family history
- Spontaneous resolution: 15% per year
Prevalence
- Very common; 5 to 7 million children in the United States
- 10% of 7-year-olds; 3% of 11- to 12-year-olds; 0.5–1.7% at 16 to 17 years old (1)
- 2 to 3 times more common in males than females
- Nocturnal > daytime (3:1)
Geriatric Considerations
Infrequent; often associated with daytime incontinence (formerly referred to as diurnal enuresis)
Etiology and Pathophysiology
- A disorder of sleep arousal, a low nocturnal bladder capacity, and nocturnal polyuria are the three factors that interrelate to cause NE.
- Both functional and organic causes (below); many theories, none absolutely confirmed
- Detrusor instability
- Deficiency of arginine vasopressin (AVP); decreased nocturnal AVP or decreased AVP stimulation secondary to an empty bladder (Bladder distension stimulates AVP.)
- Maturational delay of CNS
- Severe NE with some evidence of interaction between bladder overactivity and brain arousability: association with children with severe NE and frequent cortical arousals in sleep
- Organic urologic causes in 1–4% of enuresis in children: urinary tract infection (UTI), occult spina bifida, ectopic ureter, lazy bladder syndrome, irritable bladder with wide bladder neck, posterior urethral valves, neurologic bladder dysfunction
- Organic nonurologic causes: epilepsy, diabetes mellitus, food allergies, obstructive sleep apnea, chronic renal failure, hyperthyroidism, pinworm infection, sickle cell disease
- NE occurs in all stages of sleep.
Genetics
Most commonly, NE is an autosomal-dominant inheritance pattern with high penetrance (90%).
- 1/3 of all cases are sporadic.
- 75% of children with enuresis have a first-degree relative with the condition.
- Higher rates in monozygotic versus dizygotic twins (68% vs. 36%)
- If both parents had NE, risk in child is 77%; 44% if one parent is affected. Parental age of resolution often predicts when child’s enuresis should resolve.
Risk Factors
- Family history
- Stressors (emotional, environmental) common in secondary enuresis (e.g., divorce, death)
- Constipation and/or encopresis
- Organic disease: 1% of monosymptomatic NE (e.g., urologic and nonurologic causes)
- Psychological disorders
- Comorbid disorders are highest with secondary NE: depression, anxiety, social phobias, conduct disorder, hyperkinetic syndrome, internalizing disorders.
- Association with ADHD; more pronounced in ages 9 to 12 years
- Altered mental status or impaired mobility
Commonly Associated Conditions
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Citation
Domino, Frank J., et al., editors. "Enuresis." 5-Minute Clinical Consult, 33rd ed., Wolters Kluwer, 2025. Medicine Central, im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/116208/0.0/Enuresis.
Enuresis. In: Domino FJF, Baldor RAR, Golding JJ, et al, eds. 5-Minute Clinical Consult. Wolters Kluwer; 2025. https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/116208/0.0/Enuresis. Accessed December 11, 2024.
Enuresis. (2025). In Domino, F. J., Baldor, R. A., Golding, J., & Stephens, M. B. (Eds.), 5-Minute Clinical Consult (33rd ed.). Wolters Kluwer. https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/116208/0.0/Enuresis
Enuresis [Internet]. In: Domino FJF, Baldor RAR, Golding JJ, Stephens MBM, editors. 5-Minute Clinical Consult. Wolters Kluwer; 2025. [cited 2024 December 11]. Available from: https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/116208/0.0/Enuresis.
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