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Enuresis

Enuresis is a topic covered in the 5-Minute Clinical Consult.

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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, posturination dribbling, lower abdominal or genital discomfort, or sensation of incomplete emptying

ALERT
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 (1)
  • 10% of 7-year-olds; 3% of 11 to 12-year-olds; 0.5–1.7% at 16 to 17-year-olds (2)
  • 1.5 to 2 times more common in males than females
  • Nocturnal > day (3:1)

Geriatric Considerations
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: 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

General Prevention

No known measures

Commonly Associated Conditions

  • Obstructive sleep apnea syndrome (10–54%) (1): Atrial natriuretic factor inhibits renin-angiotensin-aldosterone pathway leading to diuresis.
  • Constipation (33–75%) (1)
  • Behavioral problems (specifically ADHD in 12–17%) (1)
  • Overactive bladder or dysfunctional voiding (up to 41%) (1)
  • Urinary tract infection (18–60%) (1)

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Citation

Stephens, Mark B., et al., editors. "Enuresis." 5-Minute Clinical Consult, 27th ed., Wolters Kluwer, 2019. Medicine Central, im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/116208/all/Enuresis.
Enuresis. In: Stephens MB, Golding J, Baldor RA, et al, eds. 5-Minute Clinical Consult. 27th ed. Wolters Kluwer; 2019. https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/116208/all/Enuresis. Accessed April 18, 2019.
Enuresis. (2019). In Stephens, M. B., Golding, J., Baldor, R. A., & Domino, F. J. (Eds.), 5-Minute Clinical Consult. Available from https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/116208/all/Enuresis
Enuresis [Internet]. In: Stephens MB, Golding J, Baldor RA, Domino FJ, editors. 5-Minute Clinical Consult. Wolters Kluwer; 2019. [cited 2019 April 18]. Available from: https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/116208/all/Enuresis.
* Article titles in AMA citation format should be in sentence-case
TY - ELEC T1 - Enuresis ID - 116208 ED - Stephens,Mark B, ED - Golding,Jeremy, ED - Baldor,Robert A, ED - Domino,Frank J, BT - 5-Minute Clinical Consult, Updating UR - https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/116208/all/Enuresis PB - Wolters Kluwer ET - 27 DB - Medicine Central DP - Unbound Medicine ER -