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- 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
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
- Depends on family history
- Spontaneous resolution: 15% per year
- 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)
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.
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.
- 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
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)