Nocturnal enuresis usually presents with voiding of urine during sleep in a child for 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.
Secondary incontinence usually occurs in the context of a new life event that is stressful such as abuse or parental divorce.
Signs indicating a child has a nighttime wetting condition, if they are at least 5 years old, may include:
It is recommended that children are made aware that bedwetting is not their fault, especially due to preconceived notions of inadequate parenting or psychiatric issues leading to enuresis. Untreated enuresis may lead to a lack of self-esteem or avoidance of social activities. Children with nocturnal enuresis are found to have lower quality of life, but it is not clear which aspects are most affected. More studies are needed to understand the impact of nocturnal enuresis on parents.
Bedwetting children are often normal emotionally and physically, although enuresis can be caused by other health conditions. Primary nocturnal enuresis can have multiple causes, which can make approaching a course of treatment more difficult.
A pediatric day can be categorized into 3 periods: 7 AM to 12 PM, 12 PM to 5 PM, and after 5 PM. Children with enuresis are usually dehydrated and drink the most after 5 PM. This can be remedied by having the child drink 40% of daily fluid requirement before noon, 40% from noon to 4:30 PM, and 20% in the evening.
Children with enuresis have lower functional bladder capacity than healthy children. This means that their bladders hold less urine, often over 50% less.
It is uncommon for nocturnal enuresis, in the absence of other symptoms, to be caused by an infection. Pinworms have also been linked with sudden onset enuresis in young girls.
Mastering urinary control during sleep time is a normal part of childhood development and may be delayed by stress and social pressures. The risk for enuresis increases threefold for children who experience stress, demonstrated by the higher prevalence of enuresis in lower socioeconomic groups.
Anxiety experienced by a child between ages 2 to 4 also increases the risk for enuresis because this particular time period is sensitive for the development of nighttime bladder control.
Nocturnal enuresis has been found to be more common in those with developmental delay, physical or intellectual disabilities, and psychological or behavioral disorders.
Urodynamic sleep studies show that enuretic children have high pressure bladder contractions more frequently while they are asleep when compared to healthy children.
Nocturnal polyuria is defined as having more than 130% of the expected bladder capacity, which is specific for each age. Many children with nocturnal enuresis have altered nighttime secretion levels of antidiuretic hormone, which controls water retention in the body. This results in low antidiuretic hormone levels and excessive amounts of urine produced during sleep time.
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-5 criteria:
All these criteria must be met in order to diagnose an individual. Generally, healthcare providers may further investigate for bladder control issues if a child is still enuretic in the daytime by age 4, or if they are still enuretic at nighttime by age 5 or 6.
The International Children's Continence Society (ICCS) has developed the following standard terminology:
There are a number of management options for enuresis. Management of enuresis, both nocturnal and daytime, can include behavioral therapy, drug therapy, traditional Chinese medicine (TCM), and other alternative medicine therapies. Treatment of enuresis for children under 5 years old is not recommended. In adults with nocturnal enuresis, use of a bedwetting diary, which keeps track of when enuresis occurs, may be helpful for healthcare providers to figure out the causes of a person's enuresis and their best route for treatment.
Simple behavioral interventions may prove to be superior in comparison to no ongoing form of treatment and are recommended as initial treatment.
Waking a child up at night is not a medically supported long-term cure or solution for nocturnal enuresis, and may just be a one-time solution even if it appears to resolve enuresis.
Evidence suggests that neurostimulation therapy may be an efficacious and safe form of treatment of pediatric primary enuresis, also known as bedwetting. Neurostimulation of the sacral nerve is an option for children in which all other therapies have failed. Neurostimulation treatment of adult enuresis may be considered prior to pursuing surgical methods. For adult enuresis, sacral nerve stimulation can be administered to decrease bladder muscle activity so that the bladder muscles are not constantly in a contracted state to help improve enuresis symptoms.
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 (FDA) 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.
There are multiple studies examining the efficacy of acupuncture in treating nocturnal enuresis in children, but the evidence is generally of low quality and has multiple limitations. Therefore, there is not strong evidence to suggest that acupuncture is useful for treating enuresis.
Approximately 10% of six- to seven-year-olds around the world experience enuresis. While 15% to 20% of five‐year‐old children experience nocturnal enuresis which usually goes away as they grow older, approximately 2% to 5% of young adults experience nocturnal enuresis. About 3% of teenagers and 0.5% to 1% of adults experience enuresis or bedwetting, with the chance of it resolving being lower if it is considered frequent.
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