Bedwetting (nocturnal enuresis)

Bedwetting ceases and toilet training is developed by the age of 3 to 4 years in the majority of children. It is important to note that nocturnal enuresis (NE) is not necessarily an abnormal condition or disease even after that age, but it should be generally concluded that at the age of 5 to 6 it is medically indicated to deal with the issue of bedwetting.
Bedwetting is a common condition affecting 10% of the children at age 7; 3% at age 12, and it can appear even at the age of 18 in 1% of the population. The female–male ratio is 2 to 1. Bedwetting is described as involuntary voiding of urine during the night and/or daytime sleep. Familial accumulation is quite common: the child has 50% chance to wet the bed if one of the parents wetted the bed in childhood, and if both parents were affected by this problem, the child has 75% chance to develop the same condition. NE is self-limiting in 15% of regular bedwetting children. However, disregarding it may result in severe psychic and social developmental problems in the affected child. The untreated or inappropriately treated child may become too reserved, and social adjustment and behavioral disorders may develop. The adequate flow of information (via internet and other media) made it possible for parents to be informed about the disease and not to consider this problem a shame, but to turn to the appropriate specialist.

Bedwetting is considered primary if the problem has been constant since the child stopped using the diaper, or the child had no symptoms for less than 6 months.
Secondary enuresis is described as bedwetting recurring in a child who was asymptomatic for more than 6 months.
Enuresis is considered mono symptomatic if wetting occurs exclusively during the night.
Poly symptomatic enuresis is described as bedwetting accompanied by one or more of the following symptoms: urinary infection, constipation, urinary frequency, and small bladder capacity.

Frequent causes in the background of the disease can be:

  1. bladder innervation disorders,
  2. insufficient production of antidiuretic hormone (ADH) at night, which is responsible for the amount of the urine,
  3. difficulty breathing during sleep (sleep apnea), and
  4. an extreme distribution of the daily amount of fluid consumption.

Less frequent causes can be:

  1. urinary tract infection,
  2. developmental disorder of the urinary tract,
  3. trauma to the spine or central nervous system,
  4. psychiatric or psychological diseases,
  5. increased calcium voiding, or
  6. other factors (e.g., constipation, inflammation of the vulva or the foreskin).

The procedure of investigation

History taking:

Familial accumulation is very common; it is frequently reported that either one of the parents or both of them had the same problem. Accordingly, bedwetting frequently develops in the siblings as well.
During taking history from the parents, it is important for the doctor to gain information on how many times the child wets the bed during the week, if the child has ever been dry during the night, and whether the child also has wetting problems during the day. The latter one refers not only to dripping or leaking of urine, but that the child ignores the urge for urination and rather continues playing, and might apply certain techniques (e.g., sitting on the heels) to hold back the urine. Stooling habits are also important to be considered as the child might have some fecal incontinence or constipation as well, and you should detect whether further inconvenient complaints also accompany enuresis (e.g., feeling of discomfort after voiding urine).

Physical examinations:

The possible anatomical abnormalities or developmental disorders can be identified during these tests.

Fluid intake and output:

A 24-hour record should be kept on the fluid distribution by the parents, in which the amount of the fluids taken in and eliminated, and, their time should also be recorded. Daytime data frequently contain some surprising results: several children drink very little during the day if they are in the community or attending trainings, but they try to make up for the lost amount of fluid in the afternoon or evening in a couple of hours. On the evening of the test, two hours after the child's falling asleep, he/she is woken up and asked to pass urine, and the amount of the urine is recorded. Three hours later, the child is woken up again and asked to pass urine again, and finally, the amount of the early morning urine is measured again. Assessment of specific gravity of the urine sample collected during the night can also be helpful.

Laboratory tests:

Urinalysis is performed on early morning urine.

Imaging studies:

Genitourinary organs can be easily examined by abdominal ultrasound scan, and the capacity of the bladder can be assessed as well as the volume of residual urine in the bladder.

Sleep diagnostics:

If the parents report snoring, daytime lassitude or drowsiness of the child, the presence of certain abnormalities should be ruled out, such as enlarged tonsils and adenoid, or developmental disorders of the pharynx. In other cases, a sleep diagnostic test should be performed as the amount of nighttime urine excretion is increased if the child has sleep apnea.

Therapy:

Target therapy can be initiated according to the results of the above detailed examinations.

Non-medical therapy:

Normalizing defecation, appropriate fluid intake and output, bladder training (asking the child to pass urine regularly, and performing pelvic training exercises even from the age of 4 years); the enlarged tonsils or adenoid should be removed, and difficulty breathing during sleep (sleep apnea) should be treated.
In case of secondary nocturnal enuresis, psychological care and family therapy are recommended as well as the use of a moisture alarm, which is a small device inserted into the underwear of the child to detect the appearance of urine on the commencement of urination. It sends a signal to the other device attached to the shoulder of the child alarming him/her. This sound stimulus initiates a process as a result of which the child will be able to hold back the urine during the night or wake up when the bladder is full.
If daytime complaints are present, urinary training program is recommended.

Medical therapy:
  1. If the amount of nighttime urine is large, and the concentration is low, and the production of antidiuretic hormone (ADH) is detected to be decreased, certain medications can be applied to substitute the hormone. They are available in the form of nasal sprays or tablets. 1 puff should be applied to the nose before going to bed. If it is not sufficient, the dose can be increased to 2 puffs after a week. Ultimately, the dose can be increased to 3 or maximum 4 puffs per night. It is crucial, however, that the child should not drink at all for 8 to 10 hours after applying the drug. If this rule is broken, the risk of developing water intoxication is significantly increased.
  2. Anticholinergic agents can be administered if small amounts of urine are passed frequently during daytime, and no ADH deficiency has been detected.
  3. The administration of anxiolytics can also be considered in children with anxiety as a temporary, additional therapy for nocturnal enuresis.

 

Senior Consultant: Dr Mária Martyn
Paediatric Hospital and Outpatient Clinic of Buda, Budapest, Hungary

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