Nocturnal enuresis, or bedwetting, is a common condition in which children often go outside. Advice to parents on simple behavioral strategies is often the first step. Using support bed alarms offers the best chance for long-term success. Occasional short-term use of desmopressin is also discussed.
While investigating the causes of nocturnal urinary incontinence, some issues should be considered. The points to be considered are as follows;
At what age is bedwetting abnormal?
o Normally, what does urinary incontinence depend on?
o Are any examinations needed?
What advice can he give parents?
When should a specialist be consulted?
o Which non-drug treatments should be recommended?
o Which drugs are recommended?
Definition of Bed Wetting
Primary nocturnal enuresis is bedwetting in a child who has never continuously dried out at night for six months.
Secondary nocturnal enuresis is bedwetting in a child who has had at least six months of dryness before.
Bedwetting can create significant stress on affected individuals and their families. Although this article is mainly aimed at children, similar principles apply to adolescents and adults who are still bedwetting.
At What Age Is Bed Wetting Abnormal?
The International Children’s Continence Society defines night enuresis as:
A child of five to six years old with two or more cases of bedwetting per month
A child older than six years of age with one or more bedwetting cases a month
However, most management strategies target children aged seven and over, as bedwetting is often seen as an issue by both the child and their family. Bedwetting is common but decreases with age. It affects approximately:
o 15% of 5 year olds
o 5% of 10 year olds
o 2% of 15-year-olds
1% of adults
About 15% of affected children experience spontaneous remission each year and are more likely to occur if there is a family history of nocturnal enuresis. A recent study found that children who get bedwetting most often are more likely to sustain the problem.
It is thought that less than half of the parents who have children with nocturnal enuresis consult their doctor about the problem.
Causes of Bed Wetting
The exact cause of nocturnal enuresis is unknown. It probably seems like a multifactorial neurodevelopmental problem. Interviews with patients and parents can focus on:
Reduced night bladder capacity
o Lack of awakening
Night polyuria can be caused by an irregular circadian rhythm of antidiuretic hormone (ADH) secretion that occurs in about 70% of bedwetting children. ADH, also known as vasopressin, is a peptide secreted from the posterior pituitary and plays a key role in controlling urine production. ADH secretion is increased during the night, usually to concentrate urine, which helps to produce low volumes of urine.
Reduced night bladder capacity
A recent Chinese study involved an ultrasound examination of 500 children with nocturnal enuresis and showed reduced functional bladder capacity in about 40% of children with nocturnal enuresis.
Lack of awakening from sleep
Sleep and arousal are one of the least understood factors in the pathophysiology of enuresis. Many parents will say that their bedwetting child is a “deep sleeper.” A 1999 study using EEG analysis found that both deeper sleep and impaired arousal were more common in children with enuresis, 7 but other studies had conflicting results.
Psychological problems are rarely the primary cause of nocturnal enuresis, but teasing, bullying, or punishment may be the result. Secondary nocturnal enuresis is more likely to be due to a psychosocial stress factor, such as parental separation, a new baby in the family, illness, or problems at school.
Genetic factors play a strong role in the etiology of primary nocturnal enuresis, so it would be beneficial to have a family history of bedwetting. Approximately 70% of bedwetting children have a sibling or parent who is late to dry. Children whose one parent has enuresis has a 44% risk of nocturnal urinary incontinence, and those whose two parents are affected have a 77% risk. Most hereditary nocturnal enuresis exhibit an autosomal dominant mode of transmission with high penetrance (90%). However, one third of all cases are sporadic and the difference between sporadic and familial forms is unknown.
Differential Diagnosis of Bed Wetting
When a child presents with bedwetting, look for the presence of daytime symptoms; this could indicate that bedwetting is secondary to other causes.
UTIs and other acute illnesses can cause short-term bedwetting in a person who was previously dry.
Diabetes mellitus, diabetes insipidus or kidney failure can cause bedwetting, but there are usually other symptoms such as daytime polyuria and excessive thirst.
Chronic constipation can cause bladder imbalance, a careful history of bowel pattern is required.
Bladder imbalance can cause day and night incontinence.
Caffeinated drinks can irritate the bladder.
Investigation of Causes of Bed Wetting
It is important to determine the time in bedwetting. In addition, the following are important when making a diagnosis;
o A distinction should be made between children with nocturnal enuresis (the majority) and those with episodes of enuresis during the day.
o Distinction should be made between primary and secondary nocturnal enuresis.
o Ask about the way you urinate, the number of dry nights in the last week or month, fluid intake before bedtime, caffeine intake before bedtime (eg tea, coffee, cola, chocolate).
o Practical issues such as the child’s ability to go to the toilet, does he need light to see the way to the toilet, night fears should be discussed.
o Ask about possible stress factors at home, at school or with friends.
o Discuss what has already been tried, including penalties and rewards.
As with previous UTIs, previous medical history should be learned.
Examinations of the abdomen, perineum, spine, and nervous system are normal in a child with nocturnal enuresis. Any anomalies found will lead to additional investigation. Ultrasound examination of the kidneys and urinary tract to exclude anatomical abnormalities is only recommended in children who are wet during the day, post-UTI or incontinence at night, when they do not respond to treatment. Examination with a urine dipstick and culture may help. However, controlling specific gravity is not usually possible.
Author: Ozlem Guvenc Agaoglu