What Is Enuresis?
Enuresis is repeated voiding of urine into bed or clothes, whether involuntary or intentional. Typically, it is involuntary urination while asleep (nocturnal enuresis or bed-wetting) beyond the age at which staying dry at night is expected. However, enuresis can also occur during daytime, when it is called daytime enuresis.
But, don’t panic as yet. Enuresis is not a sign of bad toilet training. It is quite often merely a normal part of a child’s development. It is hardly of concern before age 7. However, if enuresis continues, exercise patience and understanding. Bladder training, lifestyle changes, moisture alarms and even medication can help reduce or eliminate it altogether.
The prevalence of enuresis is 5-10% among 5-year-olds, 3-5% among 10-year-olds, and around 1% among individuals 15 years or older. An estimated 5-7 million children in the US have enuresis. It is more common in boys. After age 5 years, the rate of spontaneous remission is 5-10% per year. Most children with the disorder become continent by adolescence, but in approximately 1% of cases, the disorder continues into adulthood.
In enuresis, often the only symptom is night-time bed-wetting. Daytime enuresis involves symptoms of bladder dysfunction, which include:
- Urge incontinence – an overwhelming urge to urinate, frequent urination, attempts to hold the urine and urinary tract infections.
- Voiding postponement – delaying urination in certain situations such as when at school and preoccupied.
- Stress incontinence – incontinence occurring when there is increased intra-abdominal pressure, such as during coughing.
- Giggling incontinence – incontinence occurring when laughing.
The child may exhibit holding maneuvers, such as standing on tiptoes, crossing the legs, pressing the heel or hand into the perineum. This type of enuresis suggests dysfunctional voiding, overactive bladder, or more serious pathology.
A child with enuresis could also have developmental delays, including speech, language, learning, and motor skills delays. Encopresis, sleep terror disorder, or sleepwalking could also be present. Urinary tract infections are more common in children with enuresis.
Causes of Enuresis
The cause of enuresis is not known. Factors that play a role in its causation include:
- A small bladder. The bladder cannot hold urine produced during the night.
- Nervous dysfunction. If the nerves that control the bladder are slow to mature, a full bladder may not wake the child.
- Hormonal imbalance. Inadequate production of anti-diuretic hormone (ADH) to slow night-time urine production.
- Urinary tract infection. This makes it difficult for the child to control urination.
- Sleep apnea. Sometimes bed-wetting is a sign of obstructive sleep apnea. In sleep apnea, the child’s breathing is interrupted during sleep—usually due to enlarged adenoids or tonsils. Other signs of this include daytime drowsiness and snoring.
- Diabetes. Other signs and symptoms here include an increased volume of urine, increased thirst, tiredness, and weight loss despite a good appetite.
- Chronic constipation. The same muscles control urine and stool elimination. In long-standing constipation, these muscles could become dysfunctional contributing to enuresis.
- A structural problem in the urinary tract or nervous system. There could be a defect in the child’s urinary or neurological system.
Factors that increase the risk of enuresis include:
- Stress and anxiety. Stressful events, such as birth of a sibling, starting new school, or being away from home.
- Environmental. Delayed or lax toilet training.
- Family history. If one or both parents had enuresis as children, their child has increased risk for it. The risk for childhood nocturnal enuresis is approximately 3.6 times higher in the offspring of enuretic mothers and 1 times higher in the presence of paternal urinary incontinence.
- Attention-deficit/hyperactivity disorder (ADHD). Enuresis is more common in children having ADHD.
- Repeated voiding of urine into bed or clothes, whether involuntary or intentional.
- Frequency is at least twice a week for at least 3 consecutive months or there is clinically significant distress or impairment in academic or occupational, social, or other important areas of functioning.
- Age is at least 5 years.
- It is not attributable to the physiological effects of a substance (e.g., a diuretic, an antipsychotic medication) or another medical condition (e.g., diabetes, spina bifida, a seizure disorder).
Treatment of Enuresis
There are several alternative treatments available for enuresis.
- Limiting fluid intake in the hours before bed is one way, but it has not been studied systematically
- Waking the child at night to attempt to urinate
- Bladder training – increasing bladder capacity by delaying urination for extended periods; pelvic floor and sphincter control exercises
- Instituting reward systems, such as small rewards or star charts as the child achieves control
Alarm therapy is the most effective treatment for enuresis. It should be considered for every patient. However, if this method is not successful after 3 months of consecutive use, it could be discontinued.
Bed alarms include a moisture sensor, placed on the child’s undergarments or as a pad underneath the child. You can connect this to the alarm by wire or wirelessly. The alarm is a loud, acoustic stimulus that goes off when wetness is detected. The goal is for the child to awaken at the beginning of an enuresis episode, stop urinating temporarily, shut off the alarm, go to the toilet, and finish urinating.
Pharmacologic therapy is not very effective. Although sometimes, the enuresis may come under control with medication(s), once they are stopped, the child typically begins wetting again. Yet, they may help improve the child’s functioning until behavioral treatments begin to work. Medications decrease the amount of urine produced by the kidneys or help increase the capacity of the bladder.
- Desmopressin acetate (DDAVP): This is the preferred medication for treating children with enuresis. Combination of alarm therapy with desmopressin therapy may be superior to either therapy alone
- Oxybutynin chloride and tolterodine: The combination of DDAVP and oxybutynin chloride may be efficacious in children with overactive bladder or dysfunctional voiding.
- Imipramine: An antidepressant. Not preferred nowadays due to its adverse effects and risk of death with overdose.