Nocturnal Enuresis in Children
Nocturnal Enuresis in Children
Nocturnal enuresis refers to intermittent incontinence while asleep in children ≥5 years of age. It represents a significant developmental challenge affecting both children and families.
Key Epidemiological Points:
- Prevalence: 15-20% at age 5, decreasing by 15% annually
- More common in boys (2:1 ratio)
- Strong genetic component (77% concordance in monozygotic twins)
- Spontaneous resolution rate: 15% per year
Classification
1. Primary Nocturnal Enuresis
- Never achieved consistent nighttime dryness
- Most common form (80-85% of cases)
- Strong genetic component
2. Secondary Nocturnal Enuresis
- Recurrence after ≥6 months of dryness
- Often associated with psychological stressors
- May indicate underlying pathology
Pathophysiology
Key Mechanisms:
- Nocturnal Polyuria
- Reduced nocturnal vasopressin secretion
- Increased nocturnal urine production
- Disrupted circadian rhythm
- Reduced Bladder Capacity
- Functional or anatomical reduction
- Detrusor overactivity
- Altered bladder compliance
- Arousal Deficit
- Impaired response to bladder signals
- Deep sleep patterns
- Altered brainstem function
Clinical Assessment
Essential History Elements:
- Pattern of Enuresis
- Frequency of wet nights
- Time of bedwetting episodes
- Volume of urine
- Sleep patterns
- Associated Symptoms
- Daytime symptoms
- Urinary urgency
- Frequency
- Polyuria/polydipsia
- Risk Factors
- Family history
- Developmental history
- Psychological stressors
- Sleep disorders
Physical Examination:
- Growth parameters
- Abdominal examination
- Neurological assessment
- Spinal examination
- External genitalia inspection
Diagnostic Evaluation
Initial Assessment:
- Voiding Diary (3-7 days)
- Fluid intake volumes
- Voiding frequency
- Voided volumes
- Wet episodes
- Basic Laboratory Tests
- Urinalysis
- Urine culture if indicated
- Blood glucose if suspected diabetes
Advanced Studies (When Indicated):
- Renal/Bladder Ultrasound
- Post-void residual
- Bladder wall thickness
- Upper tract anomalies
- Urodynamic Studies
- Bladder capacity
- Detrusor function
- Sphincter competence
Management Strategies
First-Line Interventions:
- Behavioral Modifications
- Fluid restriction after dinner
- Regular voiding schedule
- Double voiding before bed
- Proper sleep hygiene
- Motivational Therapy
- Reward systems
- Progress charts
- Positive reinforcement
- Alarm Therapy
- Success rate: 65-75%
- Duration: 2-3 months
- Mechanism: Conditioning response
Pharmacological Treatment
1. Desmopressin (DDAVP)
- Mechanism: Reduces urine production
- Dosing: 0.2-0.6 mg at bedtime
- Success rate: 60-70%
- Monitoring: Sodium levels, fluid intake
2. Anticholinergics
- Oxybutynin
- Used for overactive bladder
- Dose: 2.5-5 mg at bedtime
- Monitor side effects
3. Combination Therapy
- Desmopressin + Alarm
- Desmopressin + Anticholinergics
- Used in resistant cases
Complications & Psychosocial Impact
Psychological Effects:
- Low self-esteem
- Social isolation
- Behavioral problems
- Academic impact
- Family stress
Quality of Life Impact:
- Sleep disturbance
- Social activities limitation
- Family dynamics
- Financial burden
Prevention & Counseling
Preventive Measures:
- Early toilet training
- Regular voiding habits
- Proper fluid intake patterns
- Stress management
Family Counseling:
- Education about natural history
- Setting realistic expectations
- Support strategies
- Handling social situations
Video Notes with Music
Nocturnal Enuresis: Objective QnA
- What is the definition of nocturnal enuresis? Involuntary voiding during sleep in children 5 years or older
- What is the difference between primary and secondary nocturnal enuresis? Primary: never achieved 6 months of dryness; Secondary: recurrence after at least 6 months of dryness
- At what age is nocturnal enuresis considered a clinical concern? Age 5 years and older
- What percentage of 7-year-olds experience nocturnal enuresis? Approximately 10%
- What is the annual spontaneous resolution rate of nocturnal enuresis? 15%
- Which gender is more commonly affected by nocturnal enuresis? Boys
- What are the three main pathophysiological factors in nocturnal enuresis? Nocturnal polyuria, bladder overactivity, and high arousal threshold
- How does family history impact the risk of nocturnal enuresis? Increased risk if parents or siblings had enuresis
- What is the role of antidiuretic hormone (ADH) in nocturnal enuresis? Lack of normal nocturnal rise in ADH may lead to nocturnal polyuria
- What percentage of children with nocturnal enuresis have daytime symptoms? Approximately 15-20%
- How does constipation contribute to nocturnal enuresis? Full rectum can compress the bladder and affect its function
- What is the first-line treatment for nocturnal enuresis? Behavioral modifications and motivational therapy
- What is the role of fluid restriction in managing nocturnal enuresis? Limiting fluids 2-3 hours before bedtime can be helpful
- How effective are bedwetting alarms in treating nocturnal enuresis? 60-80% success rate with proper use
- What is the mechanism of action of bedwetting alarms? Condition the child to wake up or contract the pelvic floor muscles in response to bladder fullness
- Which medication is most commonly used for pharmacological treatment of nocturnal enuresis? Desmopressin (DDAVP)
- What is the mechanism of action of desmopressin? Synthetic analog of ADH, reduces urine production at night
- What is the success rate of desmopressin in treating nocturnal enuresis? 60-70% response rate
- What is the main side effect concern with desmopressin? Water intoxication if excess fluids are consumed
- When are anticholinergic medications considered in nocturnal enuresis treatment? When bladder overactivity is a significant factor
- What is the role of psychological evaluation in nocturnal enuresis? To assess for underlying stress, anxiety, or other psychological factors
- How does obstructive sleep apnea contribute to nocturnal enuresis? Can lead to increased nighttime urine production and deeper sleep
- What is the appropriate initial evaluation for a child with nocturnal enuresis? Detailed history, physical examination, and urinalysis
- When is further urological evaluation indicated in nocturnal enuresis? Presence of daytime symptoms, recurrent UTIs, or abnormal physical exam findings
- How does nocturnal enuresis impact a child's quality of life? Can affect self-esteem, social interactions, and participation in activities like sleepovers
- What is the role of bladder training exercises in managing nocturnal enuresis? Can help increase bladder capacity and improve control
- How long should bedwetting alarm therapy be continued? Typically 2-3 months or until 14 consecutive dry nights
- What is the recommended approach for children with both nocturnal enuresis and constipation? Treat constipation first, as this may resolve enuresis in some cases
- How does caffeine intake affect nocturnal enuresis? Can increase urine production and bladder irritability
- What is the long-term prognosis for children with nocturnal enuresis? Most resolve spontaneously, but 0.5-1% may persist into adulthood
Further Reading
- Nocturnal enuresis: An approach to assessment and treatment - Canadian Family Physician
- Diagnosis and Management of Nocturnal Enuresis - American Family Physician
- Bedwetting in under 19s: diagnosis and management - National Institute for Health and Care Excellence (NICE)
- Practical consensus guidelines for the management of enuresis - Journal of Pediatric Urology
