Nocturnal Enuresis

2022.1 Case 5

Nocturnal enuresis, commonly referred to as bedwetting, is a widespread condition in children. It’s important to approach it with sensitivity and understanding. Here’s a detailed overview:

Causes of Nocturnal Enuresis

  • Maturational Delay: Delay in the development of nocturnal bladder control.
  • Genetic Factors: A family history of enuresis.
  • Bladder Factors: Small functional bladder capacity or overactive bladder.
  • Sleep Disorders: Deep sleepers who don’t wake up to the signal of a full bladder.
  • Psychological Factors: Stress, anxiety, or major life events (though these are more often exacerbating than primary causes).
  • Hormonal Factors: Insufficient production of antidiuretic hormone (ADH) during sleep.
  • Constipation: Can affect bladder function.
  • Medical Conditions: Diabetes, urinary tract infections (UTIs), neurological disorders, sleep apnea.

Diagnosis (Dx)

  • History (Hx):
    • Age of onset, frequency, and pattern of bedwetting.
    • Family history of enuresis.
    • Bowel habits (to rule out constipation).
    • Fluid intake patterns, especially before bedtime.
    • Any associated symptoms like snoring (sleep apnea) or urinary symptoms (UTIs).
    • Impact on the child and family (psychosocial assessment).
  • Physical Examination (Ex):
    • General physical examination to assess overall health.
    • Abdominal examination to check for bladder distension or constipation.
    • Genitourinary examination to identify any anatomical anomalies.
    • Neurological examination, if indicated.
  • Investigations (Ix):
    • Urinalysis to rule out UTI or diabetes.
    • Renal and bladder ultrasound if structural abnormalities are suspected.
    • Uroflowmetry and bladder scans in complex or refractory cases.

Differential Diagnosis (DDx)

  • Urinary tract infections.
  • Diabetes (mellitus and insipidus).
  • Anatomical anomalies of the urinary tract.
  • Neurological disorders.

Management (Mx)

  • Reassurance and Education:
    • Educate about the condition’s prevalence and typically benign nature.
    • Reassure that most children outgrow bedwetting.
  • Behavioral Interventions:
    • Regular daytime toilet habits.
    • Adequate fluid intake during the day and reduced intake before bedtime.
    • Bladder training exercises (e.g., delayed voiding).
    • Use of bedwetting alarms which awaken the child at the onset of urination.
  • Pharmacological Treatment:
    • Desmopressin: Synthetic ADH, useful particularly for overnight stays or camps.
    • Anticholinergic agents: For children with overactive bladders.
    • Note: Medications are usually considered when behavioral interventions are ineffective.
  • Management of Constipation:
    • If constipation is present, address it with dietary modifications and possibly laxatives.
  • Psychological Support:
    • Counseling if bedwetting is causing significant distress or if psychological factors are contributing.
  • Follow-up:
    • Regular monitoring of progress and adjustment of management plans.
  • Referral:
    • Referral to a pediatrician may be necessary in refractory cases or when a significant underlying pathology is suspected.

Parental Guidance

  • Encourage positive reinforcement and avoid punishment.
  • Utilize waterproof mattress covers to ease the burden of bedwetting.
  • Plan for easy nighttime clean-ups.

In managing nocturnal enuresis, a compassionate and patient-centered approach is crucial. The condition often resolves with time, but if it persists, especially beyond the age of 7, further evaluation and intervention may be needed.