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Nocturnal Enuresis C PRACTICAL THERAPEUTICS Nocturnal Enuresis C. CAROLYN THIEDKE, M.D., Medical University of South Carolina, Charleston, South Carolina Nocturnal enuresis is a common problem that can be troubling for children and their families. Recent studies indicate that nocturnal enuresis is best regarded as a O A patient informa- group of conditions with different etiologies. A genetic component is likely in many tion handout on bed- wetting, written by affected children. Research also indicates the possibility of two subtypes of patients the author of this with nocturnal enuresis: those with a functional bladder disorder and those with a article, is provided on maturational delay in nocturnal arginine vasopressin secretion. The evaluation of page 1509. nocturnal enuresis requires a thorough history, a complete physical examination, and urinalysis. Treatment options include nonpharmacologic and pharmacologic measures. Continence training should be incorporated into the treatment regimen. Use of a bed-wetting alarm has the highest cure rate and the lowest relapse rate; however, some families may have difficulty with this treatment approach. Desmo- pressin and imipramine are the primary medications used to treat nocturnal enure- sis, but both are associated with relatively high relapse rates. (Am Fam Physician 2003; 67:1499-506,1509-10. Copyright© 2003 American Academy of Family Physicians.) Members of various octurnal enuresis is a com- wetting episodes per month, and a child older family practice depart- mon problem, affecting an than six years of age should have one or more ments develop articles estimated 5 to 7 million chil- wetting episode per month. for “Practical Therapeu- tics.” This article is one dren in the United States and in a series coordinated occurring three times more Epidemiology by the Department of Noften in boys than in girls.1 Unfortunately, At five years of age, 15 to 25 percent of chil- Family Medicine at only about one third of the families of chil- dren wet the bed.3 With each year of maturity, the Medical University dren with this frequently troubling problem the percentage of bed-wetters declines by of South Carolina. 1 Guest editor of the seek help from a physician. Recent studies 15 percent. Hence, 8 percent of 12-year-old series is William J. have provided more information about noc- Hueston, M.D. turnal enuresis, and generally effective treat- ments are available. TABLE 1 Classification Schemes for Enuresis Definitions The International Children’s Continence According to time of day Society has recommended the following stan- Nocturnal enuresis: passing of urine while asleep dardization of terminology: nocturnal enuresis Diurnal enuresis or incontinence: leakage of urine during the day is the involuntary loss of urine that occurs only According to presence of other symptoms at night.2 It is normal voiding that happens at Monosymptomatic or uncomplicated nocturnal an inappropriate and socially unacceptable enuresis: normal voiding occurring at night in time and place.2 Over the years, various terms bed in the absence of other symptoms referable have been used to describe wetting problems to the urogenital or gastrointestinal tract (Table 1). This practice has created confusion Polysymptomatic or complicated nocturnal enuresis: and impeded standardization of diagnosis. bed-wetting associated with daytime symptoms such as urgency, frequency, chronic constipation, Children are not considered enuretic until or encopresis they have reached five years of age. Mentally According to previous periods of dryness disabled children should have reached a men- Primary enuresis: bed-wetting in a child who has tal age of four years before they are considered never been dry See page 1413 for enuretic. For the diagnosis of nocturnal Secondary enuresis: bed-wetting in a child who has definitions of strength- enuresis to be established, a child five to six had at least six months of nighttime dryness of-evidence levels. years old should have two or more bed- APRIL 1, 2003 / VOLUME 67, NUMBER 7 www.aafp.org/afp AMERICAN FAMILY PHYSICIAN 1499 Familial factors that have been found to At five years of age, 15 to 25 percent of children wet the have no relationship to the achievement of bed. By the age of 12 years, 8 percent of boys and 4 percent continence include social background, stress- ful life events, and the number of changes in of girls are still bed-wetters. family constellation or residences.7 PSYCHOLOGIC FACTORS boys and 4 percent of 12-year-old girls are Nocturnal enuresis was once thought to be enuretic; only 1 to 3 percent of adolescents are a psychologic condition. It now appears that still wetting their bed. From 15 to 25 percent psychologic problems are the result of enure- of bed-wetters have secondary enuresis, but sis and not the cause. Children with nocturnal the treatment approach and anticipated enuresis have not been found to have an response are the same. increased incidence of emotional problems.3 For most children, bed-wetting is not an act of Etiology rebellion. A single explanation for nocturnal enuresis has been elusive. The current belief is that the BLADDER PROBLEMS condition is multifactorial. Numerous etio- Studies attempting to establish bladder logic factors have been investigated, and vari- problems as the cause of nocturnal enuresis ous theories have been proposed. have been contradictory. Extensive urody- namic testing has shown that bladder func- GENETIC AND FAMILIAL FACTORS tion falls within the normal range in children Genetic predisposition is the most frequently with nocturnal enuresis.6 However, one inves- supported etiologic variable. One review4 tigation8 found that while real bladder capac- found that when both parents were enuretic as ity is identical in children with and without children, their offspring had a 77 percent risk of nocturnal enuresis, functional bladder capac- having nocturnal enuresis. The risk declined to ity (the volume at which the bladder empties 43 percent when one parent was enuretic as a itself) may be less in those with enuresis. child, and to 15 percent when neither parent No correlation has been found between was enuretic. Another investigation5 found a urethral or meatal stenosis and bed-wetting. positive family history in 65 to 85 percent of Furthermore, congenital, structural, or ana- children with nocturnal enuresis. If the father tomic abnormalities rarely present solely as was enuretic as a child, the relative risk for the enuresis. child was 7.1; if the mother was enuretic, the relative risk was 5.2. In addition, certain chro- ARGININE VASOPRESSIN mosomal loci (5, 13, 12, and 22) have been It has been postulated that normal develop- implicated in nocturnal enuresis.6,7 ment may include the establishment of a cir- cadian rhythm in the secretion of arginine vasopressin, the antidiuretic hormone.9 A nocturnal rise in this hormone would The Author decrease the amount of urine produced at C. CAROLYN THIEDKE, M.D., is assistant professor in the Department of Family Med- night. It may be that children with nocturnal icine at the Medical University of South Carolina, Charleston, where she attended enuresis are delayed in achieving this circa- medical school and completed a family practice residency. Before entering academic medicine, Dr. Thiedke was in private practice for 10 years. dian rise in arginine vasopressin and, thus, may develop nocturnal polyuria. This noctur- Address correspondence to C. Carolyn Thiedke, M.D., Medical University of South Car- olina, Department of Family Medicine, 295 Calhoun St., P.O. Box 250192, Charleston, nal polyuria overwhelms the bladder’s ability SC 29425 (e-mail: [email protected]). Reprints are not available from the author. to retain urine until morning. 1500 AMERICAN FAMILY PHYSICIAN www.aafp.org/afp VOLUME 67, NUMBER 7 / APRIL 1, 2003 Nocturnal Enuresis SLEEP DISORDERS The bed-wetting alarm has been shown to be the most Neither nocturnal polyuria nor diminished effective treatment for nocturnal enuresis. functional bladder capacity adequately explains why children with nocturnal enuresis do not wake up to void. Controversy has existed for many years about whether enuresis physician needs to check carefully for signs reflects a sleep disorder.10 that might signal other problems that can pre- In most studies, sleep electroencephalo- sent with bed-wetting. Gait should be evalu- grams have demonstrated no differences or ated for evidence of a subtle neurologic only nonspecific changes in children with and deficit. The flanks and abdomen should be without nocturnal enuresis. When surveyed, palpated for masses, including an enlarged however, parents consistently maintain that bladder. The lower back should be inspected their children with nocturnal enuresis are for cutaneous lesions or an asymmetric “deep sleepers,”compared with their offspring gluteal cleft, which could suggest spinal dys- who are not bed-wetters. Other surveys have raphism, a variant of spina bifida. found that children with nocturnal enuresis Urinalysis is performed to assess specific are more subject to “confused awakenings,” gravity and urinary glucose level. It also can such as night terrors or sleepwalking, than determine the presence of infection or blood children who do not wet the bed.11 in the urine. If the findings of the physical examination Diagnosis and urinalysis are negative and the history A careful history should be obtained and a does not suggest a secondary cause of noctur- thorough physical examination should be per- nal enuresis, no further work-up is needed. If formed to look for causes of complicated urinalysis reveals evidence of infection, the enuresis in children who present with bed- child should be evaluated for vesicoureteral wetting. Causes of complicated enuresis reflux. The currently recommended work-up include spinal cord abnormalities with associ- is a voiding cystourethrogram and renal ultra- ated neurogenic bladder, urinary tract infec- sound examination.3 tion, posterior urethral valves in boys, and ectopic ureter in girls. In addition, children Treatment who have chronic constipation or encopresis NONPHARMACOLOGIC TREATMENTS may present with bed-wetting.
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