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UNJ December 98 C O N o c t u rnal Enure s i s N T I Mary Johnson N U I N G n u r esis is described as N o c t u rna l enuresis (NE), the involuntary passing of urine during involuntary urination sleep after the age at which bladder control would normally be antic- ( Taber’s Cyclopedic ipated, is a widespread and potentially disabling disorder for chil- E Medical Dictionary, d ren. The treatment of NE constitutes several approaches and its D E1977). Nocturnal enuresis (NE), pathophysiology remains unsolved. Careful consideration should be U given to the work-up of NE since there may be concurrent symptoms also re f e r r ed to as “bedwetting” C or “sleepwetting,” is described that re q u i r e attention either before or in conjunction with the tre a t- as the involuntary passing of ment. Patient/family education and a cooperative approach usually A urine during sleep after the age p roduce the most favorable results in treating NE. T at which bladder control would I n o rmally be anticipated. This O b j e c t i v e s O p r oblem occupies considerable N time in the general pediatric or This independent study offe ring is designed for nu r ses and other family practice and is often health care pro fessionals who care for and educate patients re g a rd i n g accompanied by major psy- n o c t u r nal enu re s i s . The multiple choice examination that fo l l ows is chosocial issues. Nocturn a l designed to test your ach i evement of the fo l l owing educational objec- e n u resis is just one of the vari- t i ve s . After studying this offe ri n g , you will be able to: ous forms of enuresis (see 1 . D e fine pri m a r y nocturnal enu resis in comparison to other Tables 1 & 2). These diff e re n t fo r ms of enu re s i s . f o rms of enuresis and re l a t e d 2 . D e s c ribe the appro p riate wo rk-up re q u i red in accordance to topics will be discussed and the presenting symptoms. re f e r red to later in this article. 3 . Discuss diffe rent treatment modalities used in managing noc- The principal focus of this arti- t u rnal enu re s i s . cle, however, will be on prima- ry nocturnal enuresis (PNE). E n u resis is by far the most Most general practitioners plethora of information found common voiding abnormality in receive little or no training in health care journals, updates c h i l d ren . Incontinence, in gen- about the issue, patients and on the World Wide Web, adver- eral, is described as being a families often do not want to tisements through various “ C i n d e r ella” subject (Millard & talk about it, history taking can media sources, and inform a t i o n M o o re, 1996). Even though be time consuming, examina- distributed through physicians’ nobody dies from incontinence, tion may be embarrassing, and o ffices, schools, and other re l a t- it is hardly a glamorous condi- the temptation to refer to a spe- ed programs, the causes of noc- tion (Millard & Moore, 1996). cialist may be overwhelming. t u r nal enuresis are still not H o w e v e r, when a child can gain e n t i rely understood and man- success with the help of the var- agement continues to be subject ious methods of treatment, it of contro v e r s y . p r omises to be a dream come M a ry Johnson, B S N , R N , is a Pe d i a t ric Urology Nurse Specialist, true for him/her and the family, H i s t o r y Pe d i a t ric Surgical Associates, Ltd., and the practitioner gains satis- N o c t u r nal enuresis has M i n n e a p o l i s, MN. faction as well. Despite a plagued humans for centuries. It UROLOGIC NURSING / December 1998 / Volume 18 Number 4 259 C F i g u re 1. urinary control is a matura- O Age and Sex Distribution of Enure s i s tional process, one should N understand that nocturn a l enuresis is a bothersome alter- T ation in normal development. I It is important to comprehend N the usual development of con- U tinence in a child. During the I first stages of development of bladder control, the infant N voids through a reflex mecha- G nism. Between the ages of 1 and 2 years, there is a gradual E e n l a rgement of the bladder D capacity and neural maturation of the frontal and parietal lobes U occurs (McLorie & Husmann, C 1987). This is the time that con- A scious sensation of bladder full- T ness develops. During the 2nd I Adapted with permission from Gleich, P., & Reinberg, Y. (1991). Nocturn a l and 3rd years of life, the child e n u resis: To treat or not to treat. Ramsey Medical Bulletin, 5(1), 2-6. is able to void or inhibit void- O ing voluntarily. By the ages of 4 N and 5 years, maturation of the bladder should be complete, has been recognized as a pro b- child’s sacrum (Glicklich, 1951). allowing the child to have an lem since the time of Papyrus In 1927, Friedell described using adult pattern of urinary control. Ebers, dated 1550 B.C. This was psychic treatment by re s t r i c t i n g The characteristic sequence for one of only a few medical texts fluids and injecting sterile water developing bladder and bowel of the time and the mere men- along with positive re a s s u r a n c e control is as follows: (a) noc- tion of NE gave some merit to that this treatment will work. turnal bowel control, (b) day- its problematic nature. In a clas- His findings demonstrated an time bowel control, (c) daytime sic and frequently quoted article 87% success rate and those chil- control of voiding, and (d) noc- by Glicklich (1951), she outlines d r en who did not respond were t u r nal control of voiding the treatment of enuresis over found to have low urine specif- (Rushton, 1995). time and describes the cruel ic gravity at night (Friedell, and barbaric methods used and 1927). This monitoring of urine E p i d e m i o l o g y the ultimate futility of the tre a t- concentration holds significant At age 5, appro x i m a t e l y ments. Some of these early merit in regards to common 20% of children have a bed- t rea tment modalities include t reatment modalities used wetting episode at least using various potions from ani- today. Punishment and public monthly. The incidence mals, organs, or plants. For humiliation were also historical- d e c r eases to appro x i m a t e l y example, some re m e d i e s ly very common. Unfortunately, 10% by age 6 years with 15% included placing a comb from a p a rents still punish their chil- of these children subsequently hen in tepid water and giving it d r en for wetting the bed. Haque attaining nighttime contro l to the child to drink or putting et al. (1981), found that 61% of each year so that by age 15, testicles from a hare into a glass American parents perc e i v e d only 1% to 2% of adolescents of wine and having the child bed-wetting as a significant remain enuretic. The male to drink it. Others tried drying the p roblem and that one-third female ratio for NE is three to comb of a cock and scattering it dealt with it by punishment. two (see Figure 1). Overall, over the enuretic’s bed. In the 60% of bed-wetters and more mid-1800s, another tre a t m e n t B a c k g ro u n d than 90% of nightly bed-wet- was to induce blisters on the Because development of ters are male (Schmitt, 1997). 260 UROLOGIC NURSING / December 1998 / Volume 18 Number 4 E t i o l o g y that children with NE exhibit functional bladder capacity C While there are numero u s f requent uninhibited bladder despite normal bladder func- O theories outlining the specific contractions and a lower func- tion, or may be unre s p o n s i v e N cause(s) of NE, many etiologic tional bladder capacity than during sleep, or both (Jarvelin et factors are generally re c o g n i z e d their nonenuretic counterparts al., 1988; Kass, Diokno, & T and accepted. Conversely, (Johnstone, 1972; Persson- Montealegus, 1979). I many of these continue to be Junemann, Seemann, Kohr- N cause for debate among practi- mann, Junemann, & Alken, Sleep Disord e r s U tioners. For many children with 1993; Pompeius, 1971; Robert et Many parents will describe I NE, there may not be an exclu- al., 1993; Troup & Hodgson, their child with PNE as being a sive explanation and the find- 1971).
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