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Management of Nocturnal Enuresis

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Management of Nocturnal Enuresis CLINICAL REVIEW Management of nocturnal enuresis Follow the link from the online version of this article to obtain certi ed continuing 1 2 1 3 4 medical education credits Patrina H Y Caldwell, Aniruddh V Deshpande, Alexander Von Gontard 1Centre for Kidney Research, Nocturnal enuresis (enuresis or bedwetting) is the most com- SOURCES AND SELECTION CRITERIA Children’s Hospital at Westmead, mon type of urinary incontinence in children. Depending on Australia We searched Medline, Embase, and the Cochrane 2Discipline of Paediatrics and the definition, prevalence is 8-20% for 5 year olds, 1.5-10% Database of Systematic Reviews using the search terms Child Health, University of Sydney, for 10 year olds, and 0.5-2% for adults, with 2.6% of 7.5 year “enuresis” or “bedwetting” as keywords. Systematic Australia old children wetting on two or more nights a week.1 Preva- reviews, meta-analyses, population based studies, 3 John Hunter Children’s Hospital, lence seems to be similar worldwide. Here, we review current randomised controlled trials, and studies published in the Newcastle, Australia past five years were prioritised. 4Department of Child and knowledge about the treatment of this common condition. Adolescent Psychiatry, Saarland University Hospital, Homburg What is nocturnal enuresis? (20-40% compared with 10% of continent children),10 and (Saar), Germany Nocturnal enuresis is intermittent involuntary voiding dur- can interact with underlying genetic and environmental Correspondence to: P H Y Caldwell, Discipline of Paediatrics and Child ing sleep in the absence of physical disease in a child aged factors (such as diet, fluid consumption, toileting habits, Health, Children’s Hospital at 5 years or more. A minimum of one episode a month for at and urinary tract infections), they are not the main cause Westmead, Westmead NSW 2145, least three months is required for the diagnosis to be made.2 of nocturnal enuresis. Australia [email protected]. gov.au Who gets nocturnal enuresis? What is the underlying pathophysiology of nocturnal Cite this as: BMJ 2013;347:f6259 A large epidemiological study showed that nocturnal enure- enuresis? doi: 10.1136/bmj.f6259 sis is more common in males at all ages, and is more likely to A history of nocturnal enuresis in a parent or relative is persist in those with frequent wetting.3 Nocturnal enuresis found in 20-40% and 60-70% of affected children, respec- bmj.com 11 is usually idiopathic and is commonly associated with day- tively. Advances in neuroimaging led by functional mag- Previous articles in time urinary incontinence (seen in 3.3% of 7.5 year olds in netic resonance imaging have shown that children with this series a large epidemiological study1), faecal incontinence, and enuresis have microstructural abnormalities and delay in Ж An introduction to chronic constipation. In a tertiary continence service, 36% the maturation of the neuronal circuits in the prefrontal advance care planning in of children with nocturnal enuresis reported constipation,4 cortex. These findings support the theory of delayed matu- practice and enuresis resolves in about two thirds of such children ration as a cause for nocturnal enuresis.12 13 (BMJ 2013;347:f6064) when constipation is treated.5 About 30% of children with Nocturnal enuresis results from the interplay of three Ж Post-mastectomy sleep disordered breathing have nocturnal enuresis, prob- physiological factors: defective sleep arousal; nocturnal breast reconstruction ably because of impaired sleep quality, and enuresis resolves polyuria; and bladder factors, such as lack of inhibition of (BMJ 2013;347:f5903) in half of these children after corrective surgery.6 Similarly, bladder emptying during sleep, reduced bladder capacity, Ж Identifying brain about 30% of obese children have nocturnal enuresis,7 or bladder overactivity (box).14 8 tumours in children and which is more resistant to treatment. The child’s bladder capacity can be determined by young adults Nocturnal enuresis is more common in children with comparing the maximum voided volume (largest void (BMJ 2013;347:f5844) developmental delay, physical or intellectual disabilities, during the day) with the expected bladder capacity. Ж Gout and psychological or behavioural disorders. It occurs in An acceptable range is 65-150% of expected bladder (BMJ 2013;347:f5648) 20-40% of children with psychological or behavioural capacity. If the maximum voided volume is noticeably disorders, such as attention-deficit/hyperactivity disorder smaller than the expected bladder capacity, it may indi- Ж Testicular germ cell (ADHD) (the most common), autism spectrum disorder, anx- cate poor fluid intake, constipation, or overactive bladder tumours iety, and depressive or conduct disorders.2 In these children, syndrome (non-monosymptomatic nocturnal enuresis). (BMJ 2013;347:f5526) enuresis is more likely to be persistent, possibly because of According to a case-control study, children with a small or lower adherence to treatment. overactive bladder wet during sleep when urine volume According to a US survey,9 many parents attribute an exceeds bladder capacity or as a result of detrusor over- emotional cause to nocturnal enuresis. Although comorbid activity.19 Usually, these children will also show daytime psychological disorders are more common in these children bladder symptoms, although this is not always the case.20 A case-control study comparing children with severe SUMMARY POINTS refractory nocturnal enuresis with controls found signifi- Nocturnal enuresis can be associated with daytime urinary incontinence, bowel cantly more cortical arousal (without complete awakening) problems, developmental or psychological problems, and sleep disordered breathing during sleep in those with enuresis, which correlated with Nocturnal enuresis commonly results from defective sleep arousal, nocturnal polyuria, unprovoked bladder contractions. It is therefore thought lack of inhibition of bladder emptying during sleep, and reduced bladder capacity that these children may have chronic overstimulation of Nocturnal enuresis affects quality of life and self esteem, which improve with successful the arousal centre, which may cause a paradoxical sup- treatment pression and an inability to arouse to bladder signals.21 The condition responds well to enuresis alarm training or desmopressin. In non- monosymptomatic nocturnal enuresis, treat daytime lower urinary tract symptoms first How do you assess nocturnal enuresis? In treatment resistance, a repeat thorough assessment and combination therapy may be effective The International Children’s Continence Society (ICCS) classifies nocturnal enuresis according to when it started 28 BMJ | 2 NOVEMBER 2013 | VOLUME 347 CLINICAL REVIEW (primary or secondary) and whether lower urinary tract Physiological factors involved in nocturnal enuresis symptoms are present (non-monosymptomatic or mono- Defective sleep arousal symptomatic).2 Clinical, therapeutic, and pathogenic In most children with enuresis the arousal response differences between these subtypes influence treatment is defective during sleep. When urine volume exceeds choice. bladder capacity, bedwetting occurs.15 Although Obtaining an accurate history is crucial for assessment arousability is reduced, the sleep architecture itself is and is recommended by the ICCS report and the National usually unaltered, and enuresis occurs in all sleep stages, Institute for Health and Care Excellence (NICE) guideline, particularly during non-REM (rapid eye movement) sleep16 2 22 which are based on reviews of the literature. The aim Nocturnal polyuria of this thorough assessment is to establish the diagnosis, According to case-control studies, many children with identify or exclude underlying causes, identify factors that nocturnal enuresis have an altered diurnal rhythm of may influence the choice of management strategy, and vasopressin secretion,17 resulting in the production of understand what the family wants.22 excessive amounts of relatively dilute urine overnight. The In primary care, a detailed history of the wetting, toilet- expected bladder capacity is calculated by the formula: (age in years +1)×30 mL, which is valid from 2 to 12 years. ing patterns, fluid intake, comorbidities, and the family’s Nocturnal polyuria is defined as greater than 130% of the situation, as well as a thorough examination to assess for expected bladder capacity for age constipation and neurogenic and urological causes, are Bladder factors recommended. A bladder diary documenting daytime In children with nocturnal enuresis, the emptying reflexes of fluid intake and urine output over 48 hours and inconti- the full bladder are not adequately inhibited during sleep, nence episodes over seven days should also be obtained, resulting in involuntary voiding.18 The pontine micturition and a screening questionnaire for behavioural symptoms centre of the brain stem is involved in this process undertaken. Urine analysis to exclude diabetes, kidney disease, and urinary tract infections; renal ultrasound to How does nocturnal enuresis affect the child and family? identify underlying urological disease in those with non- Nocturnal enuresis is socially stigmatising and can affect monosymptomatic enuresis; and uroflowmetry to assess quality of life and psychosocial wellbeing. Children report bladder function can be useful but are non-essential,2 22 lower self esteem, which improves with successful treat- because of a lack of evidence to support their non-selective ment.26 In
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