Enuresis

Enuresis
A child may ignore the body's signal of a full bladder in order to engage in an enjoyable activity, such as playing on a playground.
Classification and external resources
ICD-10	F98.0, R32
ICD-9	307.6 788.30 307.6
DiseasesDB	4326
Patient UK	Enuresis
MeSH	D004775

Enuresis (from the Ancient Greek ἐνούρησις / enoúrēsis), refers to a repeated inability to control urination.^[1] Use of the term is usually limited to describing individuals old enough to be expected to exercise such control.^[2] Involuntary urination is also known as urinary incontinence.^[3]

Epidemiology

In the United States, approximately 15 to 20 percent of 5 year old children will develop symptoms related to disorder. Prevalence changes significantly with age. To be more specific, about 33 percent of 5 year-olds, 25 percent of 7 year olds, 15 percent of 9 year olds, 8 percent of 11 year olds, 4 percent of 13 year-olds, and 3 percent of 15 to 17 year-olds. Numbers show that diurnal enuresis is much less common. Overall, about 60 percent of those suffering are male. However, this too depends on age. From ages 4 to 6, the number of boys and girls is about equal. However, the ratio changes so that by 11 years of age there are twice as many boys as girls. Incidence varies with social class with more incidences among those with low socioeconomic status. No evidence has been found related to ethnic differences. Approximately 85% of children with enuresis have primary enuresis because they have never maintained consistent bedwetting behaviors for at least 6 months.

Classification

Types of enuresis include:

• Nocturnal enuresis (bedwetting)
• Diurnal enuresis
• Mixed enuresis - Includes a combination of nocturnal and diurnal type. Therefore, urine is passed during both waking and sleeping hours.

Also,

• Primary enuresis refers to children who have never been successfully trained to control urination. This represents a fixation.
• Secondary enuresis refers to children who have been successfully trained ( are for at least 6 months dry ) but revert to wetting in a response to some sort of stressful situation. This represents a regression.

Pathogenesis

Rare Causes

The proposed condition PANDAS (pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections) has been used to describe a set of children who have a rapid onset of OCD and/or tic disorders following a streptococcal infection, with a link to other symptoms such as enuresis.^[4] A broader classification of this hypothesis, PANS, has been proposed which states that some patients suffer these symptoms in response to mycoplasma or lyme disease or even viruses rather than streptococcal. PANS is an acronym for Pediatric acute-onset neuropsychiatric syndrome. This hypothesis describes children who have abrupt, dramatic onset of obsessive-compulsive disorder (OCD) or anorexia nervosa coincident with the presence of two or more neuropsychiatric symptoms. It is believed that these children experience a rise in dopamine levels as a result of a of cross-reactive anti-neuronal antibodies. The rise in dopamine can cause such side effects as enuresis, bed-wetting, and urinary urgency.^[5]

Diagnosis

Clinical definition of enuresis is urinary incontinence beyond age of 4 years for daytime and beyond 6 years for nighttime, or loss of continence after 3 months of dryness.^[6] Current DSM-IV-TR Criteria:

1. Repeated voiding of urine into bed or clothes (whether involuntary or intentional)
2. Behavior must be clinically significant as manifested by either a frequency of twice a week for at least 3 consecutive months or the presence of clinically significant distress or impairment in social, academic (occupational), or other important areas of functioning.
3. Chronological age is at least 5 years of age (or equivalent developmental level).
4. The behavior is not due exclusively to the direct physiological effect of a substance (such as a diuretic) or a general medical condition (such as diabetes, spina bifida, a seizure disorder, etc.).

All these criteria must be met in order to diagnose an individual.

Nocturnal enuresis

Causes

After age 5, wetting at night—often called bedwetting or sleepwetting—is more common than daytime wetting in boys. Experts do not know what causes nighttime incontinence. Young people who experience nighttime wetting tend to be physically and emotionally normal. Most cases probably result from a mix of factors including slower physical development, an overproduction of urine at night, a lack of ability to recognize bladder filling when asleep, and, in some cases, anxiety. For many, there is a strong family history of bedwetting, suggesting an inherited factor.

Slower physical development

Between the ages of 5 and 10, incontinence may be the result of a small bladder capacity, long sleeping periods, and underdevelopment of the body's alarms in the brain that signal a full or emptying bladder. This form of incontinence will fade away as the bladder grows and the natural alarms become operational.

Excessive output of urine during sleep

Normally, the body produces a hormone that can slow the making of urine. This hormone is called antidiuretic hormone, or ADH. The body normally produces more ADH during sleep so that the need to urinate is lower. If the body does not produce enough ADH at night, the making of urine may not be slowed down, leading to bladder overfilling. If a child does not sense the bladder filling and awaken to urinate, then wetting will occur.

Anxiety

Experts suggest that anxiety-causing events occurring in the lives of children ages 2 to 4 might lead to incontinence before the child achieves total bladder control. Anxiety experienced after age 4 might lead to wetting after the child has been dry for a period of 6 months or more. Such events include angry parents, unfamiliar social situations, and overwhelming family events such as the birth of a brother or sister.

Incontinence itself is an anxiety-causing event. Strong bladder contractions leading to leakage in the daytime can cause embarrassment and anxiety that lead to wetting at night.

Genetics

Certain inherited genes appear to contribute to incontinence. In 1995, Danish researchers announced they had found a site on human chromosome 13 that is responsible, at least in part, for nighttime wetting. If both parents were enuretic, 77% of their children are too; if only one parent was enuretic, then 44% of their offspring are also. Experts believe that other, undetermined genes also may be involved in incontinence.

Obstructive sleep apnea

Nighttime incontinence may be one sign of another condition called obstructive sleep apnea, in which the child's breathing is interrupted during sleep, often because of inflamed or enlarged tonsils or adenoids. Other symptoms of this condition include snoring, mouth breathing, frequent ear and sinus infections, sore throat, choking, and daytime drowsiness. In some cases, successful treatment of this breathing disorder may also resolve the associated nighttime incontinence.

Structural problems

Finally, a small number of cases of incontinence are caused by physical problems in the urinary system in children. A condition known as urinary reflux or vesicoureteral reflux, in which urine backs up into one or both ureters, can cause urinary tract infections and incontinence. Rarely, a blocked bladder or urethra may cause the bladder to overfill and leak. Nerve damage associated with the birth defect spina bifida can cause incontinence. An ectopic ureter, a misplacement of the ureter outside the bladder, can also commonly cause incontinence. In these cases, the incontinence can appear as a constant dribbling of urine.

Diurnal enuresis

Causes

Daytime incontinence that is not associated with urinary infection or anatomic abnormalities is less common than nighttime incontinence and tends to disappear much earlier than the nighttime versions. One possible cause of daytime incontinence is an overactive bladder. Many children with daytime incontinence have abnormal voiding habits, the most common being infrequent voiding. This form of incontinence occurs more often in girls than in boys.

An overactive bladder

Muscles surrounding the urethra (the tube that takes urine away from the bladder) have the job of keeping the passage closed, preventing urine from passing out of the body. If the bladder contracts strongly and without warning, the muscles surrounding the urethra may not be able to keep urine from passing. This often happens as a consequence of urinary tract infection and is more common in girls.

Infrequent voiding

Infrequent voiding refers to a child's voluntarily holding of urine for prolonged intervals. For example, a child may not want to use toilets at school or may not want to interrupt enjoyable activities, so he or she ignores the body's signal of a full bladder. In these cases, the bladder can overfill and leak urine. Additionally, these children often develop urinary tract infections (UTIs), leading to an irritable or overactive bladder.

Other causes

Some of the same factors that contribute to nighttime incontinence may act together with infrequent voiding to produce daytime incontinence. These factors include a small bladder capacity, constipation and food containing caffeine, chocolate or artificial coloring.

Sometimes overly strenuous toilet training may make the child unable to relax the sphincter and the pelvic floor to completely empty the bladder. Retaining urine (incomplete emptying) sets the stage for urinary tract infections.

Treatment

Growth and development

Many children overcome incontinence naturally (without treatment) as they grow older. The number of cases of incontinence goes down by 15 percent for each year after the age of 5.

Moisture alarms

At night, moisture alarms, also known as bedwetting alarms, can awaken a person when he or she begins to urinate. These devices include a water-sensitive sensor that is clipped on the pajamas, a wire connecting to a battery-driven control, and an alarm that sounds when moisture is first detected. For the alarm to be effective, the child must awaken or be awakened as soon as the alarm goes off. This may require having another person sleep in the same room to awaken the bedwetter. Bed-wetting alarms have been around since 1938, when O. H. Mowrer and W. M. Mowrer first invented the "bell and pad". This behavioral training is one of the safest and more effective treatments. By twelve weeks, the child will most likely have mastered his nighttime bladder control.

Medications

Nighttime incontinence may be treated by increasing ADH levels. The hormone can be boosted by a synthetic version known as desmopressin, or DDAVP, which recently became available in pill form. Patients can also spray a mist containing desmopressin into their nostrils. Desmopressin is approved for use by children. There is difficulty in keeping the bed dry after medication is stopped, with as high as an 80% relapse rate.

Another medication, called imipramine, is also used to treat sleepwetting. It acts on both the brain and the urinary bladder. Unfortunately, total dryness with either of the medications available is achieved in only about 20 percent of patients.

If a young person experiences incontinence resulting from an overactive bladder, a doctor might prescribe a medicine that helps to calm the bladder muscle, such as oxybutynin. This medicine controls muscle spasms and belongs to a class of medications called anticholinergics.

Dry-bed training

During a visit to a doctor's office, parents can be instructed in bladder retention control training by having their child drink more and more fluids during the day and delay urination for longer periods of time, attempting to strengthen bladder control. They are also encouraged to enforced hourly wakings for trips to the bathroom during the night and to develop a cleanup routine for the child (possibly including cleaning more than just the sheets), in addition to positively reinforcing dry nights (nights without urination incidents).

Bladder training and related strategies

Techniques that may help daytime incontinence include:

• Urinating on a schedule, such as every 2 hours (this is called timed voiding)
• Avoiding caffeine or other foods or drinks that may contribute to a child's incontinence
• Following suggestions for healthy urination, such as relaxing muscles and taking your time

History

Found evidence of mention in Egyptian medical texts as early as 1550 B.C.

References