Enuresis (includes Bedwetting)
This term refers to the involuntary passage of urine in a child developmentally old enough to have achieved bladder control.
98% of children are dry by age 4 years, during the day, 70% are dry at night by that age. The prevalence of Enuresis is 7% at age 5 years for Males and 2% for Females. At 18 yrs of age, the prevalence is 1% for Males and rare for Females.
Enuresis can be divided into Nocturnal Enuresis (bedwetting at night), Diurnal Enuresis (voiding urine while awake) and Nocturnal/Diurnal Enuresis which involves passage of urine while awake and asleep. Each of these types may be further subdivided into Primary Enuresis (bladder control was never achieved) and Secondary Enuresis (occurring after a period of dryness of 6 – 12 months).
Nocturnal Enuresis occurs in 10% of 5 year olds. It tends to improve with time at a rate of 15% per year over the age of 6 years. There is a positive family history in 50% of patients.
There are thought to be many contributing factors to Nocturnal Enuresis, including:-
- Sleep Disorder (these children are typically described as deep sleepers.) Enuresis can occur at any stage of sleep.
- Delayed Maturation of the cortical (brain) pathways that affect voluntary control of micturition.
- Disturbed production of antiduretic hormone ( a hormone which reduces urines output) with a resultant increased urine output at nights.
- Genetic factors.
- Psychological factors.
- Organic factors; e.g. Diabetes mellitus/insipidus, urinary tract infections, urine concentration defect, dysfunctional voiding (2o constipation), nocturnal epilepsy.
Diurnal Enuresis is more common in girls and is rare beyond 9 years of age.
- Micturition deferral (waiting until the last minute to void)
- Urge, stress, giggle incontinence (involuntary passage of urine).
- Post void dribbling.
- Paediatric unstable bladder (unhibited bladder spasms).
- Neurogenic bladder (large bladder with reduced sense of bladder filling or a spastic bladder, secondary to neurological problem.
- Urinary tract abnormalities
The Management of Enuresis involves obtaining a complete history and performing a thorough physical examination to rule out any organic pathology which may require specific treatment, or referral to a Nephrologist.
Baseline investigations should rule out a urinary tract infection, urine concentrating defect, electrolyte abnormalities, diabetes mellitus, chronic renal disease, sickle cell anaemia. Further investigations should be guided by the historical and physical findings and the results of investigations.
Treatment modalities include Behavioural and Pharmacological Arms.
Behavioural Modification includes:
- Witholding of fluids 2 hours before bedtime.
- Encouraging micturition before bedtime.
- Awakening once at night to pass urine.
- Charting of dry nights with reward for dry nights
- Discontinuation of punitive measures for accidents.
- Encouraging older children to assist with laundering soiled linen.
- Enuresis alarms – which awaken the patient as soon as he/she starts voiding (good success rate – 30% relapse).
- Bladder strengthening exercises.
Pharmacological Drug Therapy is a last resort. It is not recommended for patients under 5 years and should be used in combination with other measures; and only after those have failed. There is a high relapse rate after discontinuation of medications.
The successful management of Enuresis requires patience, compassion and a willingness to provide positive reinforcement for the child.
Scolding and Punishment have no role in the management of this disorder.