Enuresis

Stephen Confer, MD Ben O. Donovan, MD Brad Kropp, MD Dominic Frimberger, MD

University of Oklahoma Department of Urology Section of Pediatric Urology

Enuresis
Involuntary discharge of urine Nocturnal enuresis - nighttime wetting Diurnal enuresis - daytime wetting 15% normal children have nocturnal enuresis at 5 years of age 99% are dry by age 15 Nocturnal enuresis is 50% more common in boys More girls dry day and night by age 2

Enuresis
80% enuretics are wet only at night
most are primary enuretics - never been dry

25% are secondary enuretics

initially dry at night by age 12 relapse for 2.5 years may be associated with emotional stress

Only 10% who develop daytime dryness relapse

wet for 1.2 years

Rule of 15s

Development of Urinary Control

Infant
spontaneous micturation as a spinal cord reflex distention simulates a detrusor contraction voluntary sphincter is integrated into the reflex
constricts to prevent incontinence relaxation during micturation low pressure voinding

As bladder capacity increases and fluid intake decreases, number of voidings decrease

Development of Urinary Control

Development of adult type control
Capacity of the bladder must increase Voluntary control over the striated sphincter
usually complete by 3 years

Direct volitional control over the spinal micturition reflex to initiate or inhibit bladder contraction

Complete by age 4

Development of Urinary Control

Order of Control
Control of bowel at night

Control of bowel during the day

Control of bladder during the day Control of bladder at night

Etiology
Nocturnal enuretics
normal psychologically and physiologically fail to awaken when bladder is full or contracts unknown etiology

Etiology
Urodynamic Factors
Reduced bladder capacity by 50%
anticholinergics increase capacity by 25 - 60%

Bladder instability seen in many with day and night enuresis

in children with daytime symptoms of frequency/urgency anticholinergics are helpful

Those with nocturnal enuresis do not have a higher incidence of daytime instability
nighttime contraction is just as likely to wake the child as to cause wetting anticholinergics not effective

Etiology
Sleep Factors
Theory that sleep disturbance causing the child to sleep too deeply or fail to awaken Enuretics do not sleep more soundly than controls Enuresis occurs in deep sleep and in REM sleep Enuresis may be a developmental delay
perception and inhibition of bladder filling and contraction by the CNS

Etiology
Sleep Factors - Types of Enuresis
Type I
Stable bladder with EEG response during enuresis

Type IIa
Stable bladder with no EEG response during enuresis 80% change to I

Type IIb
Unstable bladder with no EEG response during enuresis 20% change to IIa 60% change to I

Etiology
Alteration in Vasopressin Secretion and Nocturnal Polyuria
High ADH as night leads to less urine production Enuretics have stable ADH during the day and night
larger amounts of dilute urine at night may be delayed development of the ADH circadian rhythm

ADH levels increase normally with bladder fullness

Bladder emptying may cause decreased nighttime ADH levels in enuretics

Etiology
Developmental Delay
Altered urodynamic function, sleep and ADH secretion occur normally in infants and young children Nocturnal enuresis may be an arrest in development Each physiologic alteration tends to resolve spontaneously Neurologic disease is rare with monosymptomatic nocturnal enuresis

Etiology
Developmental Delay
Stress has been shown to delay development of urinary control
enuresis is 3 times higher when associated with stressful circumstances

Associated with encopresis 10 - 25%

delay in development is not isolated to urinary control

Etiology
Genetic Factors
33% fathers 20% mothers One parent enuretic - 44% When mother and father were enuretics, 77% children affected 15% enuresis in children of nonenuretics

Etiology
Organic Urinary Tract Disease
Enuretics are predisposed to UTIs especially girls many have diurnal symptoms due to bladder instability Most with monosymptomatic nocturnal enuresis do not have an organic cause <10% meatal stenosis is not a cause - meatotomy does not cure Increased incidence of organic abnormalities with diurnal symptoms These may need U/S to exclude obstruction - esp. boys controversial

Evaluation
Families with a history of enuresis await spontaneous cure - more tolerant Families without such a history can place great pressure on the physician to perform tests and produce a cure Urologic tests are rarely indicated for monosymptomatic bedwetters
Rarely find an organic lesion

Evaluation
Negative Screening Evaluation for Enuresis
Prepubertal age Lifelong enuresis Nocturnal enuresis only No daytime wetting, urgency, polyuria No UTI Negative UA and Culture Normal PE - including neurologic exam

Evaluation
Screening creates 3 groups
Children with nocturnal enuresis
no further evaluation

Children with UTI or neuropathy

full urologic workup

Children without UTI or neuropathy with day and night enuresis or dysfunctional voiding
U/S to exclude anatomic abnormality Assesses hydro, bladder wall thickening, emptying

Evaluation
Screening creates 3 groups
Normal U/S
pharmacologic therapy is symptoms are not severe If dysfunction persists or is severe - Urodynamics to exclude neuropathy and guide further treatment

Treatment
Treatment is discouraged before age 7
less successful age when bedwetting interferes with social activities

Treatment - Drug Therapy

Anticholinergics
Only 5 - 40% effective (equal to placebo) in nocturnal enuretics useful to eliminate bladder instability
urgency, frequency, day and night incontinence (87%) more effective in urodynamically proven instability (90%)

Treatment - Drug Therapy

Reduction of Urinary Output
limiting fluids in the day is not effective DDAVP - intranasal or oral
significantly reduces number of wet nights only 25% dry for 14 or more consecutive days temporary treatment - only 33% cured may lead to hyponatremic seizures - limit fluids before administering dose not first-line treatment

Treatment - Drug Therapy

Imipramine
Cure > 50% Improvement - 80% Discontinuation - 60% relapse Peripheral action
weak anticholinergic weak smooth muscle antispasmotic

Central action
antidepressant activity not involved decreases REM early sleep - less enuresis early in the night and more common in the last third of sleep
does not lead to more awakenings at night effect on sleep is independent of its effect on enuresis

Treatment - Drug Therapy

Imipramine
Recommended dosage
25 mg age 5-8 50 mg for older children results in optimal plasma levels in only 30% increased dosage not justified
toxicity 25% are nonresponders despite higher doses

2 week trial
adjust dosage and timing of administration

Long-term effects not known in children

weaning the drug reduces relapses

Treatment - Behavior Modification

When used in a motivated family, result in most effective rate of sustained cure 1st line therapy in these patients

Treatment - Behavior Modification

Bladder Training
goal is to increase the time interval between voiding enlarges functional capacity of bladder Child is encouraged to retain urine after 1st urge When combined with conditioning therapy, very successful

Treatment - Behavior Modification

Responsibility Reinforcement
motivation
child assumes responsibility for wet and credit for dry

reward
with progressively longer dry intervals

response shaping
as a consequence of rewards for behavioral changes

reinforcment Part of a multicomponent behavioral program

Treatment - Behavior Modification

Conditioning Therapy
Use of a urinary alarm is the most effective for nocturnal enuresis - 80% cure
child wakes up and voids in toilet followed by sensation of a full bladder and production of the same inhibition as the alarm failure is often due to lack of parental understanding and cooperation may take months

Treatment - Behavior Modification

Conditioning Therapy
Once enuresis is cured (2 weeks dry) relapse is reduced by overlearning techniques
forcing fluids prior to bed - bladder overdistention provides a stronger conditioning stimulus reinforced by alarm sounding intermittently some nights but not others

May be combined with pharmacotherapy

Adult Enuresis
Occurs in 2 cases
Persistent primary enuresis - 1% of the population
More have urodynamic abnormalities (30 - 70%) Not due to anatomic abnormality - same as in children Treatment similar to that of children

Secondary adult onset enuresis

Requires anatomic investigation, neurologic evaluation and urodynamics Occurs with obstructive sleep apnea
increased atrial natriuretic peptide and activation of reninangiotensin system

Summary
Exclude- infection, neuropathy, obstruction Reassurance- harmless, perhaps genetic, high rate of spontaneous resolution Recognize- not all parents and children are ready for therapy Begin with conditioning therapy and behavior modification Add the use of medications as necessary