Urology
Nocturnal Enuresis
Enuresis is the involuntary voiding of urine -- often referred to as nighttime bed-wetting. It falls into three categories:
- Primary -- wet since birth
- Secondary -- prior dry period of more than six months
- Nocturnal -- nighttime
- Diurnal -- daytime
Certainly enuresis is not a new condition, having been alluded to as early as 1550 BC in the Ebers Papyrus. No culture of society is immune from the problem of bed-wetting. Up to 85 percent of children with enuresis are wet solely at night; 56 percent to 75 percebt of all bed wetters are primary enuretics. This symptom is certainly common, with up to 20 percent of all children still wetting the bed at least once a month at the age of 5 years. There is a spontaneous resolution rate that is directly related to age, so that only 4 percent to 5 percent of children are still wet at least once monthly by the age of 12 years; this figure further declines to 2 percent by 18 years of age. There are no data to suggest that diurnal enuresis or secondary enuresis is more commonly associated with organic disorders than is primary or nocturnal enuresis.
Slightly more than a third of children with enuresis are brought to the attention of a physician. This perhaps is related to embarrassment on the part of parents, or to the self-limiting nature and the high spontaneous cure rate associated with enuresis.
Most studies point to a slightly higher prevalence of enuresis in boys than in girls. There appears to be a genetic factor involved, in that if one or both parents were enuretics, there is a 44 percent to 77 percent chance that the child likewise will be a bed wetter. Conversely, in the absence of a parental history of enuresis, only 15 percent of offspring will be enuretics. Studies in twins show that if one twin is an enuretic, there is a strong likelihood that the other will be one as well. The Causes of Enuresis
Perhaps the most important point regarding the etiology of nocturnal enuresis is the fact that rarely is it a manifestation of a significant underlying urologic or neurologic disorder.
In all likelihood a multitude of factors contribute to cause enuresis, including a variation in maturation of the central neural influence on bladder control. A delay in such a central control mechanism may prolong the duration of enuresis. There are conflicting data supporting the role of such variable factors as socioeconomic status, the association of domestic turmoil, deep sleep, nightmares, or behavioral problems (such as nail-biting and thumb-sucking), and the timing of toilet training in enuresis.
TreatmentNumerous treatment options for the management of primary nocturnal enuresis are available, including bladder training exercises, motivational counseling, behavioral modification (conditioning) therapy and pharmacologic therapy.
Bladder retention training involves conscious attempts at "bladder stretching" by voluntarily prolonging the intervals between voidings. Motivational therapy promotes active participation of the child, who is encouraged to assume responsibility for his or her enuresis and who is rewarded as a means of stepwise response shaping.
Behavioral modification (conditioning) therapy uses an alarm device to evoke a conditioned response of awakening and inhibition of urinating in association with bladder distention. Although studies of conditioning therapy report the highest long-term cure rates, this modality is used by only a minority of American physicians.
The most commonly used pharmacologic agents for the treatment of enuresis are the tricyclic antidepressants, particularly imipramine. Cessation of enuresis occurs in up to 40 percent of children treated with imipramine; however, relapses following discontinuation of this drug are common and fatal toxicity from overdoes have been reported.
Recent studies have reported promising results from treatment with desmopressin, an analog of vasopressin. Desmopressin appears to be safe and effective, although relapses are common after discontinuation of use.
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