Enuresis

Enuresis is a prevalent concern for children and families. By the age of 5, 15% of children continue to have incomplete continence of urine, with the majority experiencing isolated nocturnal enuresis. According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, enuresis is repeated, involuntary urination during sleep that happens at least twice a week in children 5 or older for a minimum of 3 months or enuresis that results in clinically significant distress or social, functional, or academic impairment. Enuresis is the most frequent urologic complaint in pediatric patients in primary care and specialty settings. The condition significantly impacts both the child and the family. Children with enuresis often have low self-esteem and social isolation due to the stigma surrounding bedwetting. This condition can also hinder academic performance, as psychological stress and disrupted sleep patterns take a toll. Additionally, parents may punish children with enuresis, heightening the risk of physical and emotional abuse.

Clinicians divide enuresis into monosymptomatic (MNE) and non-monosymptomatic (NMNE). MNE occurs in children who have no additional lower urinary tract symptoms and no history of bladder dysfunction. Children with concurrent lower urinary tract symptoms like daytime incontinence, urgency, hesitancy, pain, or strategies to postpone voiding have NMNE. The NMNE subtype usually requires a more comprehensive evaluation to identify underlying etiologies. Experts describe children with NMNE and daytime symptoms as having bladder dysfunction.

MNE is further divided into primary and secondary enuresis. Children with primary enuresis have never achieved consistent nighttime dryness for a continual 6-month period. Secondary enuresis refers to bedwetting that occurs in children after being dry for at least 6 months and may correspond to a stressful life event like caregiver divorce or sibling birth, constipation, or inconsistent voiding habits during the day.

Initial evaluation includes a detailed history, physical examination, voiding diary, and urinalysis to exclude bladder dysfunction or an underlying medical condition. Imaging may involve a renal ultrasound or voiding cystourethrogram for patients with daytime symptoms, a history of urinary tract infections, or evidence of structural lower urinary tract abnormalities. Clinicians may consider magnetic resonance imaging (MRI) of the lumbosacral spine for patients with focal neurological deficits of the lower extremities or the perineum and abdominal radiographs for children with suspected constipation.

In most cases, primary MNE resolves spontaneously, indicating that a delay in the normal maturation process is central to the pathophysiology. Additional contributing factors are small bladder capacity, increased nocturnal urine output, genetic factors, and possibly detrusor overactivity. The decision to pursue treatment depends on how disruptive the patient and family perceive the enuresis and their motivation to engage in a treatment program.

Clinicians must work with caregivers and patients to establish goals and expectations. Treatment then centers around managing coexisting conditions like constipation and disordered sleep breathing, followed by providing caregiver education and advice. Clinicians can utilize these techniques plus motivational interventions like a sticker chart. If unsuccessful, adding an enuresis alarm or pharmacotherapy with desmopressin is appropriate. The International Children's Continence Society, American Academy of Pediatrics, European Society of Paediatric Nephrology, and European Society for Paediatric Urology recommend a structured approach to diagnosis and management, emphasizing the importance of addressing the child's and caregivers' concerns.