Enuresis is a common childhood problem. Children with this disorder are often described as heavy sleepers who fail to awaken at the urinary urge to void or when their bladders are full. This article includes various reasons for enuresis and ways to treat the condition.

Enuresis affects around 10% of 6–7-year-olds worldwide. Enuresis is consequently quite common, yet its effect is sometimes underestimated. Infrequently, family physicians get explicit instruction on enuresis, and the default practice is often to wait for spontaneous remission. In modern use, bedwetting is referred to as "enuresis". This could not be further from the truth, and we must eradicate this way of thinking. Hence, it's essential for GPs to know about the condition.

Enuresis is defined as the involuntary passing of urine after the age at which bladder control is considered to have been attained. They are broadly classified as follows:

Daytime enuresis- It is often overlooked and a condition that every doctor should be able to recognise and treat effectively. The majority of children in this age range are treated for urinary tract infections (UTIs) that do not exist.

Nocturnal enuresis- This happens mostly when the youngster is deeply sleeping at night (including wetting when asleep in the day).

Clinically, enuresis may be classified broadly as follows:

• Mostly during the day (diurnal) time (overactive bladder, voiding postponement, dysfunctional voiding)
• Both throughout the day and night (posterior urethral valves, tubular issues, and neurogenic bladder)
• Almost exclusively nocturnal (primary nocturnal enuresis)

There are several potential reasons for enuresis, and this article discusses both those reasons and how to treat the condition.

Overactive bladder

Features- Urgency, increased frequency, dysuria, and daytime wetting

Differential diagnosis- Urinary tract infections (UTI), local problems such as vulval redness

Clinical hints- Prevoid wetting, small volumes of urine, dribbling of urine, not waking to drink water at night, usually not wetting at night, and parents complain “waits till last minute to void”

Diagnostic clues- Ultrasound shows normal kidneys and bladder with low prevoid volume and emptying to completion

Investigation- Ultrasound scan of kidneys and bladder

Treatment

1. Treat constipation (lactulose and lactitol) used for a prolonged period (3–4 months)
2. Stop stimulants and fizzy drinks
3. Voiding diary for noting improvement
4. Anticholinergic medication (oxybutynin 0.5-0.6 mg/kg/day in two or three doses)
5. Tolterodine 2 mg for a child <35 kg once a day

Posterior urethral valves

Features- Can present as daytime wetting and wetting at night in older boys

Differential diagnosis- Mistaken for UTI, other enuresis causes

Clinical hints- May be using abdominal pressure to void, urinary stream may not be good, pre and post-void wetting

Diagnostic clues- Ultrasound may show dilated ureters and renal pelvis/pelves, but sometimes may not. The high post-void residue (even after the second void)

Investigation- Micturating cystogram (MCU)

Treatment

Fulguration of posterior urethral valves (surgery) and long-term follow-up of renal function

Juvenile nephronophthisis

Features- Can present as daytime polyuria/wetting and nocturnal enuresis

Differential diagnosis- Overactive bladder, diabetes insipidus, diabetes mellitus, and chronic kidney failure

Clinical hints

• Nocturnal enuresis may start late
• Drinks a large amount of water
• Family history (autosomal recessive)

Diagnostic clues

• Ultrasound: Normal kidneys and bladder
• Urine analysis: Low-specific gravity (1.005), trace amount of sugar, minor hematuria and proteinuria

Investigation- Raised serum creatinine, hyposthenuria, raised urinary tubular protein, and characteristic kidney biopsy

Treatment

Need dialysis and transplantation when end-stage kidney disease

Neurogenic bladder

Features

• Wetting throughout
• Dribbling of urine
• Recurrent UTIs
• Severe constipation

Differential diagnosis- Enuresis, posterior urethral valves, other causes of recurrent UTIs

Clinical hints

• History of repair of meningomyelocele/spinal tumour/trauma
• Any lump or tuft of hair in the back
• Delayed walking/abnormal gait
• Lower limb weakness
• Severe constipation

Investigation & diagnostic clues

• USG KUB: Thick trabeculated bladder wall with often bilateral hydronephrosis
• MCUG: Thick walled trabeculated bladder and bilateral VUR and poor emptying
• MRI for spinal defect
• Urine analysis: Associated urine infection

Treatment

1. Anticholinergic treatment (oxybutynin, tolterodine)
2. Treat constipation
3. Clean intermittent catheterization (CIC)
4. Combined nephro-urology long-term management

Ectopic ureter insertion below the bladder sphincter

Features- Continuous urinary leakage and wetting, never dry when awake or asleep

Differential diagnosis

• Enuresis
• Bladder dysfunction

Diagnostic clues

• Ultrasound shows normal kidneys and bladder
• Hydroureter may be seen
• Vesicoureteral reflux may be present

Investigation

• USG KUB
• MR urography or Contrast CT KUB
• Cystoscopy

Treatment

1. Surgical therapy
2. Ureteric reimplantation

Diabetes mellitus (D)/diabetes insipidus (DI)

Features

• Increased thirst
• Frequent voiding
• Nocturnal enuresis
• Weight loss
• Irritability, and behaviour changes

Differential diagnosis- Tubular disorders, UTI, and chronic kidney disease

Clinical hints

• Enuresis, weight loss despite polyphagia, and family history
• Polydipsia and polyuria, waking at night for water and voiding urine
• CNS insult history

Diagnostic clues

• Glycosuria, high fasting and random blood sugars, and raised Hb1Ac
• Urine osmolality <300 mosm/L, hypernatremia if inability to drink

Investigation

• Blood sugar and Hb1Ac
• Paired serum and urine osmolarity, water deprivation test

Treatment

1. Dietary restrictions and insulin therapy
2. Vasopressin- intranasal/oral
3. Reduce solute intake (salt/ proteins) to reduce obligatory urine water losses
4. Thiazides/ amiloride/ indomethacin

Primary nocturnal enuresis

Features- Wetting at night persistent >5 years of age when asleep. No daytime features

Differential diagnosis- May be confused with overactive bladder, diabetes mellitus, and diabetes insipidus

Clinical hints- Wetting at least 5 nights per week, no daytime features, positive family history in parents, no complaints of polyuria or failure to thrive

Diagnostic clues- Normal USG KUB, normal urine examination

Investigation- Proper history is diagnostic, investigations not required in majority

Treatment

1. Optimisation of fluids
2. Avoid bladder irritants past evening
3. Treat constipation
4. Primary therapy

• Oral desmopressin for 3 months and reassess (>50% reduction in wetting episodes considered success)

5. Enuresis alarm
6. Combination therapy (if either monotherapy fails)

There are several causes of enuresis. After determining whether enuresis is diurnal or nocturnal, therapy should target the underlying reason-

Regardless of the therapy chosen, family physicians should recognise that enuresis may be a significant burden for families and provide basic guidance on how to manage the disease.

Disclaimer- The views and opinions expressed in this article are those of the author's and do not necessarily reflect the official policy or position of M3 India.

About the author of this article: Dr Monish Raut is a practising super specialist from New Delhi.