Enuresis is the involuntary
emptying of the bladder. Although children may ‘wet’ themselves by day or
night, the term enuresis is applied to nocturnal enuresis. When it occurs
during the day, while awake, it is known as diur-nal enuresis. Nocturnal
enuresis is more common.
In order to learn bladder control
the young child needs to overcome the infant automatic pattern of voiding. For
the young child, conscious awareness of fullness and the ability to postpone
voiding by suppressing the urge to void are not perfect. This response is first
learned for day-time control. Eventually, bladder control becomes automatic and
does not require a conscious act. Night-time bladder control requires that the
brain, during sleep, suppress the automatic emptying reflex. Learning blad-der
control at night occurs gradually, and in some children and families takes much
longer than average.
Girls achieve bladder control
earlier than boys. Enuresis is defined as the continued wetting in girls beyond
the age of 5yrs, and in boys beyond the age of 6yrs.
Enuresis may be primary, with
children not having established an appro-priate period of adequate bladder
control in early childhood, or secondary occurring after a period of
established bladder control.
strong family history.
more commonly than girls (ratio 2:1).
5-yr-olds, 5% of 10-yr-olds, and 1% of 16-yr-olds have not established total
bladder control and will wet the bed once a week or more.
of cases have no underlying organic cause and it is thought to be due to
delayed maturation of bladder control mechanisms.
Needs careful history and
investigations because of probable organic cause.
Renal tract: urinary tract infection
Neurological: spina bifida
Endocrine: diabetes mellitus, diabetes
Daytime wetting is usually caused
by bladder detrusor instability.
regular drinks (water), but restrict in last hour before bed.
If primary nocturnal enuresis is
associated with arousal from sleep or disturbance, then an enuresis alarm
should be considered. This requires careful discussion with families.
Compliance is often an issue and the fam-ily and child need to be motivated. If
enuresis associated with a small bladder, ‘bladder training’ exercises is
first-line approach. Also consider using bladder-stabilizing drugs, e.g.
oxybutynin. If nocturnal enuresis and urine output exceeds bladder capacity
consider using desmopressin (anti-diuretic hormone) and limit fluid intake 1hr
If the problem is resistant to the
above treatments, other pathologies need to be considered:
outflow obstruction in boys.