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Cynthia D’Alessandri-Silva, MD
Some people feel the rain. Others just get wet.
―Bob Dylan
Learning Objectives:
1. Delineate the classification of urinary incontinence
2. Understand the importance of history in identification of the cause of daytime wetting
3. Become familiar with different etiologies of daytime urinary incontinence and enuresis
4. Develop counseling techniques for families whose children have enuresis
5. Become familiar with pharmacologic and non-pharmacologic interventions for enuresis
Primary References:
1. Roth EB, Austin PF. Evaluation and treatment of nonmonosymptomatic enuresis. Pediatrics in
Review. 2014;35(10): 430-436.
http://pedsinreview.aappublications.org/content/35/10/430.full.pdf+html
2. Bayne AP, Skoog SJ. Nocturnal enuresis: An approach to assessment and treatment. Pediatrics in
Review. 2014;35(8): 327-334.
http://pedsinreview.aappublications.org/content/35/8/327.full.pdf+html
3. Table 2 in: von Gontard A. The impact of DSM-5 and guidelines for assessment and treatment of
elimination disorders. Eur Child Adolesc Psychiatry. 2013;22(S1): S61-S67.
http://link.springer.com/content/pdf/10.1007%2Fs00787-012-0363-9.pdf
CASE ONE:
Sally P. Freely is a 6-year-old girl whose mother is concerned about her wetting problem
for the past month. Mrs. Freely reports that Sally frequently wets her pants at school.
Sally’s teacher has told Mrs. Freely that she catches Sally squatting and holding her crotch
intermittently during the day. Sally was previously toilet-trained and had no wetting for
more than 6 months before the problem started. Mrs. Freely has stopped having Sally go
over to friend’s houses for play-dates, and has taken her off of the soccer team due to fear
of embarrassment. As you elicit this history you notice Sally constantly pulling on her
mother’s shirt for attention and climbing on the chair and jumping off. When you question
Mrs. Freely on Sally’s behavior, she admits that Sally has always been a “busy child with
the energy of 100 children.” Mrs. Freely is almost to tears and asks, “Is there a medication
to give Sally so she can just be like other kids her age?”
3. What is the most-likely etiology of Sally’s incontinence? What are some other possibilities?
What other information would you obtain regarding her symptoms to help flesh out the cause?
The differential diagnosis for daytime urinary incontinence is broad, and includes voiding
postponement (holding urine until the last minute); urinary tract infection (UTI); labial fusion; urge
incontinence; giggle incontinence; stress incontinence; postvoid dribble syndrome; diabetes mellitus;
diabetes insipidus; constipation; vaginal reflux of urine; and traumatic, neurologic, or infectious
bladder obstruction. Further history and physical exam, including full review of the neurologic and
genitourinary systems, are necessary to evaluate for these causes.
Many young children with secondary non-monosymptomatic enuresis have voiding postponement, often
because they neglect the urge to urinate while involved in other activities. Scheduled toileting is a
simple solution to this problem. UTI, another common cause, usually presents with other signs and
symptoms of infection, but can be easily ruled out with a clean-catch urine culture.
Constipation may also be a contributing factor as it is associated with a reduced functional bladder
capacity. Parents are often unaware of constipation in a self-toileting child. The provider should
directly question school-age children about this problem and they should be instructed not to flush the
toilet. The parent should record the time, frequency, and character of bowel movements, and the
presence of soiling.
Postvoid dribble syndrome is characterized by the sensation of wetting after voiding, usually in 4 to 6
year old females. The sensation may be due to small detrusor contractions after voiding. Having the
child void completely and then immediately try voiding again, or “double voiding,” may be effective in
this scenario.
Neurogenic bladder is a result of a lesion at any level in the nervous system. Children with
myelomeningocele usually have daytime wetting. Diabetes mellitus is associated with polyuria as well
as with abnormalities in the afferent nerves from the bladder, which may develop many years after
diagnosis.
Sally’s story is classic for urge incontinence, or unstable bladder, due to unwanted detrusor
contractions. Affected children are typically of school age. Urge incontinence is more common among
4. How would you treat secondary non-monosymptomatic enuresis? What about Sally’s type of
enuresis?
Treatment for secondary non-monosymptomatic enuresis would be geared towards any other causes or
contributing factors identified by history and physical (e.g., scheduled toileting for micturition
deferral, antibiotics for UTI, a bowel regimen to relieve constipation).
Treatment for urge incontinence is physiotherapy aimed at strengthening the pelvic floor muscles. By
strengthening these muscles children will learn to relax the pelvic floor muscles thereby relaxing the
detrusor. Children who require relaxation techniques need referral to an experienced physiotherapist.
If the symptoms are severe, further investigations are necessary (i.e., urodynamics and ultrasound of
the bladder and kidneys) which are best performed at a center experienced in conducting these studies
in children. Anticholinergics such as oxybutynin and hyoscyamine sulfate serve to decrease detrusor
hyperactivity and enlarge the functional capacity of the bladder. These agents may be helpful in some
cases. Children younger than 5 years of age should not be treated for urge incontinence as some
degree of irregular detrusor activity can be normal in this age group.
CASE TWO:
Peon Smith is a 12-year-old boy who presents for his annual physical. His mother reveals
that Peon is wetting his bed at night. She feels he is too old for “this type of embarrassing
behavior” and has been punishing him. You discover that she too used to wet the bed at
night and was punished by her parents. She is frustrated with his bed wetting and is
angered that she finds it difficult to wake him once she encounters his accidents. Peon
denies all urinary symptoms and has no urinary problems while awake. He has no other
medical problems. On physical exam his vital signs are stable and his BMI is >95th
percentile. The rest of his physical exam is benign.
5. What type of enuresis does Peon have? What, if any, further evaluation is necessary?
Peon has monosymptomatic enuresis (commonly referred to as nocturnal enuresis) since he has
symptoms occurring exclusively during sleep. His enuresis is primary since he has never achieved
continence.
His mother’s history of enuresis is telling. Children with nocturnal enuresis are thought to have
maturational delay in recognizing bladder fullness while asleep. When it is the solitary cause,
maturational delay typically results in primary monosymptomatic enuresis. Those with one parent who
was enuretic in childhood have 44% incidence of enuresis and those with both parents affected have
77% incidence, as compared to the 15% incidence in children whose parents did not have enuresis.
Had Peon previously achieved a period of continence (secondary monosymptomatic enuresis), then an
alternative or additional cause would be likely. In secondary monosymptomatic enuresis, clinicians
must consider other contributing etiologies such as UTI, constipation, sleep disordered breathing,
emotional stress, or anatomic, neurologic, or endocrine abnormalities. Additional history and physical
exam should target these etiologies, and must include evaluation of the nervous system and urinary
tract.
Based on Peon’s history, maturational delay is the likely explanation, though obstructive sleep apnea
may be a contributing etiology. Additional questions regarding daytime or nighttime signs and
symptoms of sleep apnea (e.g., snoring, daytime sleepiness) are indicated. Sleep apnea and upper
airway obstruction have been linked to enuresis due to difficulty arousing from sleep.
6. What non-pharmacologic treatments would you suggest for Peon’s enuresis? Would you advise
his mother to continue punishing him?
Spontaneous resolution of primary nocturnal enuresis is quite common (15% per year), lending support
to the theory of maturational delay of sensing bladder fullness. Nevertheless, all children with
enuresis can benefit from non-pharmacologic therapy, especially those children greater than 8 years of
age and those in which the behavior is a cause of family distress. In patients with secondary
monosymptomatic enuresis or concomitant daytime symptoms (i.e., non-monosymptomatic enuresis),
underlying etiologies should also be addressed as a first step in treatment.
It is important to incorporate family education and use of motivational techniques as part of any
treatment regimen for enuresis. Families must learn that enuresis is not grounds for punishment.
Punishing the child for enuresis may be counterproductive to solving the problem, and may affect the
child’s already fragile self-esteem. The parents should discourage ridicule from siblings as well.
There are a variety of effective motivational strategies available. Positive reinforcement is effective,
and can be delivered through setting up a reward system for each night the child remains dry. In
addition, the child should be kept involved in the resolution process, which will help him (and the
family) to view enuresis as an accepted problem that he is working to solve. Embarrassment should be
minimized. The child should participate in the morning clean-up and be encouraged to keep a journal
or dry bed chart.
In addition, Peon should refrain from large amounts of fluid for at least two hours before bedtime to
decrease urine production at night-time. He should empty his bladder just before bedtime, and should
also be awoken by a parent at the parent’s presumably later bedtime to do so again.
If these motivational and behavioral strategies discussed are not successful after a few months, or in
older children in whom nocturnal enuresis can be more distressing, more advanced behavioral therapy
should be implemented. A Cochrane review revealed that conditioning through use of an enuresis
alarm has the highest overall cure rate (70%), especially when used in conjunction with positive
reinforcement and charting. These devices are small and worn in the patients’ underwear. When the
device is exposed to urine, a circuit is completed and the alarm sounds. Cost can range from $15 to
$85 and is not usually covered by state insurance. The alarm can be discontinued in children who
remain dry for 3 consecutive weeks. If bedwetting recurs, the alarm can be used again successfully.
Conditioning through “dry bed training” has been successful in treating nocturnal enuresis. The
process involves waking the child nightly at decreasing intervals over several nights. The child should
change pajamas if wet and go to the toilet. The eventual goal is having the child awaken alone to
void. Although the cure rate is high, this process is labor intensive and hard for many families to
perform.
7. What medications are available to treat enuresis? At what point would you initiate
pharmacotherapy?
Desmopressin (DDAVP) is an analog of ADH which acts on the distal tubules of the kidney to increase
water reabsorption, thereby producing less urine. Desmopressin is available in both nasal spray and
oral form, but the nasal spray has greater bioavailability. Effects can be evident within a few days of
use. Children treated with desmopressin, as compared to those receiving placebo, have an average of
1.3 fewer wet nights per week. The initial dose is 10 mcg, one puff in each nostril 2 hours before
bedtime; the dose can be increased by increments of 10 mcg weekly to a dose of 40 mcg. Patients can
remain on this therapy for 3 to 6 months while behavioral methods are being applied, and the dose
should then be tapered if the enuresis is improving. If there is no resolution in a child’s enuresis after
6 months then combination therapy should be considered after revisiting possible underlying etiologies.
Additional References:
1. Fritz G, et al. AACAP practice parameter for the assessment and treatment of children and
adolescents with enuresis. Journal of the American Academy of Child & Adolescent Psychiatry.
2004;43(12):1540-50.
2. Glazener CM, et al. Simple behavioural and physical interventions for nocturnal enuresis in
children. Cochrane Database of Systematic Reviews. 2004;1: CD004668.
3. Glazener CM, Evans JH, Peto R. Alarm interventions for nocturnal enuresis in children. Cochrane
Database Systematic Reviews. 2005;2: CD002911.
4. Glazener CM, Evans JH. Desmopressin for nocturnal enuresis in children. Cochrane Database
Systematic Reviews. 2009;CD002112.
5. Lawless MR, McElderry DH. Nocturnal enuresis: current concepts. Pediatrics in Review. 2001;22(12):
399-406.
6. Makari J, Rushton HG. Nocturnal enuresis. American Family Physician. 2006;73(9):1611-3
7. McGrath KH, Caldwell PHY, Jones MP. The frequency of constipation in children with nocturnal
enuresis: a comparison of parental reporting. J Paediatr Child Health. 2008;44: 19-27.
8. Neveus T, et al. The standardization of terminology of lower urinary tract function in children and
adolescents: report from the Standardization Committee of the International Children’s Continence
Society (ICCS). Journal of Urology. 2014;176: 314-324.
9. Robson WL. Etiology, evaluation, and treatment for enuresis. New England Journal of Medicine.
2009;360: 1429.
Resource:
1. Information for patients and families from National Kidney Foundation.
http://www.kidney.org/patients/bw/BWKidsTeens.cfm
Acknowledgment:
The current author would like to thank Dr. Karen Dorsey for her work on a previous version of this
chapter.