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PubMed2001

Sleep/Arousal and enuresis subtypes.

PURPOSE: The mechanisms responsible for enuresis are maturational delays and the extent of the maturational lag equates with the severity of the clinical picture. MATERIALS AND METHODS: A literature review was conducted comparing the similar mechanisms of bladder physiology in normal and children with enuresis. RESULTS: Several mechanisms are associated with enuresis including nocturnal urine volume, nocturnal functional bladder capacity, spontaneous bladder contractions and the inability to arouse to the stimulus of a large and/or contracting bladder. There is adequate evidence for children with enuresis who demonstrate nocturnal spontaneous bladder contractions (detrusor dependent enuresis) and nocturnal polyuria (volume dependent enuresis). A recent study has shown that children with enuresis are difficult to arouse in the first two-thirds of the night, which is also associated with the period of greatest wetting frequency. Night dry children may demonstrate daytime frequency and urgency, others may have nocturia and others are difficult to arouse. Subtyping into volume dependent and detrusor dependent types may only describe specific entities of a larger array of clinical presentations. CONCLUSIONS: It is proposed that the mechanisms responsible for enuresis are maturational delays and the extent of the maturational lag equates with the severity of the clinical picture. Included in this clinical spectrum are children who demonstrate diurnal incontinence and those with secondary enuresis. The former is a condition of maturational severity and the latter is a maturational change. The ability to arouse is fundamental to those who are continent.

Arousal↗
PubMed1984

A pharmacological paradigm for urinary incontinence and enuresis.

The qualitative aspects of drugs used in enuresis control or associated with enuresis or urinary incontinence and the pathological disorders associated with enuresis or urinary incontinence are reviewed. The literature to date does not clarify the factors that account for tricyclic antidepressant effectiveness in enuresis. However, it does reveal that enuresis and urinary incontinence are common symptoms of basal ganglion disorders. Furthermore, pharmacological agents that depress or block dopamine activity produce urinary incontinence or enuresis, while those drugs augmenting the noradrenergic system facilitate continence. It is postulated that urinary incontinence and enuresis are secondary to an imbalance of catecholamine neurotransmitters within basal ganglion structures. A hypothesis is proposed suggesting that dopamine agonists could be viable therapeutic alternatives to tricyclics in treating enuresis and urinary incontinence. Additional clinical drug trials are needed to assess the characteristic responses of specific catecholamine agents in urinary incontinence and enuresis.

Adult↗
PubMed1996

Provoked enuresis-like episodes in healthy children 7 to 12 years old.

PURPOSE: We evaluated whether a water load before bedtime provoked enuresis episodes in healthy children with no previous enuresis. We also studied pelvic floor activity during an enuresis episode and the completeness of bladder emptying, attempted to identify a possible trigger mechanism for nocturnal enuresis, and investigated any age and sex differences regarding the frequency of provoked enuresis episodes. MATERIALS AND METHODS: We evaluated 55 healthy volunteers (22 girls and 33 boys) 7 to 12 years old who were dry from age 5 years and had no urological or other complaints. Subjects were admitted to the hospital for 4 consecutive nights. Night 1 was for adaptation without a water load. On nights 2 to 4, 25 ml./kg. body weight of water were given orally half an hour before bedtime. During the night pelvic floor activity was monitored, and the time and volume of enuresis and nocturia episodes were noted. RESULTS: In 17 subjects 28 enuresis-like episodes were provoked, generally comprising incomplete voidings with large residual volumes mostly in younger children and in boys. Enuresis and nocturia episodes were provoked at a volume specific for each individual without a relation to the bladder filling rate. CONCLUSIONS: Our results support the hypotheses that nocturnal polyuria is an important pathogenetic factor in enuresis and that arousal failure can be provoked in nonenuretic subjects.

Adolescent↗
PubMed2006

Adenotonsilectomy improves enuresis in children with obstructive sleep apnea syndrome.

OBJECTIVES: To evaluate the prevalence of nocturnal enuresis (NE) in children diagnosed with obstructive sleep apnea syndrome (OSAS) and the effect of tonsillectomy and adenoidectomy on enuresis. DESIGN, SETTING, AND PARTICIPANTS: All children 4-18 years of age who underwent polysomnography (PSG) between January 2003 and May 2004 were included (n=161). The evaluation was based on a retrospective review of a standard sleep questionnaire and a full overnight PSG, followed by an additional structured telephone questionnaire performed 9 months after adenotonsillectomy (T&A) (range 5-14). RESULTS: We identified 144 (89%) children with an apnea hypopnea index >1. Of these 144 children, 42 [29.2% (95% CI, 21.8-36.6)] were reported to have enuresis, 27 of these 42 underwent T&A. Among the 27 enuretic children who had undergone adenotonsillectomy, 74.1% had 3 or more wet nights per week before the procedure compared to 37%, 1 month after [n=27 (chi2=3.308, McNemar pv<0.0001)]. Of the 27 children who underwent adenotonsillectomy, any decrease in enuresis severity was reported by 70.4% (95% CI 53.2-87.62), while in 56% of these 27 (95% CI 41.96-70.06) it occurred 1 month postoperatively. In 11/27 children (41%), enuresis totally disappeared within 1 month, while in 3/27 (11%) enuresis disappeared throughout the remaining time of follow-up. CONCLUSIONS: Obstructive sleep apnea in children is frequently associated with nocturnal enuresis. Adenotonsillectomy has a favorable therapeutic effect on enuresis in children with obstructive sleep apnea presenting this symptom.

Adenoidectomy↗
PubMed2006

Resolution of diurnal incontinence and nocturnal enuresis after adenotonsillectomy in children.

PURPOSE: Adenotonsillar hyperplasia causes upper airway obstruction, leading to obstructive sleep apnea. We reviewed the incidence of nocturnal enuresis in a population of children with adenotonsillar hyperplasia. In addition, we investigated the rate of resolution or improvement in enuresis following surgery for relief of adenotonsillar hyperplasia. MATERIALS AND METHODS: We studied 86 consecutive prepubertal children, 46 boys and 40 girls, who underwent adenotonsillectomy. Severity of adenotonsillar obstruction was graded on a scale of 1 to 4. A questionnaire regarding voiding problems, including nocturnal enuresis, voids per day and daytime enuresis episodes, was filled out preoperatively and postoperatively by the patients and their parents. RESULTS: Among the 86 patients who underwent adenotonsillectomy 36 (42%) had nocturnal enuresis. In patients with nocturnal enuresis the number of episodes was significantly less after adenotonsillectomy. Overall, 12 patients (33%) had complete resolution, 11 (31%) had significant improvement and 13 (36%) showed no change. In addition, we noted a significant decrease in daytime enuresis episodes and voids per day. CONCLUSIONS: Children with upper airway obstruction have a high rate of nocturnal enuresis that improves at twice the anticipated rate after treatment of the airway obstruction. In addition, we observed that daytime voiding dysfunction improves in these patients.

Adenoidectomy↗
PubMed2001

Enuresis.

The authors do not have all of the data about enuresis, and many children are subject to relapses or failure of treatment. There is no cause for despondency, however. Enuresis is no longer a mystery. Good data exist about the natural history, epidemiology, and etiology of enuresis. In addition, multiple treatment modalities are available to practitioners. This article has sought to review the scientific literature and to relate the authors' experience with enuresis. The authors recommend a treatment program for children with monosymptomatic nocturnal enuresis that includes removal of caffeine from the diet. Enuretic children do not consume enough fluid, and the authors recommend that the daily fluid requirement be divided during the day: 40% in the morning, 40% in the afternoon, and 20% in the evening, with no restriction of fluid. Normalization of small functional bladder capacities may help to cure enuresis and has an effect on the efficacy of other therapies. Treatment of enuretics with antibiotics is effective in children with UTI, bacteriuria, or cystitis cystica. DDAVP has been shown to be effective in the treatment of enuresis, especially in children who have achieved a normal functional bladder capacity. Bladder alarm systems also offer a potential cure of enuresis, are inexpensive, and show a low relapse rate.

Behavior Therapy↗
PubMed2001

The assessment of constipation in monosymptomatic primary nocturnal enuresis.

OBJECTIVES: Nocturnal enuresis and constipation are common pediatric problems. The aim of this study was to assess the incidence of constipation in children with or without monosymptomatic primary nocturnal enuresis. METHODS: The study included 5350 children, ages 5-19 years, who were surveyed to detect the incidence of nocturnal enuresis. Of those surveyed, 679 (12.7%) had primary nocturnal enuresis. All children were questioned by mail with a standard form that addressed their micturition and defecation habits. The children those who had primary nocturnal enuresis were invited to the Pediatric Urology Section of the University Hospital. Of those 679 children, 125 kept that invitation. All 125 of those children underwent an abdominal ultrasound. Also, these children had serum creatinine levels drawn and plain abdominal films taken. RESULTS: Constipation, defined as less than 3 bowel movements per week, was seen in 48 of 679 children with nocturnal enuresis (7.06%). Of those 4671 children without nocturnal enuresis, only 68 (1.45%) had constipation. The difference in constipation between the two groups was statistically significant (z = -9.251; p = 0.000). Of note, 10 of the 125 children (8%), evaluated at the hospital, had constipation. None of the children had an abnormal neurologic examination. Finally, faecal loading was detected on the plain films of 8 of the 125 children evaluated, 7 of who had constipation. The sensitivity of grading plain films for faecal loading to denote constipation in this population was 87.5%. CONCLUSIONS: Children with primary nocturnal enuresis should be thoroughly assessed for coexisting constipation.

Anal Canal↗
PubMed2001

Enuresis and encopresis in a south Indian population of children.

INTRODUCTION: Though bladder and bowel control are important developmental milestones in all cultures, the prevalence of enuresis and encopresis has rarely been studied in developing countries despite there being factors in these countries that could affect it. This study reports the prevalence and associations of enuresis and encopresis in children in Kerala, India. METHOD: The parents of 1403 randomly selected 8-12-year-old children were interviewed. The prevalence of enuresis and encopresis was ascertained using Rutter's A2 scale. Subsamples of children underwent psychiatric, physical and psychometric evaluations. RESULTS: Of the children, 18.6% had had an episode of enuresis in the past year and 4.3% in the past week. Four per cent had had an episode of encopresis in the past year. Enuresis was associated with parents' education, physical and psychiatric symptoms in the child, poor academic achievement and lax parental attitudes to toilet training. Encopresis was associated with male sex, physical and psychiatric symptoms, poor academic achievement, early separation and not having a toilet. DISCUSSION: The prevalence of enuresis compares with western countries, but encopresis is commoner. The associations of enuresis suggested a multifactorial model in which parental competence was prominent. This study de-emphasized the importance of neurodevelopmental factors in enuresis and encopresis in this age group.

Child↗
PubMed1996

The epidemiology of childhood enuresis in Australia.

OBJECTIVE: To establish the prevalence of enuresis in 5-12-year-old Australian children, to evaluate the impact of enuresis on the children and their families and to identify common methods of managing enuresis. SUBJECTS AND METHODS: A self-administered questionnaire was completed voluntarily by the parents of 2292 5-12-year-old children during attendance at electoral polling booths in Sydney, Australia. The questionnaire inquired specifically after the child's age, gender and frequency of wetting. RESULTS: From a response rate of 74%, the overall prevalence of any reported nocturnal enuresis was 18.9% and any day wetting 5.5%. The prevalence of marked nocturnal enuresis (at least weekly) and marked day wetting was 5.1% and 1.4%, respectively. Using a 10-point visual analogue scale to measure parental concern about their child's enuresis, the mean concern score was 3.1. There was a moderate but significant relationship between the frequency of enuretic episodes and the parental concern score. Of the enuretic children, 34% had consulted with a health worker. These children were 1.4 years older and wet more frequently than those enuretic children who had not sought help. The management of enuresis involved a mean of 3.9 strategies, primarily behavioural techniques administered by the family. The lowest cure rate was seen in the children who wet more frequently. Significantly more of the dry children woke spontaneously at night to void compared with the enuretic children. There was a trend towards greater spontaneous arousal in the children who wet less frequently. CONCLUSION: These results suggest that prevalence rates for day and night wetting in Australia are similar to those in previous studies reported from the northern hemisphere. Australian families did not report a high level of concern about enuresis, even in the older child. The problem was managed primarily within the family.

Attitude to Health↗
PubMed1998

Changes in the structure of sleep spindles and delta waves on electroencephalography in patients with nocturnal enuresis.

OBJECTIVE: To evaluate the mechanism of the dysfunction of arousal in patients with Type I and Type IIa enuresis. PATIENTS AND METHODS: The numbers of sleep spindles and delta waves were analysed during electroencephalography in 19 patients with enuresis (17 male, two female, mean age 9.7 years, range 8-14). RESULTS: In four patients with Type I enuresis, who awoke spontaneously and remained dry as a result of urinary sensation, the numbers of sleep spindles and delta waves diminished gradually and finally disappeared just before the patients awoke completely. In the remaining nine patients with Type I enuresis, there was no decrease in the number of sleep spindles and delta waves, and enuresis occurred without the subjects awakening. In the six patients with Type IIa enuresis, there was no arousal reaction or generation of sleep spindles on urination while asleep. CONCLUSIONS: An immaturity in the function of the thalamus might be a cause of the arousal dysfunction in patients with Type I enuresis. In Type IIa enuresis, a possible abnormal or immature arousal mechanism in the pons or the lower tract may be responsible.

Adolescent↗
PubMed2003

Self-construing in children with primary mono-symptomatic nocturnal enuresis--an investigation of three measures.

OBJECTIVE: This study aims to measure different aspects of self-construing in children with primary mono-symptomatic nocturnal enuresis. METHOD: 25 children aged 7-14 years, with nocturnal enuresis were recruited from a paediatric outpatient's unit specialising in enuresis [mean age 10.6 [males], 9.39 [females]] and 25 children acting as controls, were recruited from one primary and one secondary school [mean age 10.08 [males], 9.39 [females]]. MEASURES: The Butler Self Image Profile [SIP], Coopersmith Self Esteem Inventory, Ouvinen-Birgerstam "I think I am" Self Perception Scale were administered. DESIGN: This study was a matched controlled group comparison. RESULTS: The only significant difference was the tendency for children with enuresis to construe themselves more negatively on the SIP. There were no significant differences between children with enuresis and the matched controls on all the other measures. CONCLUSION: Children with nocturnal enuresis generally perceive themselves similar to children without nocturnal enuresis, and are not "psychologically or emotionally disturbed." It is important to assess a child's self-construing in order to identify those children who are more vulnerable to a lower self-esteem. Future research needs to take into account self-construing in different clinical populations, i.e. those children who have non-mono symptomatic nocturnal enuresis.

Adolescent↗
PubMed2001

Nocturnal enuresis in pediatric sickle cell disease.

To assess the prevalence of nocturnal enuresis in children and adolescents with sickle cell disease (SCD) and associated factors, structured telephone interviews were conducted with primary caregivers of 217 children and adolescents with SCD aged 5 years or older. Prevalence, perceived causes, interventions undertaken, and emotional impact were assessed. Nocturnal enuresis was significantly higher for males (28.2% of males) than for females (11% of females), p = .002, and compared with cited population prevalence rates, nocturnal enuresis was significantly higher for children with SCD, p < .01. SCD was the most common reason given by primary caregivers for enuresis. Primary caregivers used a wide range of interventions for nocturnal enuresis, but few used empirically supported treatments for enuresis or spoke with their health care team about the enuresis. These data suggest that systematic assessment and intervention for nocturnal enuresis must be implemented in the follow-up care of children and adolescents with SCD.

Adolescent↗
PubMed1990

Secondary enuresis in a birth cohort of New Zealand children.

The development of secondary enuresis was examined in a birth cohort of New Zealand children studied to the age of 10 years. By this age, 7.9% of children had developed secondary enuresis. Analysis suggested two risk factors were involved in secondary enuresis. First, children who were late to attain nocturnal bladder control had significantly higher risks of secondary enuresis than children who attained early nocturnal bladder control. Secondly, the child's level of exposure to adverse life events was associated with the onset of secondary enuresis. Children who attained bladder control after 5 years were 3.39 (1.76-6.56) times more likely to develop secondary enuresis than those who attained bladder control before the age of 3 years (P less than 0.001); children who were exposed to four or more life events in a given year were 2.56 (1.18-5.50) times more likely to develop secondary enuresis in that year (P less than 0.05). These results suggest that the rate at which the child acquires primary bladder control acts as a vulnerability factor which determines the child's susceptibility to developing secondary enuresis when exposed to stress.

Child↗
PubMed2004

Child abuse as a result of enuresis.

BACKGROUND: Enuresis is a frequent manifestation with important psychological and social consequences. The aim of the present study was to describe the types of child abuse as a result of enuresis, and to investigate the association of child abuse. METHODS: A cross-sectional field study was conducted between March 2001 and August 2001 in the 5-17-year-old age group, to identify risk factors and prevalence of enuresis in the province of Trabzon, Turkey. A face-to-face interview with 889 mothers was carried out. In the questionnaire, the existence, frequency, and risks factors of enuresis were questioned in detail and the parental reactions to the child's enuresis were widely investigated. RESULTS: The prevalence of nocturnal enuresis was 17.9% in the 5-17-year-old age group. It was also found out that of 154 mothers, 86.4% (n = 133) were involved in child abuse of different types. It was found that 40.6% of children who were abused as a result of their enuresis were neglected medically, 42.1% were spanked and 12.8% were beaten. CONCLUSIONS: The high prevalence of enuresis among Turkish children leads to a high frequency of neglect. The high frequency of other types of child abuse in Turkey can be taken as being punishment.

Adolescent↗
PubMed1995

Clinical correlates of enuresis in ADHD and non-ADHD children.

Enuresis and attention deficit hyperactivity disorder (ADHD) are common childhood disorders that often co-occur. Although each has been linked to neurodevelopmental immaturity and increased risk for psychopathology, the clinical correlates of enuresis remain unclear. Subjects were 140 6-17-year-old boys with DSM-III-R ADHD and 120 non-ADHD controls. Information on enuresis and psychiatric diagnoses was obtained in a standardized manner blind to the child's clinical status. Our results show that (1) enuresis did not increase the risk for psychopathology in children with or without ADHD; (2) enuresis was not associated with psychosocial adversity or developmental immaturity; (3) enuresis was associated with increased risk for learning disability, impaired intellectual functioning, and impaired school achievement in normal control children but not in children with ADHD; and (4) the same pattern of findings was obtained after stratifying children with enuresis by primary versus secondary and by nocturnal versus diurnal subtypes. These results suggest that the clinical implications of enuresis may differ for ADHD and non-ADHD children.

Adolescent↗
PubMed2005

[Effectiveness of behavioral intervention in nocturnal enuresis].

BACKGROUND: Nocturnal enuresis is a common, often misunderstood condition that affects millions of children. Although the rate of spontaneous resolution is 15 % per year, treatment is often required for social or psychological reasons. OBJECTIVE: To determine the prevalence of nocturnal enuresis in a primary health care area, how was it diagnosed, which treatments were employed and treatment response. MATERIAL AND METHODS: A retrospective study was performed that included all the medical records of children aged between 6 and 14 years old in a basic health area. RESULTS: Twenty-seven children with a diagnosis of nocturnal enuresis were identified (4.3 %). Among these, 21 were boys (77.7 %) and six were girls (22.3 %). There was a family history of nocturnal enuresis in 15 patients (55.5 %). Nocturnal enuresis was not the reason for consultation in 24 of the 27 patients (88.8 %) but was diagnosed collaterally by anamnesis. All the children had simple primary nocturnal (monosymptomatic) enuresis. Five patients abandoned the treatment (18 %), 15 (55.5 %) recovered with behavioral intervention exclusively, the remaining seven children were treated with desmopressin, which was successful in three of them. The remaining four patients were still receiving treatment when the data were collected. CONCLUSIONS: The prevalence of nocturnal enuresis in this primary health area (4.3 %) is similar that reported in other series. In a high percentage (88.8 %) of patients, nocturnal enuresis was not the reason for consultation but was diagnosed during anamnesis. Behavioral intervention was effective in more than half (55.5 %) of the patients.

Behavior Therapy↗
PubMed1998

Lower urinary tract problems in patients with enuresis.

OBJECTIVE(S): Two hundred and thirty-eight children (170 males, and 68 females) with nocturnal enuresis were retrospectively studied for lower urinary tract problems. Surgical correction of subclinical organic obstruction in the lower urinary tract was evaluated for the improvement of bed-wetting. METHODS: One hundred and fifty-five micturating cystourethrography (MCU), and 89 urodynamic studies were performed. Optic internal urethrotomy was done in a boy, and meatoplasty in a girl for urethral 'ring' stenosis (URS). RESULTS: Nocturnal enuresis was found in 153 cases and nocturnal enuresis associated with daytime enuresis in 67 cases. Vesicoureteral reflux was found in 30, URS in 42, and posterior urethral valve in 3 cases on MCU. Detrusor instability was recognized in 39.4% of 38 cases of nocturnal enuresis associated with daytime enuresis and in 25.0% of 51 cases of nocturnal enuresis. Surgery brought 73.8% improvement of bed-wetting in 42 cases. CONCLUSIONS: Surgical correction of subclinical obstruction in the lower urinary tract might contribute to the earlier resolution of bed-wetting in children with nocturnal and/or diurnal enuresis.

Adolescent↗
PubMed1998

Enuresis and obstructive sleep apnea in adults.

Adult enuresis is an unusual symptom of obstructive sleep apnea (OSA). Although it is described as a classic symptom of childhood OSA, enuresis is encountered infrequently in adult sleep medicine. Five adults with enuresis associated with sleep apnea presented to our Sleep Disorders Center. In all five cases, the onset of enuresis was associated with the progression of sleep apnea symptoms. In each case, the enuresis resolved with treatment with nasal continuous positive airway pressure. Current medical literature on the postulated mechanisms of nocturia and enuresis in sleep apnea is reviewed. Based on the experience of the authors and review of the medical literature, one may conclude that severe OSA may lead to new-onset enuresis in adults and that effective treatment of OSA is associated with resolution of enuresis.

Adult↗