Case

The parents of a seven year old boy bring their son to the office because he has rarely been dry at night. His four year old sister is always dry and they are very concerned. He doesn't wet his pants during the day. How would you evaluate this patient and advise this family?

Enuresis is involuntary voiding at night (bedwetting). It should be differentiated from daytime or diurnal enuresis. At the age of 5, approximately 85% of children will be dry at night. Afterwards, about 15% will improve per year and 1% of adults are still bedwetting. Boys are affected three times more than girls.

Secondary enuresis is defined as the onset of bedwetting after having been dry at night for 6 months prior to wetting the bed again. The incidence is between 3-8% of 5-12 year olds. About 15% resolve yearly in this group as well. 

Pertinent history

1. Establish whether this is primary or secondary
2. Family history of enuresis- 40% incidence if one parent and 70% if both parents were enuretic
3. History of constipation or encopresis
4. Symptoms of UTI's
5. Any history of renal disease
6. Any symptoms of diabetes insipidus or mellitus
7. Voiding history- problems in daytime, number of times goes during the day, stream, difficulty starting and stopping
8. Emotional or behavioral symptoms
9. Neurologic symptoms- weakness, bowel control changes, gait changes

1. Examination of genitalia
2. Neurologic exam
3. Abdominal exam
4. Inspection of back and spinal column

1. urine analysis and culture

1. Genetic
2. Bladder capacity and function- usually not an issue in primary enuresis
3. Deep sleeper- not a proven cause
4. Sleep apnea- there is an association of sleep apnea with large adenoids and tonsils and enuresis that may improve with T&A.
5. ADH secretion abnormalities have been suggested but never proven
6. Stress and psychogenic- never proven
7. Neurologic dysfunction- may be a delay in maturation. Some "soft" neurologic signs have been associated 
8. Diet- not proven
9. Bacteriuria has been associated with secondary enuresis.

1. A careful history and physical exam are very important in the evaluation of enuresis. Any treatment modality should include the parents as well as the child. Children should limit the intake of fluids before going to sleep and should void prior to going to bed. Waking the child at night is of little value and is disruptive to the entire family. De-emphasize the significance of the problem and point out that only 1% of adults are still enuretic. Make the child responsible for changing their bed clothes and sheets and bringing them to the laundry. Never punish and appreciate that you may be dealing with a child with poor self esteem.
2. Behavioral modification- keep a calendar of dry and wet nights and give stars or other small reward for dry nights. Bring chart to office on the next visit. Encourage the child. Have the child phone you and relate how they are doing.
3. Alarm systems- cost about $60 and successful if used properly and consistently. Compliance is a problem and staying on the alarm a problem. Alarm that hooks on to undergarment work well. May be used with DDAVP which jumps starts success because may take 3 weeks for alarm to show results. Then taper DDAVP.
4. Medications
1. Ditropan- successful if bladder function or sphincter problem. 
2. Imipramine- May be useful but often when stop medicine child begins to wet again
3. DDAVP- very expensive and when stop child will often start to wet bed again. Useful for special occasions and for desperate families.
5. Treat UTI if urine culture is positive.

1. Hurley, R. Morrison. The Difference Between Night and Day. Pediatrics in Review December 1990.
2. Schmitt BD. Noctunal Enuresis. Pediatrics in Review. 1997; 18:183-191.
3. Tietjen, Douglas and Husmann, Douglas. Nocturnal Enuresis: A Guide to Evaluation and Treatment Mayo Clinic Proceedings 1996: 71:857-62.
4. Wojcik LJ and Kaplan GW. The Wet Child. Urologic Clinics of North America. 1998; 25(4):735-744.
5. Lawless Michael and McElderry D. Nocturnal Enuresis: Current Concepts  Pediatrics in Review November 2001
6. Christopherson E. Is Evidenced-Based Treatment Sufficient to Manage Nighttime Wetting Probelems (Enuresis)? Arch Pediatr Adolesc Med Vol 159 Dec 2005