Enuresis 

  • Author: Wm Lane M Robson, MA, MD, FRCP, FRCP(Glasg), FRSPH; Chief Editor: Marc Cendron, MD   more...
 
Updated: Apr 30, 2012
 

Background

The word enuresis is derived from a Greek word that means "to make water." The International Children’s Continence Society (ICCS) restricts the use of the term enuresis to wetting only at night. Enuresis can be divided into primary enuresis (PE) and secondary enuresis (SE). A child who has experienced a minimum 6-month period of continence before the onset of the bedwetting is considered to have SE. A recent study suggests that the pathogenesis of PE and SE might be similar.[1]

Psychological and social impact

In PE, psychological problems are almost always the result and only rarely the cause. By contrast, psychological problems are a possible but uncommon cause in SE. The comorbidity of behavioral problems is 2-4 times higher in children with enuresis in all epidemiologic studies. The emotional impact of enuresis on a child and family can be considerable. Children with enuresis are commonly punished and are at significant risk of emotional and physical abuse. Numerous studies report feelings of embarrassment and anxiety in children with enuresis; loss of self-esteem; and effects on self-perception, interpersonal relationships, quality of life, and school performance.[2] A significant negative impact on self-esteem is reported even in children with enuretic episodes as infrequent as once per month.

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Pathophysiology

Normal achievement of continence

Dryness at night usually follows achievement of continence by day. The table below shows the percentage of American children who achieve day and nighttime continence at varying ages.

During the second year of life, children start to develop the ability to voluntarily relax the external urethral sphincter and initiate voiding, even in the absence of the desire to void. By approximately age 4 years, all children with normal bladder function should have acquired this ability.

Table 1. Percent of Children Dry by Day and Night at Various Preschool Ages (Open Table in a new window)

Age, yDry by Day, %Dry by Night, %
22510
2.58548
39878

Genetics

Numerous studies report varying but high prevalence of the condition in other family members of patients with enuresis. The highest reported familial prevalence rates concluded that 56% of fathers, 36% of mothers, and 40% of siblings experienced a problem with enuresis. Enuresis is reported in 43% of children of enuretic fathers, 44% of children of enuretic mothers, and 77% of children when both the mother and father had enuresis. A family history of bedwetting is found in approximately 50% of children with SE.

Enuresis is usually transmitted in an autosomal dominant fashion. Chromosome 22 was identified as the site of enuresis locus in a Danish family in 1995.[3] Subsequent reports link enuresis in other families to loci chromosomes 8, 12, and 16.[4]

Identified genes cannot control for enuresis per se. Rather, an identified gene would need to control a pathophysiological factor such as arousal, nocturnal polyuria, or bladder capacity.

Whether there is a family history of enuresis does not seem to influence outcomes of any of the various treatments.

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Epidemiology

Frequency

United States

The prevalence of PE in the United States varies by age. At age 4 years, 25% of children frequently wet the bed. By age 7 years, only 5%-10% still wet the bed. Less than 5% of children wet the bed by age 10 years. The resolution rate of PE is approximately 15% per year; by the late teenaged years, very few patients have the condition. The high spontaneous resolution rate and the often-quoted resolution rate of 15% per year is often used as a justification to wait and not treat PE. The spontaneous resolution rate of 15% per year does not likely apply to children who wet every night and likely only applies to those children who have already started to have dry nights.

International

The prevalence of PE seems to be the same throughout the world, although no standardized evaluation of the prevalence of bedwetting has been made on a global basis.

Mortality/Morbidity

Mortality attributable directly to enuresis has not been reported, but children with enuresis have been fatally abused by parents and other caregivers, and bedwetting was considered a "trigger" for the abuse in some situations. The morbidity, in terms of psychosocial stress, has been recognized in the psychiatric literature. Enuresis can also be associated with significant family stress. Punishment should be considered a potential morbid consequence of enuresis.

Severe perineal, genital, and lower abdominal rash may also occur in patients with enuresis, potentially leading to skin breakdown and, rarely, cutaneous infections.

Race

Enuresis has no racial predisposition.

Sex

Enuresis is more common in males.

The reported prevalence of enuresis in boys aged 7 and 10 years is 9% and 7%, respectively, compared with 6% and 3%, respectively, in girls.

Age

The prevalence of enuresis gradually declines during childhood. Of children aged 5 years, 23% have enuresis. During elementary school years, the problem remains common, with 10% of 7-year-old children and 4% of 10-year-old children still experiencing enuresis.

The prevalence of enuresis in adulthood is reported to be 0.5%-2%.

When PE and SE are reported, a secondary onset accounts for approximately one fourth of cases. The prevalence of SE as a percentage of all cases of enuresis increases with age. In a cohort of New Zealand children, 7.9% developed SE by the time they were aged 10 years.[5]

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Contributor Information and Disclosures
Author

Wm Lane M Robson, MA, MD, FRCP, FRCP(Glasg), FRSPH  Medical Director, The Children's Clinic

Wm Lane M Robson, MA, MD, FRCP, FRCP(Glasg), FRSPH is a member of the following medical societies: International Children's Continence Society, Royal College of Physicians and Surgeons of Canada, Royal College of Physicians and Surgeons of Glasgow, and Royal Society for Public Health

Disclosure: Nothing to disclose.

Specialty Editor Board

Howard M Snyder III, MD  Professor, Department of Surgery, Division of Pediatric Urology, University of Pennsylvania School of Medicine and Children's Hospital of Philadelphia

Howard M Snyder III, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Surgeons, American Medical Association, American Urological Association, and National Kidney Foundation

Disclosure: Nothing to disclose.

Mary L Windle, PharmD  Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Harry P Koo, MD  Chairman of Urology Division and Director of Pediatric Urology, Professor of Surgery, Virginia Commonwealth University School of Medicine, Medical College of Virginia; Director of Urology, Children's Hospital of Richmond

Harry P Koo, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Surgeons, and American Urological Association

Disclosure: Nothing to disclose.

Daniel Rauch, MD, FAAP  Director, Pediatric Hospitalist Program, Associate Professor, Department of Pediatrics, New York University School of Medicine

Daniel Rauch, MD, FAAP is a member of the following medical societies: Ambulatory Pediatric Association, American Academy of Pediatrics, and Society of Hospital Medicine

Disclosure: Baxter Honoraria Consulting

Chief Editor

Marc Cendron, MD  Associate Professor of Surgery, Harvard School of Medicine; Consulting Staff, Department of Urological Surgery, Children's Hospital Boston

Marc Cendron, MD is a member of the following medical societies: American Academy of Pediatrics, American Urological Association, European Society for Paediatric Urology, Johns Hopkins Medical and Surgical Association, New Hampshire Medical Society, Society for Fetal Urology, and Society for Pediatric Urology

Disclosure: Nothing to disclose.

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Table 1. Percent of Children Dry by Day and Night at Various Preschool Ages
Age, yDry by Day, %Dry by Night, %
22510
2.58548
39878
Table 2. Causes of Primary and Secondary Enuresis
Causes of Primary EnuresisCauses of Secondary Enuresis
Idiopathic



Disorder of sleep arousal



Nocturnal polyuria



Small nocturnal bladder capacity



Idiopathic



Disorder of sleep arousal



Nocturnal polyuria



Small nocturnal bladder capacity



Overactive bladder and dysfunctional voidingOveractive bladder and dysfunctional voiding
CystitisCystitis
ConstipationConstipation
Neurogenic bladderPsychological
Urethral obstructionAcquired neurogenic bladder
PsychologicalSeizure disorder
Ectopic ureterOSA
Diabetes insipidusDiabetes mellitus
Acquired diabetes insipidus
Acquired urethral obstruction
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