Enuresis Clinical Presentation

The best time to investigate and discuss enuresis is when the parent or patient first raises the issue in the physician’s office. However, the best time to treat the behavior might depend more on the motivation of the child and the degree of parental concern.

The most important aspect of the investigation is a meticulous history, which can establish the diagnosis, lead to more precise treatment recommendations, and minimize the need for invasive and costly investigations. The history should include the following:

• Hydration history
• Daytime voiding pattern
• Toilet training history
• Number and timing of episodes of bedwetting
• Sleep history
• Family history of nocturnal enuresis
• Nutrition history
• Behavior, personality, and emotional status

If the history is not clear, the family should be asked record fluid intake, daytime voiding, and episodes of bedwetting for at least a 2-week period.

A sleep history should include the times the child goes to bed, falls asleep, and awakens in the morning. Parents should be asked to make a subjective assessment of the child’s depth of sleep. The presence of restless sleep, snoring, and the type and frequency of nocturnal arousals (eg, nightmares, sleep terrors, or sleepwalking) should be determined. Whether the child has experienced periods of dryness and the circumstances of these episodes should also be determined.

A nutrition history should include the timing, quantity, and type of fluid and solid food intake during the entire day, not merely after supper. Many children with enuresis do not drink appreciable amounts of liquids during the school day, arrive home from school thirsty, and drink most of their daily fluids in the 4-5 hours before bedtime, a pattern that favors nocturnal production of urine.

An assessment of the emotional impact on the child is important. Information should be solicited from both the parents and the child. Basic and revealing information includes whether the child has experienced teasing by family or friends or has self-restricted participation in school, sleepovers, or trips.

Alertness to symptoms reflecting common underlying problems is important. Patients with overactive bladder or dysfunctional voiding usually present with frequency, urgency, squatting behavior, and daytime and nighttime wetting. Cystitis and constipation are common associated problems in patients with overactive bladder or dysfunctional voiding.

Symptoms of cystitis include dysuria; cloudy, foul-smelling urine; visible blood in the urine; frequency; urgency; and daytime and nighttime wetting. Symptoms of cystitis can be very subtle in some children.

Constipation manifests as infrequent and painful passage of hard wide stool, encopresis, and colicky periumbilical pain. Some children with enuresis have bowel patterns that influence bladder control and capacity, but they are not constipated by conventional definitions. Thus, the history should include a careful assessment of the frequency and timing of bowel movements, whether the stool is easy to pass, and whether the child needs to push. Children who defecate later in the day, who miss days, and who need to push should be identified.

Bowel-related problems and gait abnormalities are often present in patients with neurogenic bladder.

Symptoms of sleep-disordered breathing (SDB) include snoring, mouth breathing, lack of restful sleep, and tiredness the following morning.

The hallmark symptoms of urethral obstruction are the need to wait or push to initiate voiding and a weak or interrupted stream.

When bedwetting is a feature of a major motor seizure, parents may hear nocturnal sounds associated with abnormal muscle movements.

Girls with ectopic ureter are “always” wet.

Symptoms of diabetes mellitus include polyuria, polydipsia, and weight loss despite a voracious appetite. Patients with diabetes insipidus present with polyuria, polydipsia, and symptoms related to the underlying hypothalamic or renal causes.

A comprehensive physical examination is important and should include the following:

• Measurement of blood pressure
• Inspection of external genitalia
• Palpation in the renal and suprapubic areas to look for enlarged kidneys or bladder
• Palpation of the abdomen to look for hard, wide stool in the left lower quadrant and up to the left upper quadrant or a hard stool mass in the suprapubic area
• Thorough neurologic examination of the lower extremities, including gait, muscle power, tone, sensation, reflexes, and plantar responses
• Assessment of the anal “wink”
• Inspection and palpation of the lumbosacral spine

Abnormal physical findings are usually absent in children when enuresis is the sole symptom and are not necessarily present in children with overactive bladder or dysfunctional voiding. Abnormal findings may be present in patients with cystitis, constipation, neurogenic bladder, urethral obstruction, ectopic ureter, or obstructive sleep apnea (OSA).

A spinal defect, such as a dimple, hair tuft, or skin discoloration, might be visible in approximately 50% of patients with an intraspinal lesion. Dimples above the cleft are especially suspicious.

Assessment of the anal wink or the ability of a patient to stand on the toes is a satisfactory test of the integrity of the S2-4 spinal reflex arc.

In some situations, observing the child void is helpful for assessing the urinary stream. If the child grunts audibly or uses the abdominal muscles to push, or if the stream is weak, interrupted, or deflected upward, a urethral obstruction may be present.

In girls with ectopic ureter, a constant moistness is observed in the introitus, and regular drying with tissue reveals the persistent leak of urine.

Tonsillar size in a child examined in the awake and sitting position may not correlate with OSA symptoms. Examination of the child in the prone position and during sleep may be necessary to visibly document obstruction. Referral to a pediatric otolaryngologist or a pediatric sleep specialist may be appropriate if OSA is suspected (see Treatment).