Overview
Definition:
Enuresis is involuntary urination during sleep in children aged 5 years or older, not attributable to a medical condition
Nocturnal enuresis (NE) is the most common form
Primary NE is in children who have never achieved sustained dryness, while secondary NE is in children who have had at least 6 months of dryness before relapsing.
Epidemiology:
Prevalence of NE decreases with age
approximately 15-20% of 5-year-olds, 7% of 10-year-olds, and 1-2% of 18-year-olds are affected
It is more common in boys than girls
Risk factors include family history of enuresis, constipation, and delayed bladder maturation.
Clinical Significance:
Enuresis can have significant psychosocial impact on children and families, leading to anxiety, low self-esteem, social isolation, and marital stress
Effective management is crucial for improving quality of life and patient well-being
Understanding evidence-based treatment options like alarm therapy and desmopressin is vital for DNB and NEET SS preparation.
Clinical Presentation
Symptoms:
The primary symptom is involuntary wetting of the bed during sleep
Associated symptoms may include daytime urinary symptoms like urgency, frequency, or hesitancy
Chronic constipation can be a significant co-morbidity
Psychological distress and social withdrawal are common in affected children.
Signs:
Physical examination is often normal
However, it is important to rule out underlying medical conditions
Look for signs of constipation (e.g., palpable stool in the abdomen), urinary tract infection (e.g., suprapubic tenderness), or neurological deficits
Assess for anatomical abnormalities of the genitourinary tract.
Diagnostic Criteria:
The International Children's Continence Society (ICCS) criteria define NE as involuntary voiding while asleep in children aged 5 years or older
It is further classified as primary or secondary, and monosymptomatic (only nocturnal wetting) or non-monosymptomatic (associated with daytime symptoms).
Diagnostic Approach
History Taking:
Detailed history is paramount
Inquire about the age of onset, frequency and pattern of wetting, presence of daytime symptoms, bowel habits (including constipation), sleep patterns, fluid intake, family history of enuresis, and any previous treatments
Screen for emotional or behavioral issues
Red flags include: sudden onset of enuresis, daytime symptoms, painful urination, significant constipation, or neurological abnormalities.
Physical Examination:
Perform a complete physical examination, including assessment of growth parameters, abdominal palpation for stool or masses, external genitalia examination to assess for anatomical abnormalities or signs of infection, and a neurological examination focusing on lower extremity reflexes and sensation
A basic urinalysis is essential to rule out infection or glucosuria.
Investigations:
For uncomplicated NE, investigations are often not required
However, if daytime symptoms are present, consider a urinalysis for infection, protein, or glucose
Uroflowmetry and post-void residual ultrasound can be useful in non-monosymptomatic NE
Renal ultrasound may be considered if there are red flags or a strong family history of renal disease
In rare cases, a voiding cystourethrogram (VCUG) or cystoscopy might be indicated.
Differential Diagnosis:
Conditions to consider include: urinary tract infection (UTI), diabetes mellitus, diabetes insipidus, constipation with overflow incontinence, structural abnormalities of the urinary tract, epilepsy, obstructive sleep apnea, and behavioral or psychological disorders
Distinguishing monosymptomatic NE from non-monosymptomatic NE is crucial for guiding management.
Management
Initial Management:
The initial approach should focus on education, reassurance, and lifestyle modifications
This includes fluid management (limiting fluids before bedtime), timed voiding before sleep, and avoiding punishment
Training the child and family on basic bladder and bowel care is fundamental.
Medical Management:
Two primary pharmacological options are available for monosymptomatic nocturnal enuresis (MSNE):\n\n1
Alarm Therapy:\n - Mechanism: Auditory or vibratory stimulus alerts the child to void, conditioning them to wake up
This is considered a first-line treatment for many.\n - Efficacy: High success rates (up to 70-80%) with sustained dryness after treatment completion
Relapse rates can be significant if not followed by maintenance therapy or if treatment is stopped too early.\n - Implementation: Requires significant family commitment and child cooperation.\n\n2
Desmopressin (DDAVP - 1-desamino-8-D-arginine vasopressin):\n - Mechanism: A synthetic analog of antidiuretic hormone (ADH) that reduces urine production by increasing water reabsorption in the renal tubules.\n - Dosing: Oral or nasal spray
Oral dosage for children is typically 200-400 mcg at bedtime
Nasal spray dosage is usually 10-20 mcg at bedtime
Start with the lowest effective dose.\n - Efficacy: Effective in reducing the volume of nighttime urine production, leading to fewer wet nights
Success rates vary but can be around 60-70% for those who respond
Primarily treats the symptom, not the underlying cause.\n - Precautions: Risk of hyponatremia and water intoxication, especially in children with conditions affecting water excretion or those receiving other medications that can cause SIADH
Monitor for signs of water intoxication (headache, nausea, vomiting, confusion)
Restrict fluid intake strictly during the night and for 1-2 hours before and after administration.\n\nComparison:\n- Alarm therapy aims for a cure and behavioral conditioning, while desmopressin is primarily for symptom control
Alarm therapy often has better long-term outcomes if successful.\n- Desmopressin is useful for specific occasions (e.g., sleepovers) or when alarm therapy is not feasible or effective
It works faster than alarm therapy.
Surgical Management:
Surgical intervention is rarely indicated for enuresis and is typically reserved for cases with underlying structural abnormalities of the urinary tract that are contributing to enuresis, or for severe cases refractory to all conservative and medical management
Examples include correction of meatal stenosis or other obstructive anomalies.
Supportive Care:
Psychological support for the child and family is crucial
Positive reinforcement and encouragement are vital
Addressing any associated behavioral issues or sleep disturbances is also important
Regular follow-up appointments help monitor progress, adjust treatment, and provide ongoing support.
Complications
Early Complications:
Hyponatremia and water intoxication with desmopressin use if fluid restrictions are not strictly adhered to
Skin irritation or discomfort from alarm devices
Increased anxiety or frustration if treatments are ineffective.
Late Complications:
Psychosocial sequelae like low self-esteem, social isolation, and family stress can persist if enuresis is not managed effectively
Long-term dependence on desmopressin without addressing underlying issues is not ideal.
Prevention Strategies:
Strict adherence to fluid restrictions when using desmopressin
Proper fitting and use of alarm devices
Positive reinforcement and patient education
Thorough evaluation to identify and manage contributing factors like constipation or psychological stress.
Prognosis
Factors Affecting Prognosis:
Age, presence of daytime symptoms, family history, severity of enuresis, adherence to treatment, and presence of co-morbid conditions significantly influence prognosis
Monosymptomatic enuresis generally has a better prognosis than non-monosymptomatic enuresis.
Outcomes:
With appropriate management, most children achieve dryness
Alarm therapy, when successful, can lead to lasting dryness
Desmopressin provides symptomatic relief and can achieve dryness during treatment
Many children spontaneously outgrow enuresis by adolescence.
Follow Up:
Regular follow-up is essential, especially during active treatment, to monitor efficacy, adherence, and any potential side effects
Once dry, periodic follow-up may be needed to address any relapses
The frequency of follow-up will depend on the chosen treatment and individual response.
Key Points
Exam Focus:
Understand the primary indications, mechanisms, dosing, and critical precautions for desmopressin
Differentiate between alarm therapy and desmopressin in terms of goals (cure vs
symptom control) and long-term outcomes
Recognize red flags requiring further investigation
DNB/NEET SS often tests management of both monosymptomatic and non-monosymptomatic enuresis.
Clinical Pearls:
Always start with behavioral interventions and education
Involve parents as active participants in treatment
For desmopressin, emphasize strict fluid restriction to prevent hyponatremia
Consider alarm therapy as a first-line treatment for motivated children and families seeking a more permanent solution.
Common Mistakes:
Failing to rule out secondary causes of enuresis (e.g., UTI, diabetes, constipation)
Over-reliance on pharmacological treatment without behavioral modification
Inadequate counseling on fluid restrictions with desmopressin, leading to dangerous side effects
Punitive approaches that can worsen the child's anxiety and self-esteem.