Enuresis


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Nocturnal Enuresis is commonly called bedwetting. It is the occurrence of involuntary urination while asleep after the age at which bladder control usually occurs. Most girls can stay dry by age six and most boys stay dry by age seven. By ten years old, 95% of children are dry at night. Studies place adult bedwetting rates at between 0.5% to 2.3%.

Most bedwetting, is just a developmental delay—not an emotional problem or physical illness. Only small percentages (5% to 10%) of bedwetting cases are caused by specific medical situations. Bedwetting is frequently associated with a family history of the condition.
Treatment ranges from behavioral-based options such as bedwetting alarms, to medication such as hormone replacement, and even surgery such as urethral enlargement. Since most bedwetting is simply a developmental delay, most treatment plans aim to protect or improve self-esteem.
Bedwetting children and adults can suffer emotional stress or psychological injury if they feel shamed by the condition. Treatment guidelines recommend that the physician counsel the parents, warning about psychological damage caused by pressure, shaming, or punishment for a condition child cannot control.

Types of nocturnal enuresis are:

  • Primary nocturnal enuresis (PNE)
    Nocturnal enuresis is considered primary (PNE) when a child has not yet had a prolonged period of being dry. It is the most common form of bedwetting. Bedwetting counts as a disorder once a child is old enough to stay dry, but continues either to average at least two wet nights a week with no long periods of dryness or to not sleep dry without being taken to the toilet by another person.
    Medical guidelines vary on when a child is old enough to stay dry. Common medical definitions allow doctors to diagnose PNE beginning at between 4 to 5 years old. This type of classification is frequently used by insurance companies. It defines PNE as, persistent bedwetting in the absence of any urologic, medical or neurological anomaly in a child beyond the age when over 75% of children are normally dry.
  • Secondary nocturnal enuresis (SNE)
    Secondary nocturnal enuresis (SNE) is when a child or adult begins wetting again after having stayed dry. It occurs after a patient goes through an extended period of dryness at night (roughly six months or more) and then reverts to nighttime wetting. Secondary enuresis can be caused by emotional stress or a medical condition, such as a bladder infection.

Factors responsible are:

  • Neurological-developmental delay: This is the most common cause of bedwetting. Most bedwetting children are simply delayed in developing the ability to stay dry and have no other developmental issues. Studies suggest that bedwetting may be due to a nervous system that is slow to process the feeling of a full bladder.
  • Genetics: Bedwetting has a strong genetic component. Children whose parents were not enuretic have only a 15% incidence of bedwetting. When one or both parents were bedwetters, the rates jump to 44% and 77% respectively. Genetic research shows that bedwetting is associated with the genes on chromosomes 13q and 12q (possibly 5 and 22 also).
  • Attention deficit hyperactivity disorder (ADHD)
    Children with ADHD are 2.7 times more likely to have bedwetting issues.
  • Constipation: Chronic constipation can cause bedwetting.
  • Infection/disease: Infections and disease are more strongly connected with secondary nocturnal enuresis and with daytime wetting. Less than 5% of all bedwetting cases are caused by infection or disease, the most common of which is a urinary tract infection.
  • Insufficient anti-diuretic hormone (ADH) production: Most of the bedwetting children do not produce enough of the anti-diuretic hormone. As explained above, the body normally increases ADH hormone levels at night, signaling the kidneys to produce less urine. The diurnal change may not be seen until about age 10.
  • More severe neurological-developmental issues: Patients with mental handicaps have a higher rate of bedwetting problems. One study of seven-year-olds showed that "handicapped and mentally retarded children," had a bedwetting rate almost three times higher than non-handicapped children (26.6% vs. 9.5%, respectively).
  • Physical abnormalities: Less than 10% of enuretics have urinary tract abnormalities, such as a smaller than normal bladder. Current data does support increased bladder tone in some enuretics, which functionally would decrease bladder capacity.
  • Psychological: Psychological issues (e.g., death in the family, sexual abuse, extreme bullying) are established as a cause of secondary nocturnal enuresis (a return to bedwetting), but are very rarely a cause of PNE-type bedwetting.
  • Sleep apnea: Sleep apnea stemming from an upper airway obstruction has been associated with bedwetting. Snoring and enlarged tonsils or adenoids are a sign of potential sleep apnea problems.

There are a number of treatment and condition management options for bedwetting. The following options apply when the bedwetting is not caused by a specifically identifiable medical condition such as a bladder abnormality or diabetes:

  • Waiting
    Almost all children will outgrow bedwetting. For this reason, urologists and pediatricians frequently recommend delaying treatment until the child is at least six or seven years old. Physicians may begin treatment earlier if they perceive the condition is damaging the child's self-esteem and/or relationships with family/friends.
  • Bedwetting alarms
    Physicians also frequently suggest bedwetting alarms which sound a loud tone when they sense moisture. This can help condition the child to wake at the sensation of a full bladder. These alarms are considered effective, with study participants being 13 times more likely to become dry at night. There is a 29% to 69% relapse rate, however, so the treatment may need to be repeated.
  • DDAVP (Desmopressin)
    Desmopressin tablets are a synthetic replacement for antidiuretic hormone, the hormone that reduces urine production during sleep. Desmopressin is usually used in the form of desmopressin acetate, DDAVP. Patients taking DDAVP are 4.5 times more likely to stay dry than those taking a placebo. The drug replaces the hormone for that night with no cumulative effect.
    US drug regulators have banned using desmopressin nasal sprays for treating bedwetting, but say that desmopressin pills are still considered a safe bedwetting treatment for otherwise healthy patients. The regulators reviewed the drug after two adult nasal spray users died from hyponatremia, an imbalance of sodium levels in the body.
  • Tricyclic Antidepressants
    Tricyclic antidepressant prescription drugs with anti-muscarinic properties have been proven successful in treating bedwetting, but also have an increased risk of side effects, including death from overdose. [These drugs include amitriptyline, imipramine and nortriptyline. Studies find that patients using these drugs are 4.2 times as likely to stay dry as those taking a placebo.The relapse rates after stopping the medicines are close to 50%.

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