History and exam
Key diagnostic factors
common
presence of risk factors
Key risk factors include genetic predisposition and upper airway obstruction/snoring.
increased fluid intake at night
It should be determined whether the patient takes in large amounts of fluids late at night.
urinary frequency
Is variable and can be too frequent (>8 voids per day) or too infrequent (<3 voids per day).
Detrusor overactivity can lead to urinary frequency, and detrusor underactivity may lead to urinary infrequency.
It should be determined when the child tends to void.
Acute onset of frequency and polyuria necessitates ruling out diabetes. If any of these symptoms lead to enuresis, their aetiologies can be treated specifically with the goal of normalising the voiding patterns and habits.
constipation
Impacted faeces are hypothesised to place more than the physiological amount of pressure on the bladder and thus reduce its ability to store urine. In some children, aggressive treatment of constipation alone has led to a resolution of enuresis.[31]
caffeine and other bladder irritants
Caffeine intake increases detrusor contractions, and can cause daytime incontinence, urinary urgency, and enuresis. There is weak evidence that irritants such as food colouring may do the same.
uncommon
urinary urgency
Commonly seen in children who race to the toilet in order to avoid incontinent episodes. May be due to a sudden detrusor contraction or more commonly because of voiding postponement. These can be distinguished based on the presentation.
If the patient continues to engage in activity and is preoccupied while giving physical signs that they need to void (e.g., crossing the legs, wriggling), they are most likely delaying micturition and this leads to the urgency.
Other diagnostic factors
uncommon
abnormal voiding habits
Incomplete bladder emptying or employing secondary manoeuvres to empty the bladder necessitates further work up.
abnormal breathing pattern at night
Upper airway obstruction causing disturbed sleep pattern has been associated with enuresis.
Risk factors
strong
genetic predisposition
The mode of inheritance is typically autosomal dominant with high penetrance (90%). The risk of children born to parents who both had nocturnal enuresis is 77%. This risk is 45% if only 1 parent was affected and decreases to 15% in children born to non-enuretic families.[18]
While multiple genes have been implicated, no direct genotype to phenotype correlations have been made.
Linkage analyses and foci have been found on chromosomes 8, 12, 13, and 22 but, unfortunately, these molecular genetic investigations have raised more questions than have been answered.
upper airway obstruction/sleep-disordered breathing
One study showed a significant decrease in or complete resolution of enuresis in 84% of children after surgical treatment for upper airway obstruction.[19] This suggests that the disturbances in sleep pattern due to upper airway obstruction may be causing enuresis. A prospective study evaluating patients with enuresis did not find an improvement after tonsillectomy for all causes, suggesting that the benefit is minimal or less clear.[20] However, that study did not differentiate obstructive sleep apnoea from enlarged tonsils, which clinically may be a different condition as far as it relates to enuresis. Another prospective study looking only at children with obstructive sleep apnoea showed that half had complete resolution of enuresis after surgical correction of their obstruction.[17] Snoring has been associated with a higher incidence of nocturnal enuresis. The pathophysiology is uncertain but may involve higher levels of brain natriuretic peptide, as well as disorders of arousal.[21] Ongoing research will clarify the benefit of intervening in sleep-disordered breathing for enuresis.
weak
constipation
Impacted faeces are hypothesised to cause a disproportionately high amount of pressure on the bladder and thus reduce its ability to store urine. Habitual holding of stool is also theorised to increase pelvic floor tension, which may lead to incomplete bladder emptying.
attention deficit hyperactivity disorder (ADHD)
These children have a 2.7 times increased incidence of nocturnal enuresis compared with controls.[22] They are also more likely to have concomitant daytime symptoms, and are harder to treat.
psychological disorders
Enuresis causes feelings of shame and inferiority as well as a decrease in feelings of self-worth and self-esteem.[23] Psychological improvement has been noted after successful treatment of enuresis.[24][25] Other voiding dysfunctions, including secondary enuresis, are commonly caused by psychological factors. These children have most commonly experienced a stress event such as trauma, parental divorce, admission to hospital, or sexual abuse. In these children, enuresis is a regressive symptom. Therefore, when discussing enuresis it is important to discuss the psychological issues, as they may help to determine the aetiology, change the diagnosis, or establish symptoms from which to monitor for improvement.
Use of this content is subject to our disclaimer