Enuresis is defined as the repeated voiding of urine of a child five years or older into the bed or clothes at least two time a week for no less than three consecutive months. This dysfunction appears to run in families where 44 percent and 77 percent of children were enuretic when one or both parents were themselves enuretic. The involuntary urination appears to occur at all stages of sleep. Some children present at having minimal arousal to bladder distention and an unusual pattern of uninhibited bladder contractions before the enuretic episode. Developmental immaturity is also relevant as a factor. Psychological factors may also play a role. Children who have experienced a stress such as divorce, school trauma, abuse or hospitalization may be enuretic for a period of time.
The doctor must rule out medical problems that could cause urinary incontinence, such as abnormalities in the genitourinary system, neurological signs, or spinal cord abnormalities. Urinalysis and urine cultures are standard. More invasive procedures are only pursued with specific indications. A two-week log of wet and dry nights is helpful in the assessment of enuresis.
The treatment is based on the doctor’s findings in the assessment. Medical problems will point to specific interventions. Psychosocial problems should also be considered when the history and physical examinations do not suggest a specific etiology. Enuresis can be treated with a variety of approaches. The parent should be supportive of the child. Both the child and parent need to be educated on the issue of enuresis. Journal keeping, fluid restriction and nighttime awakening are often useful. Later children can be trained with alarms, closer monitoring, and frequent reinforcement for dry periods and timely urination.
Regarding medication for enuresis, imipramine and DDAVP have been used. Many studies show a 40-to-60 percent effectiveness, although the relapse rate off the medication may be as high as 50 percent. DDAVP is a synthetic analog of the antidiuretic hormone vasopressin. This medication decreases urine production at night when taken at bedtime. Studies of DDAVP, however, show a success rate of 10-to-65 percent and relapse rates as high as 80 percent. DDAVP can be prescribed for short periods such as when a child goes to camp. Bladder-stretching exercises to increase functional bladder capacity have been used without consistent evidence of effectiveness.
Enuresis is a common psychosomatic symptom that presents both alone and in conjunction with other disorders in children and adolescents. It is frequently encountered in the general pediatric office.