Bedwetting
Sleep Enuresis or Nocturnal Bedwetting
Sleep enuresis is the preferred term because it refers to the involuntary aspect, inability to maintain urinary control during sleep.Primary enuresis refers to the inability to attain urinary control from infancy, whereas secondary enuresis denotes an enuretic relapse after control as been achieved.
Essential Features of Sleep enuresis is characterized by recurrent involuntary micturition that occurs during sleep. Persistent bed-wetting after age five in the absence of urologic, medical, or mental pathology is considered a primary enuretic disorder. Typically, the child has never achieved continuous dry nights. In secondary enuresis, the child has had at least three to six months of dryness. Enuretic episodes occur throughout all sleep stages, as well as during nocturnal awakenings. Most episodes occur in the first third of the night. Bladder control during the daytime is usually normal.
Associated Features:
- Primary enuresis is continuous from infancy, Small functional bladder capacity and an irritable bladder believes to be associated with multiple wettings at night and also with increased frequency of voiding and urgency during the day.
- In some enuretics, toilet training is not encouraged or achieved early in childhood. This finding may account for the increased prevalence of enuresis in lower-socio-economic groups, where parenting skills or expectations may be less developed.
- Dreaming is vaguely and infrequently reported in conjunction with bed-wetting, particularly when it occurs in the first hours of the night. Typically, the sleeper dreams of being in the bathroom; this occurs more commonly with older enuretics. Such dreams are initiated after the onset of micturition and are not precipitating events.
- Obstructive breathing and sleep apnea may be precipitating factors, particularly in children who have loud snoring. When obstructive sleep apnea syndrome is diagnosed, both the apnea and the enuresis often resolve after treatment of the apnea.
- Allergies may play a role in the perseverance of enuresis. Some children with the disorder have been shown to be allergic to milk products and to suffer bladder irritability.
Prevalence: Enuresis is estimated to occur in 30% of 4-year-olds, 10% of 6 year olds, 5% of 10 year olds, and 3% of 12 year olds. One percent to 3% of 18 year olds continue to have enuretic episodes. Primary enuresis comprises 70% to 90% of all cases of the disorder, with secondary enuresis representing the remaining 10% to 30%. In adults, primary enuresis is rare.
Sex Ratio: Males are affected more often than females. At age five, the male to female ratio is 3:2.
Familial Pattern: A hereditary factor involving a single recessive gene is suspected in children with primary enuresis. There is often a high prevalence of enuresis among the parents, siblings, and other relatives of the child with primary enuresis. Studies suggest an incidence of 77% when both parents were enuretic as children and a rate of 44% in children when one parent has a positive history for enuresis.
Polysomnographic Features: Enuretic episodes can occur in all sleep stages and during nocturnal wakefulness. Episodes may correlate with the presence of obstructive sleep apnea. Sleep cystometrography in enuretic children reveals elevated intravesical pressure and spike like detrusor contractions during bladder filling, similar to those occurring in infantile bladders.
Differential Diagnosis: Primary sleep enuresis is diagnosed by exclusion when secondary enuresis has been ruled out. Primary enuretics should have a physical examination that includes a urinalysis, complete enuresis history, and a sleep history. Causes of secondary enuresis can be organic, medical, or psychologic.
Organic pathology of the urinary tract is more likely if the child has daytime enuresis, abnormalities in the initiation of micturition, or abnormal urinary flow. Urinary-tract infection, diabetes mellitus, diabetes insipidus, epilepsy, sickle cell anemia, obstructive sleep apnea, and neurologic disorders can all cause enuresis.
Organic pathology of the urinary tract is more likely if the child has daytime enuresis, abnormalities in the initiation of micturition, or abnormal urinary flow. Urinary-tract infection, diabetes mellitus, diabetes insipidus, epilepsy, sickle cell anemia, obstructive sleep apnea, and neurologic disorders can all cause enuresis.
Diagnostic Criteria: Sleep Enuresis
- The patient exhibits episodic involuntary voiding of urine during sleep. The enuresis occurs at least twice per month in children between the ages of three and six years and at least once per month in older individuals.
- Polysomnographic monitoring during an episode demonstrates both of the following:
- Voiding of urine during the sleep period
- Absence of epileptic activity in association with the voiding
- The enuresis can be associated with medical or mental disorders, such as diabetes, urinary-tract infection, or epilepsy.
- Other sleep disorders (e.g. sleep enuresis-primary type or sleep enuresis-secondary type
There are formal criteria of Nocturnal Enuresis from: International Classification of Sleep Disorders.
For more current information see: A. Golbin, MD. Bedwetting (Enuresis), Its Nature and How to Correct It. Sleep and Health. September, 2006.
