Enuresis - clinical fact sheet and MCQ

Overview

Enuresis, commonly referred to as bedwetting, is the involuntary release of urine during sleep in children over 5 years of age. ‘Enuresis’ is reserved for nighttime wetting, while daytime wetting is classified separately as urinary incontinence. Enuresis can be further categorised as primary, where the child has never achieved a prolonged dry period, and secondary, where bedwetting recurs after at least 6 months of dryness. 

The condition affects up to 10% of 5-year-olds and tends to decrease with age, with only about 1% of those aged 15 and older still affected. Boys are twice as likely to experience enuresis compared to girls. Emotional support and a non-punitive approach from parents/carers are essential, as bedwetting can affect self-esteem and psychological wellbeing.

Enuresis involves a discrepancy between nocturnal urine production and functional bladder capacity, coupled with an inability to wake from sleep when the bladder is full. Additional aetiological factors include nocturnal polyuria (such as from lack of nocturnal antidiuretic hormone secretion), abnormally reduced bladder capacity, and sleep arousal disorders.

Risk factors for enuresis include:

• genetic predisposition; if both parents had nocturnal enuresis in childhood, the risk of enuresis in the child is 77% 

• sleep-disordered breathing 

• upper airway obstruction 

• constipation, due to direct pressure on the bladder and treating constipation alone resolves enuresis in up to 60% of cases

Diagnosis

A clinical history and physical examination to identify possible underlying causes is required. A useful tool in assessment is a voiding diary, which helps monitor fluid intake, urination frequency, and nighttime wetting patterns over several weeks. 

A urinalysis is usually recommended to rule out urinary tract infections (UTIs), renal disease, or new-onset diabetes mellitus. If initial management fails or if concerning symptoms arise, further investigations like ultrasound may be warranted.

Red flags indicating the need for further evaluation include:

• persistent daytime wetting alongside nocturnal enuresis (indicates a diagnosis other than monosymptomatic nocturnal enuresis)

• symptoms of recurrent UTIs (may indicate a congenital abnormality of the urinary tract or other causes UTI)

• neurological signs such as lower limb weakness (may indicate a neurological disorder underlying the voiding dysfunction)

• sudden onset of bedwetting after a prolonged dry period (secondary enuresis may be associated with stress or a new-onset medical condition)

Management

Enuresis management involves a tiered approach that begins with education, reassurance, and lifestyle modifications. Any contributing medical conditions should be managed concurrently.

1. Education and lifestyle changes: reassurance and education are often sufficient for children under 6 or 7 years old, as by this age, 93% of cases have spontaneously resolved. Parents should be encouraged to avoid punitive measures and instead use positive reinforcement, such as reward charts. Ensure the child is well-hydrated throughout the day and avoid excessive fluid intake before bed, encouraging regular daytime voiding to help regulate bladder habits.

2. Alarm therapy: bedwetting alarms, which sound when moisture is detected, are the first-line treatment for children aged 7 and older. Alarm therapy can take up to 12 weeks to show results but has a strong evidence base for effectiveness, especially in motivated families.

3. Pharmacological therapy: if alarm therapy alone is insufficient, oral desmopressin, a synthetic analogue of vasopressin (antidiuretic hormone), can be introduced if nocturnal fluid restriction is possible. It reduces nighttime urine production and provides more immediate symptom relief, though it has a higher risk of relapse when ceased compared to alarms. Desmopressin therapy is more likely to be successful if:

1. the patient has decreased urine concentration

2. bladder capacity is normal

3. enuresis occurs only once at night

4. Combination therapy: when monotherapies fail, combining alarm therapy and desmopressin may be considered.

5. Refractory cases: consider referral to a general paediatrician or continence service if enuresis continues despite treatment. 

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References

1. The Royal Children’s Hospital Melbourne. Enuresis - Bed wetting and Monosymptomatic Enuresis. 2019. https://www.rch.org.au/clinicalguide/guideline_index/Enuresis_-_Bed_wetting_and_Monosymptomatic_Enuresis/. (last viewed January 2025). 

2. The Royal Children’s Hospital Melbourne. Diabetes. 2020. https://www.rch.org.au/kidsinfo/fact_sheets/Diabetes_/. (last viewed January 2025). 

3. Nigri P, Nigri L, Peccarisi L. Overview on the management of nocturnal enuresis in children in general pediatrics. Global Pediatrics.2024;9.https://doi.org/10.1016/j.gpeds.2024.100207. 

4. The Royal Children’s Hospital Melbourne. Urinary tract infection (UTI). 2018. https://www.rch.org.au/kidsinfo/fact_sheets/urinary_tract_infection_uti/. (last viewed January 2025). 

5. BMJ Best Practice. Enuresis. 2023. Available at: https://bestpractice.bmj.com/topics/en-gb/690. (last viewed January 2025).