Nocturnal enuresis

Enuresis is uncontrolled or involuntary discharge of urine in a child, 5 years or older in the absence of a physical disease. It may be nocturnal, during the day - or both (1).

The terminology used to describe nighttime wetting has been the subject of much confusion with the terms nocturnal enuresis, enuresis, bedwetting and incontinence of urine when sleeping being used synonymously (2).

• The Diagnostic & Statistical Manual of Mental Disorders (DSM- IV) defines nocturnal enuresis as an involuntary voiding of urine during sleep, present at least twice a week, in children aged more than 5 years without any congenital or acquired defects of the central nervous system (2)
• The International Children’s Continence Society (ICCS) which uses the term “incontinence” when describing uncontrollable leakage of urine defines enuresis as incontinence in discrete episodes while asleep in children who are at least 5 years or older
  • enuresis can be termed nocturnal enuresis to add greater clarity when needed
  • the symptom of bedwetting is termed as enuresis or intermittent nocturnal incontinence regardless of whether concurrent daytime symptoms are present or not (3)

Nocturnal enuresis can be

• primary - the child has never achieved continence
• secondary - the child was dry for at least 6 months before wetting restarted (4)

Enuresis can also be divided into

• monosymptomatic - occurs in the absence of any daytime voiding symptoms, such as frequency, urgency, or incontinence
• nonmonosymptomatic - more common; a detailed history will elicit at least subtle daytime symptoms in the majority of children (5)

Nocturnal enuresis is not a benign disorder (6)

• it has severe repercussions for the child and the family
• children are often punished and are at risk for physical and emotional abuse
• many children become isolated, lack self-esteem, and have poor academic performance

Day time wetting is rare but is considered to be a significant problem and investigations should be carried out to identify any physical (organic) causes such as urinary tract dysfunction, congenital malformation and neurogenic disorders (7).

• Jarvelin et al found that structural abnormalities and functional disorders of the urinary tract (such as unstable bladder contractions or urinary tract infections) was more often seen in children with day time wetting than in children who had night- time wetting alone (7).

Reference:

1. Watson L. Enuresis. InnovAiT2010;3(2):91-94
2. NICE (October 2010).Nocturnal enuresis - The management of bedwetting in children and young people
3. Nevéus T et al. The standardization of terminology of lower urinary tract function in children and adolescents: report from the Standardisation Committee of the International Children's Continence Society. J Urol. 2006;176(1):314-24.
4. Drug and Therapeutics Bulletin (2004); 42(5):33-7.
5. Robson WL. Evaluation and management of enuresis. N Engl J Med. 2009;360(14):1429-36
6. Gomez Rincon M, Leslie SW, Lotfollahzadeh S. Nocturnal Enuresis. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK545181/
7. Glazener CM, Evans JH. Simple behavioural and physical interventions for nocturnal enuresis in children. Cochrane Database Syst Rev. 2004;(2)