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Bedwetting (nocturnal enuresis) (Risk factors (Male gender, Delayed…
Bedwetting
(nocturnal enuresis)
Definition
Involuntary wetting during sleep,
without frequency or pathology
Epidemiology
Common
Normal <5y. pathological >5y
15% 5y, 5% 10y
Girls achieve bladder control
earlier than boys (5 vs 6y)
Pathophysiology
Classification
Primary w/o daytime symptoms:
child never achieved continence at night, but no daytime symptoms
Primary with daytime symptoms:
child never achieved continence at night and has daytime LUTS
Secondary:
after child has been dry at night for >6m
Mechanism
If primary, then likely bladder dysfunction; secondary may be systemic disease or psychological/social problems
Aetiology
Idiopathic
OAB, neurogenic bladder
Chronic constipation
Developmental
Late bladder maturity (often FH)
Structural abnormality
Small bladder capacity
Infection
UTI
Metabolic
T1DM
Functional
Behavioural/emotional problems
Abuse
Risk
factors
Male gender
Delayed bladder control
FH
Obesity
Developmental delay
Psychological/behavioural disorders
Sleep apnoea/upper airway obstruction
Diagnosis
Examination
General examination
Abdominal examination (tenderness for UTI)
Neuological examination: any UMN/LMN signs (neuro cause)
History
PMH
Birth and development,
Other milestones
DH
Any meds, allergies
PC/HPC
Bedwetting (frequency, night and day),
any LUTS, previously continent or not,
any behavioural/developmental issues,
eating and drinking, bowel function
FH
Neurological/urological disease
SH
Nursery/school, living arrangements,
stress at home, eating and drinking
Diagnostic
criteria
DSM-5
Involuntary wetting during sleep,
2+/week in children >5y with no
congenital or acquired CNS defect
Investigations
Urine
Dipstick, MCS (infection, glucose)
Bedside
Obs (any fever)
Imaging
USS KUB: suspected structural pathology
MRI spine; spinal pathology
Management
Conservative
Identify cause
Information and advice
Information, advice, support (normal <5y, often self resolves)
Lifestyle (avoid caffeine, toilet use regularly throughout day, easy toilet access at night e.g. potty by bed)
Conservative measures
Indication: 1L primary w/o daytime S+S
E.g. Bedwetting/enuresis alarms and reward schemes
MOA: enuresis alarm detects bed wetness and wakes child;
reward schemes for positive behaviours (drinking, toilet use in day,
NOT
for dryness as they can't control this)
Referral
Primary w/o daytime S+S:
if no response to alarm/desmopressin
Primary with daytime S+S:
straight away
Secondary:
if unclear cause
Medical
Desmopressin
Indication: 2L primary w/o daytime S+S
or for short-term control e.g. school trip
MOA: increases salt and water retention, reducing urine volume
TCA
Indication: 3L primary w/o daytime S+S (specialist use)
E.g. imiprimine
Antimuscarinic
Indication: 3L primary w/o daytime S+S (specialist use)
E.g. oxybutynin
Complications
Child
Guilt, shame, humiliation
Loss of self-esteem
Helplessness/hopelessness
Behavioural/conduct problems
Parents
Stress (work, finanacial)
Punishing child (NAI)
Clinical
presentation
Wetness at night
Urgency
Frequency (>7/d)
Abdo straining
Poor stream
Dysuria
Prognosis
Most children w/o daytime symptoms
become continent by adolescence
Resolves spontaneously in ~10%/y
1% wet bed into adulthood