Enuresis

Enuresis is the repeated voiding of urine in inappropriate places that may be voluntary or involuntary.Toilet training is a ritual and results in behavior that urine is voided in the toilet rather than in the clothes during the day and the bed at night.By definition, enuresis does not exist until the chlid is 5 years old. Primary enuresis occurs if the child has never been “dry” and secondary enuresis implies that there has been a period of “dryness” (at least 1 year) followed by “wetting.” Again by definition, enuresis is functional in etiology and therfore is not caused by a medical condition.The major cause of enuresis or delay in toilet training is conflict over the use of the toilet between the child and the parent.

                Non-functional enuresis is also called organic enuresis and is urinary incontinence on the basis of a medical explanation.Table 5-2 lists some of the organic causes of enuresis and these should be ruled out in a child who present with enuresis.Mental retardation is a major cause of primary enuresis and psychopathology and stress are important causes of secondary enuresis.Enuresis may be the presenting symptom of a urinary-tract infection and it is more common if diuretics are being taken.

TABLE 5-2. ORGANIC CAUSES OF ENURESIS

Urinary-tract infection

Neurogenic bladder

Spinal cord anomalies

Hypospadias (ectopic urethra)

Constipation

Diabetes

Sickle cell diseaseor trait

Psychosocial/emotional disorder

                The prevalence of enuresis decreases during childhood so that 15-20 percent of 5-year-olds, 5 percent of 10-year-olds, and 2 percent of 12-14-year-olds have nocturnal enuresis.Boys are twice as common as girls to have noctural enuresis but girls more commonly have daytime enuresis.A genetic component seems likely because 70 percent of enuresis children have a firstdegree relative with the disorder.

                Enuretic episodes typically occur at night during the first 4 hours of sleep.The evaluation should include a careful history, including family history, and physical examination.The majority of children with functional enuresis are not emotionally disturbed, and the majority of children with emotional problems are not enuretic.There is higher incidence of enuresis among emotionally disturbed children which might be expected if one of the factors causing enuresis is stress.The most common problems are anxienty, family stress, and immaturity.

                Treatment for functional enuresis involves waiting for spontaneous improvement, which occurs with time.Behavioral therapy includes resricting fluids before bedtime, bladder training exercises, and midsleep awakening for toilet use.Rewarding “dry nights” may be helpful in some children.Night alarms consist of electrodes that activate a buzzer or bell when they become wet.They have been succesful in many cases (50-90 percent) but there is a high relapse rate (25-40 percent) when they are stopped.

                Pharmacologic treatment is useful in the management of enuresis and imipramine (Tofranil) has been widely used.Initial  improvement (50-90 percent) may be followed by relapse (20-60 percent) when stopped.Tricyclic antidepressants require monitoring of drug levels and electrocardiogram,and the may have significant anticholinergic effects resulting in urinary retention, constipation, orthostatic hypotension, and sedation.There could be a risk of accidental or intentional overdose by the patient or sibling.Treatment with anticholinergic agents such as oxybutin,propantheline, or terodiline may be beneficial for those patients with small bladder capacity or an irritable or neurogenic bladder.The synthetic analogue of the antidiuretic hormone vasopressin (desmopressin) has been shown to be useful in the treatment of enuretic symptoms and may help some cases.