The word enuresis is derived from a Greek word that means "to make water." In North America, the term is used to refer to wetting by night or day. Enuresis

The word enuresis is derived from a Greek word that means "to make water." In North America, the term is used to refer to wetting by night or day. Enuresis can be divided into primary enuresis (PE) and secondary enuresis (SE). A child who has experienced a minimum 6-month period of continence before the onset of the bedwetting is considered to have SE. A recent study suggests that the pathogenesis of PE and SE might be similar. Robson WL, Leung AK, Van Howe R. Primary and secondary nocturnal enuresis: similarities in presentation. Pediatrics. Apr 2005;115(4):956-9.

Dryness at night usually follows achievement of continence by day. During the second year of life, children start to develop the ability to voluntarily relax the external urethral sphincter and initiate voiding, even in the absence of the desire to void. By approximately age 4 years, all children with normal bladder function should have acquired this ability.

Genetics: Enuresis is reported in 43% of children of enuretic fathers, 44% of children of enuretic mothers, and 77% of children when both the mother and father had enuresis. A family history of bedwetting is found in approximately 50% of children with SE. Enuresis is usually transmitted in an autosomal dominant fashion. Chromosome 22 was identified as the site of enuresis locus in a Danish family in 1995. [3] Subsequent reports link enuresis in other families to loci chromosomes 8, 12, and 16. von Gontard A, Eiberg H, Hollmann E, et al. Molecular genetics of nocturnal enuresis: linkage to a locus on chromosome 22. Scand J Urol Nephrol Suppl. 1999;202:76-80.

Enuresis is more common in males. The reported prevalence of enuresis in boys aged 7 and 10 years is 9% and 7%, respectively, compared with 6% and 3%, respectively, in girls.

Presence of common underlying problems is indicated by the following: Patients with overactive bladder or dysfunctional voiding usually present with frequency, urgency, squatting behavior, and daytime and nighttime wetting. Constipation and cystitis are common associated problems in patients with overactive bladder or dysfunctional voiding. Symptoms of cystitis include dysuria; cloudy, foul-smelling urine; visible blood in the urine; frequency; urgency; and day and nighttime wetting. Symptoms of cystitis can be very subtle in some children. Constipation manifests as infrequent and painful passage of hard wide stool, encopresis, and colicky periumbilical pain. Bowel-related problems and gait abnormalities are often present in patients with neurogenic bladder.

Symptoms of sleep disordered breathing (SDB) include snoring, mouth breathing, lack of restful sleep, and tiredness the following morning. The hallmark symptoms of urethral obstruction are the need to wait or push to initiate voiding and a weak or interrupted stream. When bedwetting is a feature of a major motor seizure, parents may hear nocturnal sounds associated with abnormal muscle movements. Girls with ectopic ureter are "always" wet. Symptoms of diabetes mellitus include polyuria, polydipsia, and weight loss Patients with diabetes insipidus present with polyuria, polydipsia, and symptoms related to the underlying hypothalamic or renal causes.

Causes: 1. Nocturnal polyuria which may be due to fluid ingestion before bedtime, food consumption before bedtime, low nocturnal secretion of ADH, increased nocturnal solute excretion & excess intake of caffeine Although nocturnal polyuria is important in the pathophysiology of enuresis, it doest explain why children with enuresis do not wake up to the sensation of a full or contracting bladder or enuresis that occurs during daytime naps.

2. Overactive bladder/dysfunctional voiding is more common in preschool- and elementary schoolaged girls and usually presents with urinary frequency, urgency, squatting behavior, daytime wetting, and enuresis. 3. Cystitis which causes uninhibited detrusor contractions that can lead to episodes of day and nighttime wetting.

4. Psychological causes including birth of a new sibling, parental divorce or separation, a death in the family, child abuse, or any other cause of social dysfunction at home or school. Stressful life events and psychiatric diagnoses are reported to precede the diagnosis of SE. The later the onset of SE, the more likely the possibility of preceding psychological stress.

5. Seizure disorder SE may be a symptom of an unobserved overnight major motor convulsion in a child with a known seizure disorder. But new-onset seizures rarely occur only at night, and bedwetting is, therefore, a rare manifestation.

6. Diabetes insipidus is an uncommon cause of enuresis. Although nocturnal polyuria is often presumed to be the cause of bedwetting, a disorder of arousal may also be present.

7. Diabetes mellitus Enuresis is usually not the presenting complaint in a child with new-onset diabetes mellitus. Conventional symptoms of insulin deficiency usually overshadow the presence of bedwetting. SE in a child with established diabetes mellitus may be a symptom of suboptimal control with nocturnal polyuria due to hyperglycemia. Although nocturnal polyuria is presumed to be the cause of the bedwetting, a disorder of arousal is also likely present because most school-aged patients develop nocturia but maintain a dry bed. Diabetes mellitus is also associated with abnormalities in the afferent sensory pathways to the bladder, which may contribute to enuresis.

8. Ectopic ureter which is a rare congenital abnormality, enuresis results when the insertion is distal to the external urethral sphincter.

9. Urethral obstruction can be congenital, such as with posterior urethral valves, congenital stricture, or urethral diverticula, or acquired because of a traumatic or infectious stricture. Traumatic strictures may develop after a traumatic urethral catheterization, a foreign body in the urethra, or pelvic trauma.

10. Constipation can cause both PE and SE and is a common aggravating factor that should be considered when other causes are present. Although the mechanism is not clear, the pressure effect of stool in the descending or sigmoid colon likely compromises bladder capacity, and colonic movements at night might trigger an uninhibited detrusor contraction. Constipation is usually present in children with neurogenic bladder and is more common in those with overactive bladder and dysfunctional voiding.

Investigations: 1. Urinalysis is the most important screening test in a child with enuresis. Children with cystitis usually have WBCs or bacteria evident in the microscopic urinalysis. Children with overactive bladder or dysfunctional voiding, urethral obstruction, neurogenic bladder, ectopic ureter, or diabetes mellitus are predisposed to cystitis. Urethral obstruction may be associated with RBCs in the urine. The presence of glucose suggests diabetes mellitus. A random or first-morning specific gravity greater than 1.020 excludes diabetes insipidus.

2. Ultrasonography of the kidneys and bladder (prevoiding and postvoiding) Failure to empty the bladder is a significant risk factor for cystitis and is common in patients with overactive bladder, dysfunctional voiding, neurogenic bladder, and urethral obstruction. The residual volume of urine is normally less than 5 mL. 3. Urodynamic studies help to clarify the diagnosis of neurogenic bladder.

4. Uroflowmetry is a simple, noninvasive measurement of urine flow that is helpful to screen patients for neurogenic bladder and urethral obstruction.

5. MRI of the spine is indicated in any patient with an abnormal neurologic examination finding of the lower extremities; a visible defect in the lumbosacral spine; or the triad of encopresis, gait abnormality, and daytime symptoms.

Treatment: The most important reason to treat enuresis is to minimize the embarrassment and anxiety of the child and the frustration experienced by the parents. Most children with enuresis feel very much alone with their problem.

Doctors consider treatment when there is a specific medical condition such as bladder abnormalities, infection, or diabetes. Physicians also treat bedwetting when it may harm the child's self-esteem or relationships with family/friends. Only a small percentage of bedwetting is caused by a specific medical condition, so most treatment is prompted by concern for the child's emotional welfare. Behavioral treatment of bedwetting overall tends to show increased self esteem for children

Parents become concerned much earlier than doctors. A study in 1980 asked parents and physicians the age that children should stay dry at night. The average parent response was 2.75 years old, while the average physician response was 5.13 years old. Punishment is not effective and can interfere with treatment. Shelov SP, Gundy J, Weiss JC, et al. (May 1981). "Enuresis: a contrast of attitudes of parents and physicians". Pediatrics 67 (5): 70710

1. Waiting Almost all children will outgrow bedwetting. For this reason, urologists and pediatricians frequently recommend delaying treatment until the child is at least six or seven years old. Physicians may begin treatment earlier if they perceive the condition is damaging the child's self- esteem and/or relationships with family/friends.

2. Desmopressin acetate therapy DDAVP tablets or oral disintegrating tablets should be administered 1 hour before bedtime. The recommended starting dose for the tablet is 0.2 mg, and the drug can be titrated as necessary to a maximum of 0.6 mg. The equivalent starting dosage for the melt is 120 mcg and the maximum dose is 360 mcg.

3. An anticholinergic medication may be helpful in some patients, especially those with overactive bladder, dysfunctional voiding, or neurogenic bladder. The combination of DDAVP and oxybutynin chloride may be effective in children with overactive bladder or dysfunctional voiding who respond to anticholinergic therapy with improved daytime symptoms but who continue to wet at night.

4. Physicians also frequently suggest bedwetting alarms which sound a loud tone when they sense moisture. This can help condition the child to wake at the sensation of a fullbladder.

5. Star chart A star chart allows a child and parents to track dry nights, as a record and/or as part of a reward program. This can be done either alone or with other treatments. There is no research to show effectiveness, either in reducing bedwetting or in helping self-esteem. Some psychologists, however, recommend star charts as a way to celebrate successes and help a child's self-esteem

Mortality/Morbidity: Mortality attributable directly to enuresis has not been reported, but children with enuresis have been fatally abused by parents and other caregivers, and bedwetting was considered a "trigger" for the abuse in some situations. The morbidity, in terms of psychosocial stress, has been recognized in the psychiatric literature. Enuresis can also be associated with significant family stress. Punishment should be considered a potential morbid consequence of enuresis.

A study was done to To determine whether occult megarectum remains a commonly unrecognized cause of enuresis and whether treating it will cure enuresis in most children. A landmark study proved constipation was a commonly unrecognized cause of enuresis in which constipation was defined as abnormal rectal distension. However, modern recommendations have focused on signs of functional constipation, such as hard or rare stools. All patients demonstrated rectal distension according to the rectal/pelvic outlet ratio, and 80% were constipated according to the Leech criteria. Only 10% of the patient or families reported clinical symptoms of constipation. All the adolescent patients in our study and 80% of the younger patients were cured of enuresis with laxative therapy. Occult megarectum remains a commonly undiagnosed cause of nocturnal enuresis. Abdominal radiographs represent a simple, noninvasive method to diagnose megarectum and might improve the treatment of nocturnal enuresis. Urology.Urology. 2012 Feb;79(2):421-4.

NOCTURNAL ENURESIS AMONG CHILDREN ATTENDING KIFAN PRIMARY HEALTH CARE CENTRE IN KUWAIT Objective: This study aimed at describing the general profile of nocturnal enuresis in Kuwaiti children 5-15 years old attending primary health care centers and identifying factors associated with the condition.

Methods: The study design is a case control one conducted in Kifan health center, Capital health region, Kuwait during September 2006 - March 2007. 118 children with nocturnal enuresis 5-15 years old as cases and 118 controls in the same age groups were included. Data collection form included personal and family characteristics as well as data regarding child development and psychosocial characteristics. Data were analyzed using univariate and multiple logistic regression analyses.

Results: The final analyses revealed that children pertaining to large families with positive history of nocturnal enuresis were at higher risk of nocturnal enuresis Higher social class as indicated by mother education and high income was proved to be a protective factor against this condition. Children suffering from nocturnal enuresis were proved to be sad and more fitful.

Conclusions: Children from large, low income families with positive family history of nocturnal enuresis were at higher risk of enuresis and seemed to be sad and more fitful.

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The word enuresis is derived from a Greek word that means "to make water." In North America, the term is used to refer to wetting by night or day. Enuresis