Review – Pediatric Urology
Primary and Secondary Enuresis: Pathophysiology, Diagnosis, and Treatment

https://doi.org/10.1016/j.euf.2017.08.010Get rights and content

Abstract

Context

Enuresis is a common and possibly underestimated condition. While 5–10% of school-aged children suffer from the condition, a lack of background knowledge may impede timely child-adapted and successful therapy.

Objective

To provide a comprehensive overview of the pathophysiology, diagnosis, and treatment of enuresis.

Evidence acquisition

Guideline and position papers from the European Society of Pediatric Urology, the European Association of Urology, and the International Children’s Continence Society were acquired. PubMed was searched for literature on enuresis, and all papers published in the last 5 yr were considered. The most relevant information from the papers with the highest level of evidence was extracted and incorporated into the review.

Evidence synthesis

An altered antidiuretic hormone profile, arousal failure, and delayed bladder maturation are the main pathophysiological factors in primary enuresis. Coexisting constipation, obstructive airway disease, attention deficit hyperactivity disorder, obesity, and genetic preconditions influence its prevalence. Diagnosis relies on history-taking and simple noninvasive examinations to differentiate monosymptomatic enuresis and patients with daytime symptoms. It is essential to exclude daytime voiding symptoms, overactive bladder, dysfunctional voiding, and urinary tract infections. Further imaging is indicated in complex cases with a suspicion of underlying congenital malformations or systemic or endocrine diseases and in children refractory to initial therapy. In secondary enuresis, psychological causes should also be taken into consideration. While desmopressin melt tablets and alarm systems constitute the mainstays of treatment in monosymptomatic enuresis, anticholinergics and urotherapy play an additional role in nonmonosymptomatic enuresis. For therapy-refractory cases, after a thorough re-investigation to identify any missed comorbidities and anatomical or functional causes of enuresis, combination therapy and stationary urotherapy might be promising options.

Conclusions

While enuresis seems to be an often underestimated condition in terms of the suffering that children and their families, there are efficacious therapy options once a correct and full diagnosis is made.

Patient summary

This article reviews primary and secondary nocturnal enuresis, which is the medical term for the condition whereby children wet their beds regularly after their first birthday. We describe the background of enuresis,including its complex underlying mechanisms, as well as diagnosis and treatment in the light of current scientific publications. We conclude that while enuresis seems to be an often underestimated condition in terms of the suffering that children and their families may undergo, there are efficacious therapy options once a correct and full diagnosis is made.

Introduction

Nocturnal enuresis is a frequent condition in children that is often undervalued and underestimated in terms of the suffering of both children and their families. Approximately 10% of all 7-yr-old children, 5% of all 10-yr-olds and 0.5–1% of adults are affected more than three times per week [1], [2]. It is reported that the rate of spontaneous resolution is approximately 15% per year. Boys are more often affected than girls [3], [4]. Besides its negative impact on the self-esteem of affected children, especially if the condition persists at older ages [5], enuresis is associated with poorer performance in school [1] and poorer quality of life among parents [6]. While historical reports address punishing and brutal treatment recommendations such as beating the affected child [7], current mainstays of treatment involve targeted behavioral and pharmacological interventions, relying on the hindsight that psychological problems in most enuretic children are consequences rather than the cause of the condition. However, there are recent reports suggesting that harmful practices in enuresis treatment are still applied in some communities [8]. Awareness of this common problem is often lacking in the direct surroundings of affected children [1], [9] and there is an urgent need for broad education of parents, teachers, and primary physicians. A consistently high number of publications over the last 20 yr indicates the ongoing scientific activity to further improve understanding of this condition and the quality of its treatment (Fig. 1). Global initiatives such as World Bed-wetting Day (www.worldbedwettingday.com) are aimed at promoting awareness and uniform high-standard treatment practices.

Section snippets

Evidence acquisition

Here we present a narrative review, with a comprehensive yet concise overview of the pathophysiology, diagnosis, and treatment of enuresis in light of recent literature from the authors’ point of view on this important and timely topic. Information from the literature was extracted nonsystematically, with a focus on original papers on the many topics covered as well as guidelines and position statements by the leading associations in the field of pediatric urology.

Guideline and position papers

Definitions

As defined by the ICCS, enuresis consists of wetting in discrete portions while asleep by a child who has passed his or her fifth birthday [2]. Enuresis, as well as daytime voiding conditions, is considered significant if it occurs more than once per month and at a frequency of at least three times per 3 mo. It is recommended to term enuresis as frequent if there are more than 3 episodes per week. If there are concomitant day time voiding symptoms (incontinence, frequency, urgency, low voided

Conclusions

Review of the literature on enuresis provides a comprehensive knowledge base confirming the importance of this problem and providing treating physicians with a large armamentarium of diagnostic and therapeutic tools. Given optimal management, the prospects for children with enuresis are optimistic, although there is good reason to consider enuresis a nontrivial problem.


Author contributions: Bernhard Haid had full access to all the data in the study and takes responsibility for the integrity of

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