Pediatric Nephrology

, Volume 26, Issue 8, pp 1207–1214 | Cite as

Nocturnal enuresis—theoretic background and practical guidelines

Educational Review

Abstract

Nocturnal polyuria, nocturnal detrusor overactivity and high arousal thresholds are central in the pathogenesis of enuresis. An underlying mechanism on the brainstem level is probably common to these mechanisms. Enuretic children have an increased risk for psychosocial comorbidity. The primary evaluation of the enuretic child is usually straightforward, with no radiology or invasive procedures required, and can be carried out by any adequately educated nurse or physician. The first-line treatment, once the few cases with underlying disorders, such as diabetes, kidney disease or urogenital malformations, have been ruled out, is the enuresis alarm, which has a definite curative potential but requires much work and motivation. For families not able to comply with the alarm, desmopressin should be the treatment of choice. In therapy-resistant cases, occult constipation needs to be ruled out, and then anticholinergic treatment—often combined with desmopressin—can be tried. In situations when all other treatments have failed, imipramine treatment is warranted, provided the cardiac risks are taken into account.

Keywords

Enuresis Incontinence Enuresis alarm Desmopressin Anticholinergics Imipramine 

Notes

References

  1. 1.
    Nevéus T, von Gontard A, Hoebeke P, Hjälmås K, Bauer S, Bower W, Jørgensen TM, Rittig S, Vande Walle J, Yeung CK, Djurhuus JC (2006) 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 (ICCS). J Urol 176:314–324PubMedCrossRefGoogle Scholar
  2. 2.
    Bower WF, Moore KH, Shepherd RB, Adams RD (1996) The epidemiology of childhood enuresis in Australia. Br J Urol 78:602–606PubMedGoogle Scholar
  3. 3.
    Rittig S, Knudsen UB, Nørgaard JP, Pedersen EB, Djurhuus JC (1989) Abnormal diurnal rhythm of plasma Vasopressin and urinary output in patients with enuresis. Am J Physiol 256:F664–F671PubMedGoogle Scholar
  4. 4.
    Rasmussen PV, Kirk J, Borup K, Nørgaard JP, Djurhuus JC (1996) Enuresis nocturna can be provoked in normal healthy children by increasing the nocturnal urine output. Scand J Urol Nephrol 30:57–61PubMedCrossRefGoogle Scholar
  5. 5.
    Hunsballe JM, Hansen TK, Rittig S, Nørgaard JP, Pedersen EB, Djurhuus JC (1995) Polyuric and non-polyuric bedwetting—pathogenetic differences in nocturnal enuresis. Scand J Urol Nephrol S173:77–79Google Scholar
  6. 6.
    Mattsson S, Lindström S (1994) Diuresis and voiding pattern in healthy schoolchildren. Br J Urol 76:783–789Google Scholar
  7. 7.
    Fonseca EG, Bordallo AP, Garcia PK, Munhoz C, Silva CP (2009) Lower urinary tract symptoms in enuretic and nonenuretic children. J Urol 182[4 Suppl]:1978–1983PubMedCrossRefGoogle Scholar
  8. 8.
    Nevéus T, Tuvemo T, Läckgren G, Stenberg A (2001) Bladder capacity and renal concentrating ability in enuresis—pathogenic implications. J Urol 165:2022–2025PubMedCrossRefGoogle Scholar
  9. 9.
    Yeung CK, Chiu HN, Sit FK (1999) Bladder dysfunction in children with refractory monosymptomatic primary nocturnal enuresis. J Urol 162:1049–1055PubMedCrossRefGoogle Scholar
  10. 10.
    Page ME, Valentino RJ (1994) Locus coeruleus activation by physiological challenges. Brain Res Bull 35:557–560PubMedCrossRefGoogle Scholar
  11. 11.
    Nevéus T, Hetta J, Cnattingius S, Tuvemo T, Läckgren G, Olsson U, Stenberg A (1999) Depth of sleep and sleep habits among enuretic and incontinent children. Acta Paediatr 88:748–752PubMedCrossRefGoogle Scholar
  12. 12.
    Wolfish NM, Pivik RT, Busby KA (1997) Elevated sleep arousal thresholds in enuretic boys: clinical implications. Acta Paediatr 86:381–384PubMedCrossRefGoogle Scholar
  13. 13.
    Kayama Y, Koyama Y (1998) Brainstem neural mechanisms of sleep and wakefulness. Eur Urol 33:12–15PubMedCrossRefGoogle Scholar
  14. 14.
    Holstege G, Griffiths D, De Wall H, Dalm E (1986) Anatomical and physiological observations on supraspinal control of bladder and urethral sphincter muscles in the cat. J Comp Neurol 250:449–461PubMedCrossRefGoogle Scholar
  15. 15.
    Lightman SL, Todd K, Everitt BJ (1984) Ascending noradrenergic projections from the brainstem: evidence for a major role in the regulation of blood pressure and Vasopressin secretion. Exp Brain Res 55:145–151PubMedCrossRefGoogle Scholar
  16. 16.
    Ornitz EM, Russell AT, Hanna GL, Gabikian P, Gehricke JG, Song D, Guthrie D (1999) Prepulse inhibition of startle and the neurobiology of primary nocturnal enuresis. Biol Psychiatry 45:1455–1466PubMedCrossRefGoogle Scholar
  17. 17.
    Danysz W, Kostowski W, Hauptmann M (1985) Evidence for the locus coeruleus involvement in desipramine action in animal models of depression. Pol J Pharmacol Pharm 37:855–864PubMedGoogle Scholar
  18. 18.
    Roche EF, Menon A, Gill D, Hoey H (2005) Clinical presentation of type 1 diabetes. Pediatr Diab 6:75–78CrossRefGoogle Scholar
  19. 19.
    Yazbeck S, Schick E, O'Regan S (1987) Relevance of constipation to enuresis, urinary tract infection and reflux. A review. Eur Urol 13:318–321PubMedGoogle Scholar
  20. 20.
    Umlauf MG, Chasens ER (2003) Sleep disordered breathing and nocturnal polyuria: nocturia and enuresis. Sleep Med Rev 7:403–411PubMedCrossRefGoogle Scholar
  21. 21.
    Glazener CM, Evans JH (2002) Desmopressin for nocturnal enuresis. Cochrane Database Syst Rev:CD002112Google Scholar
  22. 22.
    Schulz-Juergensen S, Rieger M, Schaefer J, Neusuess A, Eggert P (2007) Effect of 1-desamino-8-d-arginine vasopressin on prepulse inhibition of startle supports a central etiology of primary monosymptomatic enuresis. J Pediatr 151:571–574PubMedCrossRefGoogle Scholar
  23. 23.
    Hjälmås K, Hanson E, Hellström A-L, Kruse S, Sillén U (1998) Long-term treatment with desmopressin in children with primary monosymptomatic nocturnal enuresis: an open multicentre study. Swedish Enuresis Trial (SWEET) Group. Br J Urol 82:704–709PubMedGoogle Scholar
  24. 24.
    Robson WL, Nørgaard JP, Leung AK (1996) Hyponatremia in patients with nocturnal enuresis treated with DDAVP. Eur J Pediatr 155:959–962PubMedCrossRefGoogle Scholar
  25. 25.
    Nevéus T, Eggert P, Evans J, Macedo A, Rittig S, Tekgül S, Vande Walle J, Yeung CK, Robson L (2010) Evaluation and treatment of monosymptomatic enuresis - a standardisation document from the International Children's Continence Society (ICCS). J Urol 183:441–447PubMedCrossRefGoogle Scholar
  26. 26.
    Kruse S, Hellström A-L, Hjälmås K (1999) Daytime bladder dysfunction in therapy-resistant nocturnal enuresis. A pilot study in urotherapy. Scand J Urol Nephrol 33:49–52PubMedCrossRefGoogle Scholar
  27. 27.
    Robson LM, Leung AK (2002) Urotherapy recommendations for bedwetting. J Natl Med Assoc 94:577–580PubMedGoogle Scholar
  28. 28.
    Harris LS, Purohit AP (1977) Bladder training and enuresis: a controlled trial. Behav Res Ther 11:289–297Google Scholar
  29. 29.
    Nevéus T, Läckgren G, Stenberg A, Nørgaard JP (2005) Anticholinergic treatment for nocturnal enuresis: current understanding and future expectations. Dialogues Pediatr Urol 26:9–11Google Scholar
  30. 30.
    Lovering JS, Tallett SE, McKendry BI (1988) Oxybutynin efficacy in the treatment of primary enuresis. Pediatrics 82:104–106PubMedGoogle Scholar
  31. 31.
    Austin PF, Ferguson G, Yan Y, Campigotto MJ, Royer ME, Coplen DE (2008) Combination therapy with desmopressin and an anticholinergic medication for nonresponders to desmopressin for monosymptomatic nocturnal enuresis: randomized, double-blind, placebo-controlled trial. Pediatrics 122:1027–1032PubMedCrossRefGoogle Scholar
  32. 32.
    Gish P, Mosholder AD, Truffa M, Johann-Liang R (2009) Spectrum of central anticholinergic adverse effects associated with oxybutynin: comparison of pediatric and adult cases. J Pediatr 155:432–434PubMedCrossRefGoogle Scholar
  33. 33.
    Oredsson AF, Jørgensen TM (1998) Changes in nocturnal bladder capacity during treatment with the bell and pad for monosymptomatic nocturnal enuresis. J Urol 160:166–169PubMedCrossRefGoogle Scholar
  34. 34.
    Glazener CM, Evans JH (2007) Alarm interventions for nocturnal enuresis in children (Cochrane Review). The Cochrane Library. Update Software, OxfordGoogle Scholar
  35. 35.
    Morgan RTT (1978) Relapse and therapeutic response in the conditioning treatment of enuresis: a review of recent findings on intermittent reinforcement, overlearning and stimulus intensity. Behav Res Ther 16:273–279PubMedCrossRefGoogle Scholar
  36. 36.
    Glazener CM, Evans JH (2000) Tricyclic and related drugs for nocturnal enuresis in children. Cochrane Database Syst Rev 2000:CD002117Google Scholar
  37. 37.
    Gepertz S, Nevéus T (2004) Imipramine for therapy resistant enuresis: a retrospective evaluation. J Urol 171:2607–2610PubMedCrossRefGoogle Scholar
  38. 38.
    Varley CK (2000) Sudden death of a child treated with imipramine. Case study. J Child Adolesc Psychopharmachol 10:321–325CrossRefGoogle Scholar
  39. 39.
    Seabrook JA, Gorodzinsky F, Freedman S (2005) Treatment of primary nocturnal enuresis: a randomized clinical trial comparing hypnotherapy and alarm therapy. Paediatr Child Health 10:609–610PubMedGoogle Scholar
  40. 40.
    Glazener CM, Evans J, Cheuk DK (2005) Complementary and miscellaneous interventions for nocturnal enuresis in children. Cochrane Database Syst Rev 18:CD005230Google Scholar
  41. 41.
    Glazener CM, Evans JH (2004) Simple behavioural and physical interventions for nocturnal enuresis in children. Cochrane Database Syst Rev:CD003637Google Scholar
  42. 42.
    Hirasing RA, van Leerdam FJ, Bolk-Bennink L, Janknegt RA (1997) Enuresis nocturna in adults. Scand J Urol Nephrol 31:533–536PubMedCrossRefGoogle Scholar
  43. 43.
    Yeung CK, Sihoe JD, Sit FK, Bower WF, Sreedhar B, Lau J (2004) Characteristics of primary nocturnal enuresis in adults: an epidemiological study. BJU Int 93:341–345PubMedCrossRefGoogle Scholar
  44. 44.
    Yeung CK, Sreedhar B, Sihoe JD, Sit FK, Lau J (2006) Differences in characteristics of nocturnal enuresis between children and adolescents: a critical appraisal from a large epidemiological study. BJU Int 97:1069–1073PubMedCrossRefGoogle Scholar
  45. 45.
    Kuh D, Cardozo L, Hardy R (1999) Urinary incontinence in middle aged women: childhood enuresis and other lifetime risk factors in a British prospective cohort. J Epidemiol Community Health 53:453–458PubMedCrossRefGoogle Scholar
  46. 46.
    Coyne KS, Kaplan SA, Chapple CR, Sexton CC, Kopp ZS, Bush EN, Aiyer LP (2009) Risk factors and comorbid conditions associated with lower urinary tract symptoms: EpiLUTS. BJU Int 103:24–32PubMedCrossRefGoogle Scholar
  47. 47.
    Hägglöf B, Andrén O, Bergström E, Marklund L, Wendelius M (1997) Self-esteem before and after treatment in children with nocturnal enuresis and urinary incontinence. Scand J Urol Nephrol 31:79–82Google Scholar
  48. 48.
    Duel BP, Steinberg-Epstein R, Hill M, Lerner M (2003) A survey of voiding dysfunction in children with attention deficit-hyperactivity disorder. J Urol 170:1521–1524PubMedCrossRefGoogle Scholar
  49. 49.
    Baeyens D, Roeyers H, Hoebeke P, Verte S, Van Hoecke E, Vande Walle J (2004) Attention deficit/hyperactivity disorder in children with nocturnal enuresis. J Urol 171:2576–2579PubMedCrossRefGoogle Scholar
  50. 50.
    Elia J, Takeda T, Deberardinis R, Burke J, Accardo J, Ambrosini PJ, Blum NJ, Brown LW, Lantieri F, Berrettini W, Devoto M, Hakonarson H (2009) Nocturnal enuresis: a suggestive endophenotype marker for a subgroup of inattentive attention-deficit/hyperactivity disorder. J Pediatr 155:239–244, e5PubMedCrossRefGoogle Scholar
  51. 51.
    von Gontard A, Mauer-Mucke K, Pluck J, Berner W, Lehmkuhl G (1999) Clinical behavioral problems in day- and night-wetting children. Pediatr Nephrol 13:662–667CrossRefGoogle Scholar
  52. 52.
    Bijos A, Czerwionka-Szaflarska M, Mazur A, Romanczuk W (2008) The usefulness of ultrasound examination of the bowel as a method of assessment of functional chronic constipation in children. Pediatr Radiol 37:1247–1252CrossRefGoogle Scholar

Copyright information

© IPNA 2011

Authors and Affiliations

  1. 1.Uppsala University Children’s HospitalUppsalaSweden

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