Pupillometric assessment of autonomic nervous system in children with functional enuresis


Functional enuresis is defined as repeated voiding of urine into bed or clothes in children after 5 years of age following the exclusion of major somatic diseases. Autonomic nervous system dysregulation has been proposed as a pathophysiologic mechanism in the etiopathogenesis. The objective of this study was to evaluate autonomic nervous system functions with pupil diameter measurement in enuretic children. The study group consisted of 17 children with functional enuresis (ten boys, seven girls), and the control group consisted of 34 healthy children (20 boys, 14 girls). Pupil diameter measurements were performed under photopic and mesopic lighting conditions by using a pupillometer. Mean photopic pupil diameter was found to be larger in the enuretic children than in the healthy controls (4.47 ± 0.52 mm vs. 4.03 ± 0.75 mm; P = 0.03). Autonomic nervous system imbalance of the ocular system is considered to be part of the autonomic nervous system dysregulation in functional enuretic children.

This is a preview of subscription content, log in to check access.

Fig. 1


  1. 1.

    American Psychiatric Association (2000) Diagnostic and statistical manual of mental disorders, 4th edition, text revision (DSM-IV-TR). American Psychiatric Association, Washington, DC

    Google Scholar 

  2. 2.

    Hjalmas K (1998) Nocturnal enuresis: basic facts and new horizons. Eur Urol 33(Suppl 3):53–57. doi:10.1159/000052245

    PubMed  Google Scholar 

  3. 3.

    Neveus T, Lackgren G, Tuvemo T et al (2000) Enuresis—background and treatment. Scand J Urol Nephrol Suppl 206:1–44

    PubMed  Google Scholar 

  4. 4.

    Yakinci C, Müngen B, Durmaz Y et al (1997) Autonomic nervous system functions in children with nocturnal enuresis. Brain Dev 19:485–487. doi:10.1016/S0387-7604(97)00069-7

    PubMed  Article  CAS  Google Scholar 

  5. 5.

    Fujiwara J, Kimura S, Tsukayama H et al (2001) Evaluation of the autonomic nervous function in children with primary monosymptomatic nocturnal enuresis-power spectrum analysis of heart rate variability using 24 hour Holter electrocardiograms. Scand J Urol Nephrol 35:350–356. doi:10.1080/003655901753224396

    PubMed  Article  CAS  Google Scholar 

  6. 6.

    Dundaroz MR, Denli M, Uzun M et al (2001) Analysis of heart rate variability in children with primary nocturnal enuresis. Int Urol Nephrol 32:393–397. doi:10.1023/A:1017539317009

    PubMed  Article  CAS  Google Scholar 

  7. 7.

    Piha SJ, Halonen JP (1994) Infrared pupillometry in the assessment of autonomic function. Diabetes Res Clin Pract 26:61–66. doi:10.1016/0168-8227(94)90140-6

    PubMed  Article  CAS  Google Scholar 

  8. 8.

    Gavriysky VS (1995) Human pupillary light reflex during and after two-fold Valsalva maneuver. J Auton Nerv Syst 54:247–252. doi:10.1016/0165-1838(95)00017-R

    PubMed  Article  CAS  Google Scholar 

  9. 9.

    Fotiou F, Fountoulakis KN, Goulas A, Alexopoulos L, Palikaras A (2000) Automated standardized pupillometry with optical method for purposes of clinical practice and research. Clin Physiol 20:336–347. doi:10.1046/j.1365-2281.2000.00259.x

    PubMed  Article  CAS  Google Scholar 

  10. 10.

    El-Badawi A, Schenk EA (1966) Dual innervation of the mammalian urinary bladder: a histochemical study of the distribution of cholinergic and adrenergic nerves. Am J Anat 119(3):405–427. doi:10.1002/aja.1001190305

    PubMed  Article  CAS  Google Scholar 

  11. 11.

    Nergardh A, Boreus LO (1972) Autonomic receptor function in the lower urinary tract of man and cat. Scand J Urol Nephrol 6:32–36. doi:10.3109/00365597209132077

    PubMed  Article  CAS  Google Scholar 

  12. 12.

    Yoshimura N, Sasa M, Ohno Y, Yoshida O, Takaori S (1988) Contraction of urinary bladder by central norepinephrine originating in the locus coeruleus. J Urol 139:423–427

    PubMed  CAS  Google Scholar 

  13. 13.

    Yakinci C, Er H, Müngen B, Durmaz Y, Karabiber H (1999) Pupil cycle time in children with nocturnal enuresis. Tr J Med Sci 29:69–70

    Google Scholar 

  14. 14.

    Martyn CN, Ewing DJ (1986) Pupil cycle time: a simple way of measuring an autonomic reflex. J Neurol Neurosurg Psychiatry 49:771–774

    PubMed  Article  CAS  Google Scholar 

  15. 15.

    Popov I (1989) Autonomic infantilism. Med Pregl 42:41–44

    PubMed  CAS  Google Scholar 

  16. 16.

    Shaffer D (1985) Enuresis. In: Rutter M, Herso L (eds) Child and adolescent psychiatry: modern approaches. Blackwell Scientific, London, pp 465–481

    Google Scholar 

  17. 17.

    Fritz G, Rockney R, Bernet W et al (2004) Practice parameter for the assessment and treatment of children and adolescents with enuresis. J Am Acad Child Adolesc Psychiatry 43:1540–1550. doi:10.1097/01.chi.0000142196.41215.cc

    PubMed  Article  Google Scholar 

  18. 18.

    Forsythe WI, Redmond A (1974) Enuresis: spontaneous cure rate. Study of 1,129 enuretics. Arch Dis Child 49:259–263

    PubMed  Article  CAS  Google Scholar 

  19. 19.

    Feehan M, McGee R, Stanton W et al (1990) A 6 year follow-up of childhood enuresis: prevalence in adolescence and consequences for mental health. J Paediatr Child Health 26:75–79. doi:10.1111/j.1440-1754.1990.tb02390.x

    PubMed  Article  CAS  Google Scholar 

  20. 20.

    Ohtuka K, Nishimura Y, Kubo Y et al (1998) Chromos and chaos: heart rate variability in healthy Japanese. Auton Nerv Syst 35:271–279

    Google Scholar 

  21. 21.

    Broughton RJ (1968) Sleep disorders: disorders of arousal? Enuresis, somnambulism, and nightmares occur in confusional states of arousal, not in “dreaming sleep”. Science 159:1070–1078. doi:10.1126/science.159.3819.1070

    PubMed  Article  CAS  Google Scholar 

  22. 22.

    Sampei M, Dakeishi M, Wood DC et al (2007) Spontaneous awakening from nocturnal sleep and cardiac autonomic function in pre-school children. Auton Neurosci 133:170–174. doi:10.1016/j.autneu.2007.01.002

    PubMed  Article  Google Scholar 

  23. 23.

    Heller PH, Perry F, Jewett DL et al (1990) Autonomic components of the human pupillary light reflex. Invest Ophthalmol Vis Sci 31:156–162

    PubMed  CAS  Google Scholar 

  24. 24.

    Hill CE, Klemm M, Edwards FR et al (1993) Sympathetic transmission to the dilator muscle of the rat iris. J Auton Nerv Syst 45:107–123. doi:10.1016/0165-1838(93)90123-C

    PubMed  Article  CAS  Google Scholar 

  25. 25.

    Winn B, Whitaker D, Elliot DB et al (1994) Factors affecting light-adapted pupil size in normal human subjects. Invest Ophthalmol Vis Sci 35:1132–1137

    PubMed  CAS  Google Scholar 

  26. 26.

    Beatty J (1986) The pupillary system. In: Coles MGH, Donchin E, Porges SW (eds) Psychophysiology: systems, processes, and applications. Guilford Press, New York

    Google Scholar 

  27. 27.

    Hugdahl K (1995) Psychophysiology: the mind–body perspective. Harvard University Press, Cambridge, MA

    Google Scholar 

  28. 28.

    Lowestein O, Loewenfeld IE (1962) The pupil. In: Davson H (ed) The eye, vol 3: muscular mechanisms. Academic Press, New York, pp 231–267

    Google Scholar 

Download references

Author information



Corresponding author

Correspondence to Onur Sakallioglu.

Rights and permissions

Reprints and Permissions

About this article

Cite this article

Dundaroz, R., Turkbay, T., Erdem, U. et al. Pupillometric assessment of autonomic nervous system in children with functional enuresis. Int Urol Nephrol 41, 231 (2009). https://doi.org/10.1007/s11255-008-9481-1

Download citation


  • Autonomic dysregulation
  • Children
  • Enuresis
  • Pupillometry