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REVIEW ARTICLE
Year : 2012  |  Volume : 5  |  Issue : 1  |  Page : 14-17  

Elimination disorders: Enuresis


Department of Psychiatry, Dr. D. Y. Patil Medical College, Pimpri, Pune, Maharashtra, India

Date of Web Publication20-Jun-2012

Correspondence Address:
Vishal Patel
Department of Psychiatry, Dr. D. Y. Patil Medical College, Pimpri, Pune - 411 018, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0975-2870.97500

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  Abstract 

Enuresis is a common childhood condition which is usually treatable. Enuresis at any age can lead to embarrassment. This coupled with teasing by peers resulting in social withdrawal, avoidance of overnight stay at relatives, and friends can have a long term effect in relationships than the enuresis itself. Organic and psychological causes should be considered, especially with the late onset or exacerbation of existing enuresis. Principles of management should be focused to address any precipitating and maintaining factors and also provide appropriate advice and explanation.

Keywords: Oxybutynin, desmopressin, enuresis


How to cite this article:
Patel V, Golwalkar R, Beniwal S, Chaudhari B, Javdekar A, Saldanha D, Bhattacharya L. Elimination disorders: Enuresis. Med J DY Patil Univ 2012;5:14-7

How to cite this URL:
Patel V, Golwalkar R, Beniwal S, Chaudhari B, Javdekar A, Saldanha D, Bhattacharya L. Elimination disorders: Enuresis. Med J DY Patil Univ [serial online] 2012 [cited 2017 Jul 21];5:14-7. Available from: http://www.mjdrdypu.org/text.asp?2012/5/1/14/97500


  Introduction Top


Urinary continence in young children is achieved by the age of 3 or 4 years. However, approximately 7% of the children are enuretic above the age of 5 years which is a significant number and is a source of major concern for the parents of the child. The disorder of enuresis has been recognized for centuries. A scholarly review of the history of enuresis found references dating back 3550 years to Papyrus Ebers. [1] The term "Enuresis" in Greek means to void urine. Enuresis is the involuntary voiding of urine. It takes months for a toddler to master control over involuntary voiding of urine.

The prevalence of enuresis decreases with increasing age. The diagnosis of enuresis is not made until the child attains the chronological and developmental age of 5 years. Prevalence of enuresis varies between 2% and 5% among school children. [2] More often than not it is associated with stress and inconvenience as well as social and emotional stigmata to both children and their parents. Birth of a sibling, parental separation, and family discord is some of the common emotional problems which lead to the persistence of enuretic behaviour. Teasing from siblings, parental disapproval, and repeated treatment failure leads enuretic children to have low self-esteem. Enuresis has been defined according to the timing of episodes throughout the day. Episodes occurring only at night are referred to as nocturnal and in the large majority it is monosymptomatic [3] and not accompanied by daytime wetting or other urological conditions. Child either sleeps through or wakes up by the moisture. 30% of children have both nocturnal and daytime enuresis. [4] Most children display only nocturnal enuresis but some manifest diurnal or nocturnal or nocturnal-diurnal pattern. Two types of enuresis are as follows.

  1. Primary type-refers to children who have never established urinary continence.
  2. Secondary type-refers to the disturbance in bladder control (enuresis) develops after a period of established urinary continence.

  Etiology Top


Although multiple etiologies are involved in enuresis, three major mechanisms are thought to underline the enuretic problem: [1] low nocturnal release of vasopressin which may lead to increase of urinary volume and decreased osmolality; [2],[5] bladder abnormalities (small functional volume/ detrusor hyperactivity; [3] inability to achieve adequate arousal during sleep to experience bladder fullness. These mechanisms are not necessarily independent. Robertson et al.[6] found in 1% of enuretic adults it was the reduced sensitivity of kidneys to the diuretic effects of vasopressin to be the cause of enuresis. It is observed that enuresis tends to run in families. Approximately 65-70% of children of this disorder have first-degree relatives. A large pedigree points toward a specific genetic loci involving chromosome 22 in 40% of families and there is evidence to suggest genetic heterogeneity involving chromosomes 8, 12, and 13 among several others. [7] In some cases, it is the disorders of sleep or diurnal rhythm i.e., failure of the reticular activating system to produce adequate level of arousal during sleep to regulate bladder control result in enuresis. [8] EEG findings are still debated as enuretic episodes can occur during any EEG stage.

The available evidence suggests that a single unified theory of enuresis that applies to all children cannot be identified. There is a connection between enuresis and psychological disturbance that increases with age. Children with enuresis have significantly more developmental delays and minor neurological dysfunctions than non-enuretic children. The most commonly reported co-morbid diagnosis is attention deficit hyperactivity disorder (ADHD). [9] The association between behavioral disturbance and enuresis is stronger with secondary enuresis. Approximately 50% of the children with functional enuresis have emotional or behavioral symptoms due to a variety of causes that is related to stress, trauma or psychosocial crisis such as birth of a sibling, hospitalization, start of school, parental absence, etc. However, the role of these psychosocial stressors has been questioned. [10] Enuresis is also directly related to the functional bladder capacity [Table 1]. Detrusor muscle instability results in contractions when the bladder is only partly full, with reduced capacity, and daytime symptoms of urgency, frequency, and sometimes daytime wetting. Irregular patterns of micturition through the day, along with inadequate intake of fluid and chronic stress and anxiety, all contribute to detrusor instability. The main causes of daytime (Diurnal) and night time enuresis is shown in [Table 2] and [Table 3].
Table 1: Functional Bladder Capacity

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Table 2: Causes of Diurnal (Daytime) Enuresis

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Table 3: Causes of Secondary/Nocturnal Enuresis

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  Course and Prognosis Top


Enuresis remits spontaneously. In adults, nocturnal enuresis without daytime symptoms often signifies serious urological pathology. [11]


  Diagnosis Top


An extensive urological and sleep evaluation to rule out organic causes for enuresis should be carried out. A routine EEG is not required. Maturational indices may be helpful in developmental variance. A specific form of "Giggle incontinence" appears to result from altered muscle tone during laughter or emotionally intense moments should be routinely considered. Psychiatric evaluation of the child and parents to ascertain if there is any association of psychopathology as possible cause for the enuretic problem has to be kept in mind. Since there is a strong link between ADHD (9) and enuresis, evaluation of ADHD is a must for every enuretic child. The diagnosis of enuresis is based on the DSM-IV-TR (307.6) [12] diagnostic criteria which is given in [Table 4].
Table 4: Establishing the diagnosis

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  Treatment Top


In all children, the following principles of management are advocated after organic causes have been ruled out.

  • Address precipitating and maintaining factors.
  • Give appropriate explanation, advice and reassurance.
  • Consider appropriate behavioral techniques.
  • Consider the use of an enuresis alarm or medications (usually children over 7 years).
Mostly functional enuresis is treated by Pediatricians who prefer behavioural methods to pharmacological intervention. [13] These include fluid restrictions at bedtime, planned mid sleep awakenings for voiding in toilet, and rewards for successful nights.


  Medication for Enuresis Top


Most common used drugs are Desmopressin, TCA, Carbamazepine, and Reboxetine (Norepinephrine reuptake inhibitor). Out of these, desmopressin is seen as "first line" of the drug options. In general, medication is reserved for children aged 7 years and above. Occasionally, there is a case for its use in younger children.


  Desmopressin Top


This is a synthetic analog of arginine vasopressin (AVP). It makes renal tubules more permeable, resulting in greater water absorption and production of a smaller volume of more concentrated urine. [14]

Desmopressin is given as a tablet or as a nasal spray in the dose of 20-40 μg at bedtime. Because of the antidiuretic effect, the child and parents should be warned that excessive drinking of fluid at bedtime or through the night must be avoided. Otherwise fluid overload could result in hyponatremia, fits or coma, although such complications are extremely rare (in the order of one in a million). It is safe for a child to drink up to one glass of water (240 ml) in the 9 h period commencing 1 h before taking the medication. The medication should be stopped if the child is ill with fever, diarrhea, or vomiting. The only disadvantage of using the drug is its high cost.


  Tricyclic Antidepressants Top


Imipramine and other TCA such as amitriptyline have been found to be effective and useful in low doses (2 mg/kg nightly), if patients do not respond well to other behavioural interventions, if daytime and night time enuresis is present, or if mood/anxiety disorder is associated. TCAs have been found useful in many double-blind studies. [15] In an open trial of 22 children who were non-responsive to alarm method, desmopressin, and anticholinergic agents, 13 children (59%) responded to Reboxetine, a norepinephrine reuptake inhibitor with a non-cardio toxic side effect profile in the dose of 4 to 8 mg. This was found to be safer than Imipramine. [16] They are not used for an antidepressant effect, and their mode of action is not fully understood. Compared to desmopressin, there is a greater frequency of side effects, and therefore they are used as second-line of treatment under supervision. Once again, a treatment break every 3 months is advisable for longer use. Where there are symptoms of detrusor instability, such as daytime wetting, urgency, and frequency, use of anticholinergic such as oxybutynin will help day- and night-time symptoms by relaxing bladder smooth muscle and reducing involuntary detrusor contractions. Start with a small dose (e.g., 2.5 mg twice daily) and increase slowly to achieve the desired effect. Oxybutynin has been reported to produce significant improvements in 54% of cases. [17] A once daily modified release tablet is also available. It acts as a smooth muscle relaxant which blocks cholinergic receptors on detrusor muscle. It can be used in combination with desmopressin or even with TCAs. [18]


  Behaviour Therapy Top


Behavior therapy is based on classical conditioning principle. Since 1930s, the "bell and pad" method (Moisture sensitive blanket during enuretic episode sounds Bell and arouses the child) has had a success rate of 80-90% as well as high relapse rate (15-40%). One recent innovation has been the use of noninvasive ultrasound device that detects bladder size and gives feedback when bladder volume reaches critical size. [19]

Bladder training, encouragement, or reward for delaying the maturation has been used but the method is inferior to the bell and pad method.


  Psychotherapy Top


Concomitant use of psychotherapy may be useful in dealing with coexisting psychiatric problems, emotional issues, and family difficulties that are secondary to chronic enuresis. However, it has to be remembered that psychotherapy alone is ineffective in short-term treatment of enuresis.

 
  References Top

1.Edwin JM. Elimination Disorders. In: Sadock BJ, Sadok VA, Pedro R, editors. Comprehensive textbook of psychiatry. 9 th ed. 530 Walnut Street, Philadelphia: Lippincott Williams and Wilkins; 2009. p. 3624.  Back to cited text no. 1
    
2.Darling JC. Management of nocturnal enuresis. Trends Urology, Gynecol. Sexual Health 2010;15:18-22.   Back to cited text no. 2
    
3.Varan B, Saatc IU, Ozen S, Bakkaloðlu A, Beþbaþ N. Efficacy of oxybutynin, pseudoephedrine and indomethacin in the treatment of primary nocturnal enuresis. Turk J Pediatr 1996;38:155-9.  Back to cited text no. 3
    
4.Kalo BB, Bella H. Enuresis. Prevalence and associated factors among primary school children in Saudi Arabia. Acta Paediatr 1996;85:1217-22.  Back to cited text no. 4
[PUBMED]    
5.Aikawa T, Kasahara T, Uchiyama M. Circadian variation of plasma arginine vasopressin concentration or arginine vasopressin in enuresis. Scand J Urol Nephrol Suppl 1999;202:47-9.  Back to cited text no. 5
[PUBMED]    
6.Robertson G, Rittig S, Kovacs L, Gaskill MB, Zee P, Nanninga J. Pathophysiology and treatment of enuresis in adults. Scand J Urol Nephrol Suppl 1999;202:36-8.  Back to cited text no. 6
[PUBMED]    
7.Arnell H, Hjalmas k, Jagerval lM, Läckgren G, Stenberg A, Bengtsson B, et al. Genetics of primary nocturnal enuresis: Inheritance and suggestion of a second major gene on chromosome 12q. J Med Genet 1997;34:360-5.  Back to cited text no. 7
    
8.Neveus T, Lackgren G, Tuveno T, Hetta J, Hjälmås K, Stenberg A. Enuresis: Background and treatement. Scand J Urol Nephrol Suppl 2000;206:1-44.  Back to cited text no. 8
    
9.Robson Wl, Jackson HP, Blackhurst D, Leung AK. Enuresis in children with attention- deficit hyperactivity disorder. South Med J 1997;90:503-5.  Back to cited text no. 9
[PUBMED]  [FULLTEXT]  
10.Fergusson DM, Horwood LJ, Shannon FT. Factors related to the age of attainment of nocturnal bladder control. Pediatrics 1986;78:884-90.  Back to cited text no. 10
[PUBMED]    
11.Sakamoto K, Blaivas JG. Adult onset nocturnal enuresis. J Urol 2001;165:1914-7.  Back to cited text no. 11
[PUBMED]    
12.American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Text Revision. Washington DC: American Psychiatric Association; 2000.  Back to cited text no. 12
    
13.Skoog SJ, Stokes A, Turner KL. Oral Desmopressin: A randomized double blind placebo controlled study of effectiveness in children with primary nocturnal enuresis. J Urol 1997;158:1035-40.  Back to cited text no. 13
    
14.Glazener CM, Evans JH. Desmopressin for nocturnal enuresis in children. Cochrane Database Syst Rev 2000;2:CD002112.  Back to cited text no. 14
    
15.Glazener CM, Evans JH. Alarm interventions for nocturnal enuresis in children. Cochrane Database Syst Rev 2000;3:CD002112.  Back to cited text no. 15
[PUBMED]  [FULLTEXT]  
16.Elimination Disorders. In: Sadock BJ, Sadok VA, editors. Kaplan and Sadock's concise textbook of Clinical Psychiatry. 3 rd ed. Philadelphia: Lippincott Williams and Wilkins; 2008. p. 643.  Back to cited text no. 16
    
17.Caione P, Arena F, Biraghi M, Cigna RM, Chendi D, Chiozza ML, et al. Nocturnal enuresis and day time wetting: A multicentric trial with Oxbutynin and Desmopressin. Eur Urol 1997;31:459-63.  Back to cited text no. 17
[PUBMED]    
18.Kaneko K, Fujinaga S, Ohtomo Y, Shimizu T, Yamashiro Y. Combined pharmacotherapy of nocturnal enuresis. Pediatr Nephrol 2001;16:662-4.  Back to cited text no. 18
[PUBMED]  [FULLTEXT]  
19.Prêtlow RA. Treatment of nocturnal enuresis with an ultrasound bladder volume controlled alarm device. J Urol 1999;162:1224-8.  Back to cited text no. 19
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]


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  In this article
   Abstract
  Introduction
  Etiology
  Course and Prognosis
  Diagnosis
  Treatment
   Medication for E...
  Desmopressin
   Tricyclic Antide...
  Behaviour Therapy
  Psychotherapy
   References
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