|Year : 2012 | Volume
| Issue : 1 | Page : 14-17
Elimination disorders: Enuresis
Vishal Patel, Rujuta Golwalkar, Sumit Beniwal, Bhushan Chaudhari, Archana Javdekar, Daniel Saldanha, Labanya Bhattacharya
Department of Psychiatry, Dr. D. Y. Patil Medical College, Pimpri, Pune, Maharashtra, India
|Date of Web Publication||20-Jun-2012|
Department of Psychiatry, Dr. D. Y. Patil Medical College, Pimpri, Pune - 411 018, Maharashtra
Source of Support: None, Conflict of Interest: None
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
| Introduction|| |
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.  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.  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  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.  Most children display only nocturnal enuresis but some manifest diurnal or nocturnal or nocturnal-diurnal pattern. Two types of enuresis are as follows.
- Primary type-refers to children who have never established urinary continence.
- Secondary type-refers to the disturbance in bladder control (enuresis) develops after a period of established urinary continence.
| Etiology|| |
Although multiple etiologies are involved in enuresis, three major mechanisms are thought to underline the enuretic problem:  low nocturnal release of vasopressin which may lead to increase of urinary volume and decreased osmolality; , bladder abnormalities (small functional volume/ detrusor hyperactivity;  inability to achieve adequate arousal during sleep to experience bladder fullness. These mechanisms are not necessarily independent. Robertson et al. 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.  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.  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).  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.  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].
| Course and Prognosis|| |
Enuresis remits spontaneously. In adults, nocturnal enuresis without daytime symptoms often signifies serious urological pathology. 
| Diagnosis|| |
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)  diagnostic criteria which is given in [Table 4].
| Treatment|| |
In all children, the following principles of management are advocated after organic causes have been ruled out.
Mostly functional enuresis is treated by Pediatricians who prefer behavioural methods to pharmacological intervention.  These include fluid restrictions at bedtime, planned mid sleep awakenings for voiding in toilet, and rewards for successful nights.
- 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).
| Medication for Enuresis|| |
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|| |
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. 
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|| |
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.  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.  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.  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. 
| Behaviour Therapy|| |
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. 
Bladder training, encouragement, or reward for delaying the maturation has been used but the method is inferior to the bell and pad method.
| Psychotherapy|| |
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.
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[Table 1], [Table 2], [Table 3], [Table 4]