Recommendations are identified as falling into one of four categories of endorsement. These categories, which are defined at the end of the "Major Recommendations" field, indicate the degree of importance or certainty of each recommendation.
Definitions
Enuresis is defined in the Diagnostic and Statistical Manual of Mental Disorders - Fourth Edition - text revision (DSM-IV-TR) as the repeated voiding of urine into the bed or clothes at least twice a week for at least 3 consecutive months in a child who is at least 5 years of age. The DSM-IV-TR definition also considers a child to be enuretic if the frequency or duration is less but there is associated distress or functional impairment. Nocturnal enuresis refers to voiding during sleep; diurnal enuresis defines wetting while awake. Primary enuresis occurs in children who have never been consistently dry through the night, while secondary enuresis refers to the resumption of wetting after at least 6 months of dryness.
Etiology and Clinical Presentation
There is a clear genetic component to enuresis. Compared with a 15% incidence of enuresis in children from nonenuretic families, 44% and 77% of children were enuretic when one or both parents, respectively, were themselves enuretic. Data are accumulating that link foci on two chromosomes with enuresis.
Sleep studies have demonstrated a random pattern of wetting that occurs in all stages of sleep in proportion to the amount of time spent in each stage. A subgroup of enuretic patients has been identified in whom there is no arousal to bladder distension and an unusual pattern of uninhibited bladder contractions prior to the enuretic episode. The dysfunctional arousal system during sleep may be a key etiologic factor for this subgroup of children. One specific sleep disorder, sleep apnea stemming from upper airway obstruction, has been associated with enuresis.
Developmental immaturity, including motor and language milestones, is relevant in the etiology of enuresis for some children, although the mechanism is unknown.
Identifiable psychological factors are clearly contributory in a minority of children with enuresis. These children are most frequently secondary enuretics who have experienced a stress, such as parental divorce, school trauma, sexual abuse, or hospitalization; their enuresis is a regressive symptom in response to the stress or trauma. Psychological factors can also be seen as etiologically central in the rare instance in which family disorganization or neglect has resulted in there never having been a reasonable effort made at toilet training. Other signs of neglect are usually evident in these cases.
Assessment
When enuresis is identified, either as the chief complaint or as an incidental part of an evaluation for another problem, the psychiatric assessment must be expanded to include enuresis-specific elements [MS]. In every instance both the parents and the child should be interviewed, and sensitivity to the emotional consequences of the symptom should be high. The enuresis-specific history should explore every aspect of urinary incontinence, with thorough review of the genitourinary and neurologic systems [MS]. A thorough physical examination is essential; enlarged adenoids or tonsils, bladder distension, fecal impaction, genital abnormalities, spinal cord anomaly, and neurologic signs should be noted [MS]. Routine laboratory tests need only include urinalysis and possibly urine culture; more invasive tests are pursued only with specific indications [CG]. First-morning specific gravity may be helpful in predicting who will respond to desmopressin acetate (DDAVP) treatments [OP]. A 2-week baseline record of wet and dry nights is useful [CG].
Treatment
Treatment is based on the findings of the assessment. Positive findings on history, physical examination, or laboratory tests are indications for specific treatments. Daytime wetting, abnormal voiding (unusual posturing, discomfort, straining, or a poor urine stream), a history of urinary tract infections or evidence of infection on urinalysis or culture, and genital abnormalities are indications for urologic referral and treatment [MS]. A history of constipation, encopresis, or palpable stool impaction suggests mechanical pressure on the bladder. Disimpaction and treatment leading to a healthy bowel regimen will often eliminate the enuresis [CG]. Snoring and enlarged tonsils or adenoids may signal sleep apnea and indicate specific treatment. Surgical correction of upper airway obstruction has led to improvement or cure of enuresis [CG].
Psychosocial problems directly contributory to enuresis (as opposed to co-occurring with or resulting from the symptom) are relatively rare. Enuresis can be assumed to be of psychological origin when a previously dry child begins wetting during a period of stress (parental divorce, out-of-home placement, school trauma, abuse, hospitalization, etc.). At an early age, control struggles between parent and child may focus on urination patterns as a "battlefield"; this struggle serves to maintain the enuresis symptom as the child matures. In the uncommon instance in which family disorganization or neglect has resulted in a failure to toilet train the child, the symptom is seen to have psychosocial etiology. Individual psychotherapy, crisis intervention, and family therapy are specific psychological treatments applied on an individual basis [CG]. Effective treatment of the underlying psychological problem eliminates the enuresis in such cases.
When the history and physical examination do not suggest a specific etiology and the urinalysis results are completely normal, uncomplicated monosymptomatic primary nocturnal enuresis is treated with nonspecific approaches. Supportive approaches should always include education, demystification, and ensuring that parents do not punish the child for enuretic episodes [MS]. Journal keeping, fluid restriction, and night awakening may also fit in the category of nonspecific supportive approaches [OP].
Conditioning, using a modern, portable, battery-operated alarm - along with a written contract, thorough instruction, frequent monitoring, over-learning, and intermittent reinforcement before discontinuation --- makes this behavioral treatment highly effective as the first line of treatment with cooperative, motivated families [MS].
Two medications, imipramine and DDAVP, have proven efficacy in the treatment of enuresis [OP]. Imipramine in a single bedtime dose of 1 to 2.5 mg/kg has been used for many years if conditioning treatment fails or is not feasible. Many studies document 40% to 60% effectiveness, although the relapse rate is as high as 50%. The mechanism of action of imipramine in treating enuresis is unknown and not conclusively related to blood level. Because of the possibility of cardiac arrhythmia associated with tricyclic antidepressants, including imipramine, a pretreatment electrocardiogram may be obtained to detect an underlying rhythm disorder (even though the highest dose used to treat enuresis is lower than the dose commonly used to treat depression).
DDAVP is a synthetic analog of the antidiuretic hormone (ADH) vasopressin, which decreases urine production at night when taken at bedtime. It is administered intranasally as a spray in doses of 10 to 40 micrograms (1-4 sprays) nightly; the lowest effective dose is determined empirically with each child. DDAVP is also available in 0.2-mg tablets applied in doses of 0.2 to 0.6 mg nightly. Water intoxication is a rare side effect but is serious enough to merit electrolyte monitoring if intercurrent illness complicates the picture during treatment [CG]. Studies of DDAVP have reported success rates of 10% to 65% and relapse rates as high as 80%. DDAVP can be prescribed for short periods, such as when the child is going to camp. Long-term administration has not been associated with depression of endogenous antidiuretic hormone secretion. The combination of DDAVP and a sustained-release anticholinergic agent may be more effective than DDAVP alone [OP].
Bladder-stretching exercises to increase functional bladder capacity have been used without consistent evidence of effectiveness, and the effort not to void despite considerable urgency is unpleasant for both the child and the family [NE]. Despite anecdotal reports, there is no empirical evidence to suggest efficacy of hypnotherapy, dietary manipulation, and desensitization to allergens [NE].
Definitions:
[MS] "Minimal Standards" are recommendations that are based on substantial empirical evidence (such as well-controlled, double-blind trials) or overwhelming clinical consensus. Minimal standards are expected to apply more than 95% of the time (i.e., in almost all cases). When the practitioner does not follow this standard of care in a particular case, the medical record should indicate the reason.
[CG] "Clinical Guidelines" are recommendations that are based on empirical evidence (such as open trials, case studies) and/or strong clinical consensus. Clinical guidelines apply approximately 75% of the time. These practices should always be considered by the clinician, but there are exceptions to their application.
[OP] "Options" are practices that are acceptable, but not required. There may be insufficient empirical evidence to support recommending these practices as minimal standards or clinical guidelines. In some cases they may be the perfect thing to do, but in other cases they should be avoided. If possible, the practice parameter will explain the pros and cons of these options.
[NE] "Not endorsed" refers to practices that are known to be ineffective or contraindicated.
