Note: This guideline has been updated. The National Guideline Clearinghouse (NGC) is working to update this summary. The recommendations that follow are based on the previous version of the guideline.
Levels of evidence (1a-4) and grades of recommendation (A-C) are defined at the end of the "Major Recommendations" field.
Definition
Enuresis is the condition describing the symptom of incontinence during night. Any wetting during sleep above the age of 5 years is enuresis. However, most importantly, there is a single symptom only. Children with other lower urinary tract (LUT) symptoms and enuresis are said to have non-monosymptomatic enuresis. Thorough history-taking, excluding any other daytime symptoms, is mandatory before diagnosing monosymptomatic enuresis. Any associated urinary tract symptoms make the condition a 'daytime LUT condition'.
The condition is described as 'primary' when the symptom has existed always and the patient has not been dry for a period longer than 6 months. The condition is described as 'secondary' when there has been a symptom-free interval of 6 months. Genetically, enuresis is a complex and heterogeneous disorder. Loci have been described on chromosomes 12, 13 and 22. Three factors play an important pathophysiological role:
- High night-time urine output
- Night-time low bladder capacity or increased detrusor activity
- Arousal disorder
Due to an imbalance between night-time urine output and night-time bladder capacity, the bladder can become easily full at night and the child will either wake up to empty the bladder or will void during sleep if there is a lack of arousal from sleep.
Diagnosis
The diagnosis is obtained by history-taking. In a patient with monosymptomatic enuresis, no further investigations are needed. A voiding diary, registering the daytime bladder function and the night-time urine output will help to guide the treatment. Weighing diapers (nappies) in the morning and adding the volume of the morning void gives an estimate of the night-time urine production. Measuring the daytime bladder capacity gives an estimate of bladder capacity compared to normal values for age.
In most children, bedwetting is a familial problem, with most affected children found to have a history of bedwetting within the family.
Treatment
Before using alarm treatment or medication, simple therapeutic interventions should be considered.
Supportive Treatment Measures
Explaining the condition to the child and his parents helps to demystify the problem. Eating and drinking habits should be reviewed, stressing normal fluid intake during day and reducing fluid intake in the hours before sleep.
Keeping a chart depicting wet and dry nights has been shown to be successful.
Counselling, provision of information, positive reinforcement and increasing (and supporting) motivation of the child should be introduced first. There is a high level of evidence showing that supportive treatment is more successful than doing nothing, though the cure rate is not significantly high. However, supportive therapy as an initial management carries a high grade of recommendation.
If supportive measures have no success, further treatment modalities must be considered, of which pharmacological treatment and alarm treatment are the two most important.
Alarm Treatment
Alarm treatment is the best form of treatment for arousal disorder (Level of evidence: 1; Grade of recommendation: A). Initial success rates of 80% with low relapse rates are realistic, especially when night-time diuresis is not too high and bladder capacity is not too low.
Medication
In the case of high night-time diuresis, success rates of 70% can be obtained with desmopressine (DDAVP), either as a nasal spray, 10-40 micrograms, or as tablets, 200-400 micrograms (Level of evidence: 1; Grade of recommendation: A). However, relapse rates are high after DDAVP discontinuation.
In the case of a small bladder capacity, treatments with antispasmodics or anticholinergics are possible. However, when these medications are necessary, the condition is no longer considered to be monosymptomatic.
Imipramine, which has been popular in the treatment of enuresis, obtains only a moderate response rate of 50% and has a high relapse rate. Furthermore, cardiotoxicity and death with overdose are described. Its use should therefore be discouraged (Level of evidence: 1; Grade of recommendation: C).
Definitions:
Levels of Evidence
1a Evidence obtained from meta-analysis of randomized trials
1b Evidence obtained from at least one randomized trial
2a Evidence obtained from at least one well-designed controlled study without randomization
2b Evidence obtained from at least one other type of well-designed quasi-experimental study
3 Evidence obtained from well-designed non-experimental studies, such as comparative studies, correlation studies and case reports
4 Evidence obtained from expert committee reports or opinions or clinical experience of respected authorities
Grades of Recommendation
- Based on clinical studies of good quality and consistency addressing the specific recommendations and including at least one randomized trial
- Based on well-conducted clinical studies, but without randomized clinical studies
- Made despite the absence of directly applicable clinical studies of good quality
