This document provides information about nocturnal enuresis (bedwetting), including its definition, epidemiology, etiology, diagnosis, and treatment. Nocturnal enuresis is defined as involuntary voiding during sleep at least twice a week for at least three months in a child aged 5 years or older. It affects more boys than girls and is often familial. Primary enuresis is caused by delayed cortical maturation while secondary enuresis can be caused by medical conditions. Treatment involves pharmacotherapy with desmopressin, imipramine, or anticholinergics as well as behavioral techniques like conditioning and alarms.

1. NOCTURNAL
ENURESIS 2019
Prof Dr Hussein H Abdeldayem. MD,DM
PROF OF PEDIATRIC NEUROLOGY,
FACULTY OF MEDICINE, ALEXANDRIA. UNIVERSITY

2. Enuresis
• Enuresis : passage of urine (Greek word ,enourein,)
• Nocturnal: at night time. /sleep time/
• Diurnal: at awake time
• Nocturnal and diurnal (nonmonosymptomatic enuresis)

3. NormalVoiding andToilet training
• Urine storage consists of sympathetic and pudendal nerve-mediated inhibition of
detrusor contractile activity accompanied by closure of the bladder neck and
proximal urethra with increased activity of the external sphincter
• The infant has reflex voiding as often as 15-20 times/day
• At 2-4yr, the child is developmentally ready to begin toilet training
• Overtime, bladder capacity increases. In children up to 14 yrs old the mean bladder
capacity in ounces is equal to age (in yrs) plus 2

4. Voluntary/ ConsciousVoiding
• Girls > boys
• Bowel control before bladder control
• NormalVoiding andToilet training:
oNormal bladder growth
oAbility to voluntary tighten the external sphincter
oCortical inhibition (suprapontine modulation) of reflex bladder contraction
oCortical awareness of bladder filling

5. Nocturnal enuresis
THE OCCURRENCE. OF VOIDING AT NIGHT (wet night)
• 1.at least twice /week
• 2.at least three consecutive months
• 3.mental age a least 5 ys old

6. DSM 5 Diagnostic Criteria
• Repeated voiding of urine in bed or clothes, whether involuntary or intentional
• The behavior either (a) occurs at least twice a week for at least 3 consecutive months
(b) results in clinically significant distress or social, functional or academic
impairment
• The behavior occurs in a child who is at least 5ys old(or has reached the equivalent
development level)
• The behavior cannot be attributed to the physiologic effects of a substance or other medical
condition

7. EPIDEMIOLOGY
• MORE IN BOYS* 60%
• LOWER SOCIOECONOMIC FAMILY
• LARGER FAMILIES
• INSTITUTIONALIZED CHILDREN
• FAMILY HISTORY +ve 50%
• 5y : 25%, 7y: 10%, 10y: 5%, Adults<1%
•

8. ETIOLOGY / CLASSIFICATION
85% PRIMARY
PRIMARY
2RY
75-90%
10-25%

9. Primary enuresis:The patient never
having been dry
Secondary: Patient having had a period of being dry and
then starting to wet

10. PRIMARY ENURESIS
PATHOGENESIS
• DELAY IN CORTICAL MATURATION
• DEEP SLEEPER
• IRRITANT DETRUSOR BLADDER MUSCLES
• SMALL BLADDER CAPACITY
• WEAK SPHINCTER
FAMILY HISTORY

11. FAMILY HISTORY ~50%
FH 1
NON
FH 1 (44%)
77%
23%
FH 2 (77%)
FH 2
NON
Polygenetics
Chromosome 12&13

12. SECONDARY ENURESIS *
( ACQUIRED )
• 1. URINARYTRACT INFECTION
• 2.IDDM
• 3. DI
• 4. SICKLE CELL ANEMIA
• 5. SPINAL CORD ABNORMALITY
• 6. CONSTIPATION
• 7. PINWORMS
• 8. Sleep disordered breathing
• 9.neurogenic bladder
• 10. Overactive bladder/ dysfunctional voiding
• 11. Others*
SECONDARYTO PSYCHICTRAUMA

13. DOC Role
1. History
• Fluid intake history
• Daytime voiding pattern
• Toilet training history
• Number and timing of episodes of bedwetting
• Sleep history
• FH of nocturnal enuresis
• Behavior , personality and emotional status

14. 2. O/E
• BP
• Inspect external genitalia
• Palpate abdomen especially kidney and suprapubic region
• Inspect and palpate lumbosacral region
• Examine LL:Tone , power , DTR , tip toe and heal gait

15. 3.INVESTIGATIONS
(exclude 2ry causes)
MUST
• BLOOD GLUCOSE
• URINEANALYSIS with specific gravity
• CBC and differential*
• U/S bladder: full and after voiding
•OCCASIONALLY
• Abdominal X RAY*
• URINE CULTURE
• SCOTCH TAPE FOR PINWORMS
• PSYHOLOGICALASSESSMENT

16. 4. Referral investigation
• Uroflowmetry with bladder scanning*
• U/S bladder before and after voiding
• Voiding cystography**
• Urodynamic studies and cystoscopy • MRI spine***

17. TREATMENT
•PHARMACOTHERAPY
• Desmopressin acetate (DDAVP)
• IMIPRAMINE
• ANTICHOLINERGIC
Mam
Child
DOC

18. CONDITIONING REFLEX
URINARY ALARM

19. Impact of N enuresis on children and family
• Low self esteem
• Shame
• Embarrassment
• Guilt
• Parent and siblings altitude toward the child
• Conflict between parent as response for enuresis
• Respond of peers *
• Avoid precipitation in school trips (sleep time)

20. N Enuresis is NOT the child fault
• Family predisposing genetic role
• Family predisposing condition
• Physiological disorder in voiding control
• Stressful home life
• Conflicts between parents
• Starting school
• A new sibling
• Moving to new home
• ADHD*
(not the cause but influence treatment outcome)

21. MATERNAL ROLE
Mother Role
• CHART INGWITH REWARSD FOR DRY NIGHTS
• MINOR REWARDS : daily then day after day and so
• MAIN REWARD:
REASSASS MONTHLY FORTHEVALUABLE
PREVIOUSLY CHOSEN REWARD BY PHYSIAN with
increasing the number of dry nights MONTHLY as 20/30
then 25/30 then 28/30 THEN 30/3 FOR three consecutive
months
Mam
Child
DOC

22. CHILD ROLE
• BLADDER CAPACITY
• SPHINCTERTRAINING
infrequent going toWC
with increasing in time before voiding
drink a lot during the first half of the day up to
6.00pm
• NIGHTTIME (6.00pm+)
VOIDING EVERY HOUR
Voiding before going to sleep
Parent should awake him hourly to void till
time of their sleeping
Avoid intake of water and drinks or food as
watermelon or orange or chocolate
Mam
Child
DOC

24. TREATMENT
•PHARMACOTHERAPY
• Desmopressin acetate (DDAVP):*intranasal, oral
• IMIPRAMINE*
• ANTICHOLINERGIC especially in urodynamic proven
instability ( eliminate bladder instability, urgency,
frequency )
Mam
Child
DOC
CONDITIONING REFLEX
URINARY ALARM
*RELAPSE

25. Desmopressin (DDAVP)
• Synthetic analogue ofADH
• Oral
• No more intranasal as leading to severe hyponatremia leading to seizures , brain edema (water
intoxication) and up to death so FDA not recommend it
• Mechanism : Na and water retention due to reabsorption from kidney
• Advantage: Rapid action so for special occasions as sleepovers
• Disadvantage:
o relapse
o Water intoxication and hyponatremia (Serious)

26. • Tablets of desmopressin
 1hr before sleep
Dose 200mcg, maximum 600mcg /dose. Begin with 100mg for a week
For certain occasions or long treatment ~3months plus

27. Imipramine
• Dose one tablet (25mg) up to two tablets . 1-2 hrs before bedtime
Disadvantages
• Cardiac: ECG changes, arrythmia (serous/fatal)
• High % Relapse
• Constipation
• CNS : Seizures , drowsiness

28. Anticholinergic /Antispasmodic Agents
oxybutynin (uripan)
• For those with small irritant/overactive bladder as with urgency and
frequency
• Dose : 5ml tds
• Duration 3 weeks
1ml/1mg

29. thank you