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Nocturnal Enuresis

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Overview

Also known as bedwetting, nocturnal enuresis describes the involuntary passing of urine during sleep. This can be normal in children under 5 years of age and most children achieve day and night time continence by around 3-4 years old.

Classification

Nocturnal enuresis can be classified as:

  • Primary nocturnal enuresis without daytime symptoms:
    • The person has never achieved continence at night time and does not have daytime symptoms
  • Primary nocturnal enuresis with daytime symptoms:
    • The person has never achieved continence at night and has daytime symptoms such as urgency, frequency, dysuria, poor urinary stream, or passing urine <4 times a day
  • Secondary nocturnal enuresis:
    • Nocturnal enuresis that occurs after the person has been previously dry at night for more than 6 months

Epidemiology

  • Nocturnal enuresis can be normal in children <5 years old
  • Most children achieve day and night time continence by 3-4 years old
  • Nocturnal enuresis is around 2 times more common in boys than girls

Causes

  • Primary nocturnal enuresis without daytime symptoms:
    • Deep sleep (e.g. inability to wake to noise or the sensation of a full bladder)
    • Polyuria – producing more urine at night than normal
    • Bladder dysfunction – overactive and/or small bladder
  • Primary nocturnal enuresis with daytime symptoms:
    • Overactive bladder
    • Urinary tract infections (UTIs)
    • Constipation
    • Structural abnormalities
    • Neurological disorders (e.g. neurogenic bladder)
  • Secondary nocturnal enuresis:
    • UTI
    • Constipation
    • Diabetes mellitus
    • Psychological problems (behavioural and/or emotional problems)
    • Family problems 

Assessment

History taking

Initially ask about:

  • Has toilet training been attempted and has it been attained?
    • If this has not been attempted, ask why
  • Are any daytime symptoms present?
    • These include urgency, frequency (>7 times a day), daytime wetting, poor urinary stream, straining, dysuria, infrequency (<4 times a day)
  • Have they previously been dry at night?
  • Consider screening for maltreatment if any of the following apply:
    • The child deliberately wets the bed
    • Parents/carers are seen or reported to punish the child despite being told that the symptoms are involuntary
    • The child has secondary daytime wetting or secondary nighttime wetting that persists despite adequate treatment in the absence of a clear cause (e.g. UTI) or clear stress that is not part of maltreatment (e.g. bereavement or parental separation)

Primary nocturnal enuresis

If the child has primary nocturnal enuresis without daytime symptoms, ask about:

  • The pattern of bedwetting:
    • How many nights per week
    • How much urine is passed
    • What times at night bed wetting occurs
    • If the child wakes up after bed wetting
  • The child’s fluid intake
  • The home situation such as if there is easy access to the toilet
  • Assess for constipation if the child is <5 years old as this can commonly cause bedwetting in younger children

If the child has primary nocturnal enuresis with daytime symptoms ask about:

  • The pattern of bedwetting:
    • Does it only happen in certain scenarios?
    • Does the child avoid toilets in school or similar settings?
    • Does the child go to the toilet more or less frequently than their peers?
  • Fluid intake
  • Consider assessing for:
    • Constipation
    • Urinary tract infections
    • Congenital malformations, such as dimples or a hairy patch on the back suggest spina bifida

Secondary nocturnal enuresis

  • Look for an underlying cause such as:
    • Constipation
    • UTI
    • Diabetes
    • Behavioural and/or emotional problems
    • Family problems
    • Child maltreatment

Investigations

Do not routinely perform urinalysis unless any of the following apply:

  • Bedwetting has started recently (over the past few days-weeks)
  • There are daytime symptoms
  • There are signs of illness
  • If a UTI is suspected
  • There are signs and or symptoms of diabetes mellitus

Management

Overview

Management involves:

  • Advice, such as:
    • Fluid intake, diet, toileting patterns, and positive reward systems agreed based on behaviour (e.g. rewards for using the toilet) rather than dry nights as nocturnal enuresis is involuntary
  • Enuresis alarm
  • Consider desmopressin if:
    • An enuresis alarm has been ineffective/is not desired or
    • Short-term control is desired
  • Refer to a specialist if initial measures have not helped

Prognosis

  • Most children with nocturnal enuresis and no daytime symptoms achieve continence by adolescence

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