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Childhood enuresis

Anne J Wright

Paediatrics and Child Health, Volume 26, Issue 8, August 2016, Pages 353–359

Commented by Konstantinos Kamperis

Enuresis is the second most common childhood chronic condition. Although a great deal of knowledge was gained during the last decades, not enough is known about the pathophysiology, evidence-based assessment and management of this condition.

In the current issue of Pediatrics and child health, Dr. Anne J Wright, Consultant Paediatrician at the Children’s Bladder Clinic, Evelina London Children’s Hospital, St Thomas’ Hospital, London, UK, gives a broad overview of the different types of enuresis, the current understanding of the pathophysiology and the logical approach towards its management.

Dr. Wright discusses the prevalence of enuresis and the definitions currently suggested by the International Children’s Continence Society through their standardization documents. The main pathophysiological mechanisms responsible are concisely presented offering a useful overview to clinicians that care for these children. These include sleep and arousal issues, nocturnal polyuria and bladder dysfunction.

Finally Dr. Wright summarizes our current knowledge on how to diagnose and treat the condition covering the use of desmopressin, the enuresis alarm, imipramine anticholinergics and combination treatments. Flow charts are provided as a tool for clinicians that seek a fast overview on the diagnosis and management of the condition.

SUMMARY

 

Enuresis/bedwetting/childhood incontinence is the second most common childhood chronic condition. However, unfortunately very little is known about the pathophysiology, evidence-based assessment and management of this condition. In the current issue of Pediatrics and child health, Dr Anne J Wright, Consultant Paediatrician at the Children’s Bladder Clinic, Evelina London Children’s Hospital, St Thomas’ Hospital, London, UK, gives a broad overview of the different types of enuresis, the current understanding of the pathophysiology and the logical approach towards its management.

Enuresis is a common phenomenon seen during childhood across cultures. According to the previous meta-analysis, the prevalence of enuresis was estimated to be 1.3%. The highest prevalence of 10% was seen at the age of 7 years (one or more episodes/1- 3 months) which progressively decreases with increase in age [3.1% at 11-12 years (one or more/month) and 0.5-1.7% at 16-17 years]. On longitudinal analysis of the medical research council (MRC) cohort data by employing different trajectories, it was estimated that approximately half of the children wetting at 4 years of age would have a good probability of wetting at 9 years and a third at 15 years of age.

There has been a difference in the definition of enuresis given by different societies. As per the current International Children’s Continence Society (ICCS) guidelines 2014, enuresis is defined as enuresis as frequently occurring (4 or more times per week) or infrequently (less than 4 times per week). Further, enuresis is classified as primary and secondary enuresis as well as monosymptomatic (MNE) which is enuresis in children without any other lower urinary tract symptoms (LUTS) or bladder dysfunction (excluding nocturia) and non-monosymptomatic (NMNE) where enuresis is accompanied by LUTS.

Lack of a normal circadian release of vasopressin during night-time was found to be responsible for enuresis and polyuria. However, it was only recently discovered that the underlying reason for enuresis is sleep-disordered arousal in response to the need to void. In sleep-disordered arousal, children are unable to wake in response to the signaling from their bladder to micturate. The other reasons are nocturnal polyuria – overproduction of urine during nighttime due to the failure of normal homeostatic mechanisms; bladder dysfunction due to a constitutionally smaller bladder or idiopathic overactive bladder with a small bladder capacity or a normal or large capacity bladder with a significant post void residual (PVR). Significantly greater number of children with clinical behavioural disorders have been reported to have enuresis.

For appropriate diagnosis and management, it is seen that a thorough history taking is most essential. By asking direct questions about wakeability from sleep and volumes and timing of urine passed during the night helps to give further etiological clues. Only for children with NMNE, it is recommended to conduct urine dipstick, abdominal palpation and lumbosacral spine examination with an anogenital examination if warranted. For management, uses the alarm to improve wakeability, desmopressin for polyuria and bladder training and an anticholinergic for symptoms of overactive bladder have been proved to be useful.


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Consensus Guidelines

Practical consensus guidelines for the management of enuresis. 
Evaluation and management of enuresis, a common condition, is not a priority in training programs for medical doctors (MDs), despite being a common condition.