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Nocturnal enuresis

Nocturnal enuresis (NE), also informally called bedwetting, is involuntary urination while asleep after the age at which bladder control usually begins[1]. Bedwetting in children and adults can result in emotional stress.[2] Complications can include urinary tract infections.[2][3][4]

For the Chris Brown song, see Wet the Bed.

Nocturnal enuresis

Nighttime urinary incontinence, sleepwetting, bedwetting

Pediatrics, Psychology, Urology

Most bedwetting is a developmental delay—not an emotional problem or physical illness. Only a small percentage (5 to 10%) of bedwetting cases have a specific medical cause.[5] Bedwetting is commonly associated with a family history of the condition.[6] Nocturnal enuresis is considered primary when a child has not yet had a prolonged period of being dry. Secondary nocturnal enuresis is when a child or adult begins wetting again after having stayed dry.


Treatments range from behavioral therapy, such as bedwetting alarms, to medication,[7][8] such as hormone replacement, and even surgery such as urethral dilatation. Since most bedwetting is simply a developmental delay, most treatment plans aim to protect or improve self-esteem.[5] Treatment guidelines recommend that the physician counsel the parents,[9] warning about psychological consequences caused by pressure, shaming, or punishment for a condition children cannot control.[5]


Bedwetting is the most common childhood complaint.[10][11][12]

How much the bedwetting limits social activities like sleep-overs and campouts

The degree of the social ostracism by peers

(Perceived) Anger, punishment, refusal and rejection by caregivers along with subsequent guilt

The number of failed treatment attempts

How long the child has been wetting

People with reported bedwetting issues are 2.7 times more likely to be diagnosed with .[31]

attention deficit hyperactivity disorder

increases urine production.[32]

Caffeine

Chronic can cause bed wetting.[33] When the bowels are full, it can put pressure on the bladder.[34] Often such children defecate normally, yet they retain a significant mass of material in the bowel which causes bedwetting.[35]

constipation

Infections and disease are more strongly connected with and with daytime wetting. Less than 5% of all bedwetting cases are caused by infection or disease, the most common of which is a urinary tract infection.[31]

secondary nocturnal enuresis

Patients with more severe neurological-developmental issues have a higher rate of bedwetting problems. One study of seven-year-olds showed that "handicapped and children" had a bedwetting rate almost three times higher than "non-handicapped children" (26.6% vs. 9.5%, respectively).[36]

intellectually disabled

Psychological issues (e.g., death in the family, , extreme bullying) are established as a cause of secondary nocturnal enuresis (a return to bedwetting), but are very rarely a cause of PNE-type bedwetting.[29][37] Bedwetting can also be a symptom of a pediatric neuropsychological disorder called PANDAS.[38]

sexual abuse

stemming from an upper airway obstruction[39] has been associated with bedwetting. Snoring and enlarged tonsils or adenoids are a sign of potential sleep apnea problems.[29]

Sleep apnea

can lead to bedwetting. During sleepwalking, the sleepwalker may think they are in another room. When the sleepwalker urinates during a sleepwalking episode, they usually think they are in the bathroom, and therefore urinate where they think the toilet should be. Cases of this have included opening a closet and urinating in it; urinating on the sofa, and simply urinating in the middle of the room.

Sleepwalking

Stress is a cause of people who return to wetting the bed. Researchers find that moving to a new town, parent conflict or divorce, arrival of a new baby, or loss of a loved one or pet can cause insecurity, contributing to returning bedwetting.

[13]

can first present as nocturnal enuresis. It is classically associated with polyuria, polydipsia, and polyphagia; weight loss, lethargy, and diaper candidiasis may also be present in those with new-onset disease.

Type 1 diabetes mellitus

is a leading cause for nocturnal enuresis among adults. Alcohol suppresses the production of anti diuretic hormones and irritates the detrusor muscle in the bladder. These factors, paired with the large amount of fluid ingested, particularly during binge drinking sessions or when paired with caffeinated drinks, can lead to episodes of nocturnal enuresis.[40]

Alcohol intoxication

Mechanism[edit]

Two physical functions prevent bedwetting. The first is a hormone that reduces urine production at night. The second is the ability to wake up when the bladder is full. Children usually achieve nighttime dryness by developing one or both of these abilities. There appear to be some hereditary factors in how and when these develop.[48]


The first ability is a hormone cycle that reduces the body's urine production. At about sunset each day, the body releases a minute burst of antidiuretic hormone (also known as arginine vasopressin or AVP). This hormone burst reduces the kidney's urine output well into the night so that the bladder does not get full until morning. This hormone cycle is not present at birth. Many children develop it between the ages of two and six years old, others between six and the end of puberty, and some not at all.[49]


The second ability that helps people stay dry is waking when the bladder is full. This ability develops in the same age range as the vasopressin hormone, but is separate from that hormone cycle.


The typical development process begins with one- and two-year-old children developing larger bladders and beginning to sense bladder fullness. Two- and three-year-old children begin to stay dry during the day. Four- and five-year-olds develop an adult pattern of urinary control and begin to stay dry at night.[5]

People are asked to observe, record and measure when and how much their child voids and drinks, as well as associated symptoms. A voiding diary in the form of a frequency volume chart records voided volume along with the time of each micturition for at least 24 hours. The frequency volume chart is enough for patients with complaints of nocturia and frequency only. If other symptoms are also present then a detailed bladder diary must be maintained. In a bladder diary, times of micturition and voided volume, incontinence episodes, pad usage, and other information such as fluid intake, the degree of urgency, and the degree of incontinence are recorded.

[50]

Motivational therapy in nocturnal enuresis mainly involves parent and child education. Guilt should be allayed by providing facts. Fluids should be restricted 2 hours prior to bed. The child should be encouraged to empty the bladder completely prior to going to bed. Positive reinforcement can be initiated by setting up a diary or chart to monitor progress and establishing a system to reward the child for each night that they are dry. The child should participate in morning cleanup as a natural, nonpunitive consequence of wetting. This method is particularly helpful in younger children (<8 years) and will achieve dryness in 15-20% of the patients.[61][62]

[60]

Waiting: Almost all children will outgrow bedwetting. For this reason, urologists and pediatricians frequently recommend delaying treatment until the child is at least six or seven years old. Physicians may begin treatment earlier if they perceive the condition is damaging the child's self-esteem and/or relationships with family/friends.

[63]

Bedwetting alarms: Physicians also frequently suggest which sound a loud tone when they sense moisture. This can help condition the child to wake at the sensation of a full bladder.[64] These alarms are considered more effective than no treatment and may have a lower risk of adverse events than some medical therapies but it is still uncertain if alarms are more effective than other treatments.[65] There may be a 29% to 69% relapse rate, so the treatment may need to be repeated.[66]

bedwetting alarms

DDAVP () tablets are a synthetic replacement for antidiuretic hormone, the hormone that reduces urine production during sleep. Desmopressin is usually used in the form of desmopressin acetate, DDAVP. Patients taking DDAVP are 4.5 times more likely to stay dry than those taking a placebo.[66] The drug replaces the hormone for that night with no cumulative effect. US drug regulators have banned using desmopressin nasal sprays for treating bedwetting since the oral form is considered safer.

desmopressin

DDAVP is most efficient in children with nocturnal polyuria (nocturnal urine production greater than 130% of expected bladder capacity for age) and normal bladder reservoir function (maximum voided volume greater than 70% of expected bladder capacity for age).[68] Other children who are likely candidates for desmopressin treatment are those in whom alarm therapy has failed or those considered unlikely to comply with alarm therapy. It can be very useful for summer camp and sleepovers to prevent enuresis.[61]

[67]

Tricyclic antidepressants: prescription drugs with anti-muscarinic properties have been proven successful in treating bedwetting, but also have an increased risk of side effects, including death from overdose.[69] These drugs include amitriptyline, imipramine and nortriptyline. Studies find that patients using these drugs are 4.2 times as likely to stay dry as those taking a placebo.[66] The relapse rates after stopping the medicines are close to 50%.

Tricyclic antidepressant

Epidemiology[edit]

Doctors frequently consider bedwetting as a self-limiting problem, since most children will outgrow it. Children 5 to 9 years old have a spontaneous cure rate of 14% per year. Adolescents 10 to 18 years old have a spontaneous cure rate of 16% per year.[76]


As can be seen from the numbers above, a portion of bedwetting children will not outgrow the problem. Adult rates of bedwetting show little change due to spontaneous cure. Persons who are still enuretic at age 17 are likely to deal with bedwetting throughout their lives.[76]


Studies of bedwetting in adults have found varying rates. The most quoted study in this area was done in the Netherlands. It found a 0.5% rate for 20- to 79-year-olds. A Hong Kong study, however, found a much higher rate. The Hong Kong researchers found a bedwetting rate of 2.3% in 16- to 40-year-olds.[76]

Enuresis

Nocturnal emission