Many cases of enuresis lack an identifiable cause. Common etiologies in children are constipation and neurodevelopmental disorders. Various etiologies have been discussed, including poor arousal from sleep, delayed bladder maturation decreased bladder capacity, and decreased vasopressin release. Enuresis has also been attributable to various medical conditions or medications listed in differential diagnoses seen below.
Risk factors for enuresis include unusual stress, low socioeconomic status, parental divorce, sibling birth, and family history of enuresis. Enuresis has high genetic susceptibility, with children having a rate of 44% if one parent wet the bed and rate of 77% if both parents had a history of wetting the bed. No specific gene has been linked to enuresis. Studies have found gene linkages on chromosomes 8, 12, 13, and 16.
Enuresis is seen in 20% of 5-years-old children. It is most frequently diagnosed in children at 7-years-old. The prevalence of enuresis in 7-years-old children is 5% to 10%. It is diagnosed in approximately 2% of adults. Enuresis occurs more frequently in boys than girls.
A study of the pathophysiology of enuresis found decreased nocturnal antidiuretic hormone (ADH) production in patients with enuresis. Due to the reduced ADH production, the patient has an increase in urine volume at night, leading to increased voiding. With this underlying pathophysiology in mind, treatments like desmopressin, an ADH analog, are used. Other theories for the pathophysiology of enuresis have included decreased bladder capacity or reduced arousal from sleep.
The 5th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) classifies enuresis as an elimination disorder. The DSM-5 Diagnostic Criteria are as follows:
Specifiers include the following subtypes:
Classification of enuresis:
In addition to the standard medical, surgical, and family histories, it is important to obtain more details regarding toilet training, nutrition, and sleep histories. Ask about any family history of enuresis and specific detailed questions that rule out differential diagnoses, such as urinary tract infection, constipation, seizure, diabetes, or sleep apnea.
Obtain a voiding diary that logs the wet days or wet nights (voiding pattern), the volume of urine, the volume of fluid intake (hydration history), and the urge to urinate on a provided scale. It can also include bed and wake times. Ideally, the diary should be done for at least three days consistently. Urine is collected using a collecting pan, also known as a "Texas Hat." The collecting pan can be obtained from the physician's office or medical supply stores.
Physical exam should include vital signs, neurological exam, and examination of the tonsilar size, suprapubic area, abdomen, external genitalia, and lumbosacral spine.
Urinalysis is often required to rule out urinary tract infection (UTI).
Bladder scan, uroflowmetry, or ultrasonography with post-void is often required for cases of suspected underlying anatomical cause. Consider voiding cystourethrography, cystoscopy, or urodynamic studies if abnormalities found on ultrasonography.
Imipramine level from serum is recommended in patients on the medication to ensure the medication does not reach a toxic level or obtains a therapeutic level. The therapeutic index (TI) for imipramine is greater than 60 ng/ml.
Seizure workup to assess for underlying epileptiform activity includes an MRI of the brain and electroencephalogram (EEG).
Abdominal X-ray if constipation is suspected.
Treatment is rarely initiated if a child is less than 7-years-old.
A study of various treatment modalities (behavioral strategies, desmopressin) found that some participants improved in the first week of the study before treatment started. The study demonstrated that the process of obtaining medical help itself could improve enuresis in some cases.
The following should be ruled out or considered in the differential diagnosis prior to diagnosing enuresis:
Normal development is children meeting milestones of being dry by day around 2-years-old, dry by night around 3-years-old, then able to toilet alone at 4-years-old. At 5-years-old, 15% of the children remain incontinent of urine. Due to these normal development milestones, enuresis cannot be diagnosed in children less than 5-years-old.
These include urinary tract infection (UTI), diabetes mellitus (DM), diabetes insipidus (DI), urethritis, seizure disorder, sickle cell disease, obstructive sleep apnea (OSA), neurogenic bladder, spina bifida, sleep disorder, genitourinary malformation, hyperthyroidism, constipation, central hormone abnormality, delayed bladder maturation, decreased bladder capacity, neurodevelopmental disorders 
Know causes include selective serotonin reuptake inhibitors (SSRI), bupropion, diuretic, and antipsychotics (risperidone).
Children with enuresis often experience increased stress, shame, and embarrassment due to enuresis. Other complications include genitourinary skin infections or rashes. There is also the financial burden of purchasing diapers, pull-ups, or replacing soiled linens or mattresses. In some cases, enuresis can continue into adolescents and adulthood.
Patients and their families should direct questions to their interprofessional team. The team will provide information on the most likely etiology of the enuresis. Parents will be provided the risk, benefits, and alternatives of various treatment options.
Parents should be provided psychoeducation that enuresis is common, not volitional, and resolves with time. Parents should be aware that children can develop stress and lowered self-esteem due to punishment or shame from enuresis. Parents should avoid blaming their child with enuresis. Parents should limit the intake of fluids in the evening. Children should be encouraged to go to the bathroom frequently during the day and before bedtime.
Effective treatment of patients with enuresis requires interprofessional communication and collaboration to improve patient outcomes. Healthcare providers should monitor children longitudinally for resolution, along with monitoring for the potential for associated urological, endocrine, and neurological abnormalities.
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