Primary Nocturnal Enuresis
By Philip E. Gleason, MD
In children, the bladder is a largely automatic or reflexic organ. Bladder distention promotes spontaneous voiding both day and night. Development of urinary control through the day and night often occurs spontaneously between ages 2-5. Ongoing bedwetting, or nocturnal enuresis, can still occur in approximately 12-15% of 6 year olds. It is often seen in 5% of 10 year olds. It has typically spontaneously resolved by approximately age 15. However, even then, approximately 1% of children will have ongoing nocturnal enuresis and this rarely carries over into the adult population.
Normal maturation of urinary control depends upon both central nervous system (CNS) and bladder physiologic maturation. In particular, CNS effects on the bladder produce a compliant, non-reflexic, inhibited bladder. CNS production of anti-diuretic hormone (ADH) also decreases the absolute volume of urine produced through the night, facilitating urine storage. Therefore, primary nocturnal enuresis is typically felt to represent delayed normal physiologic maturation of either bladder or CNS urinary control. It typically has no association with ongoing daytime wetting and should be differentiated from secondary enuresis in which there has been a dry interval of at least 6 months before resumption of bedwetting. In addition, enuresis associated with UTI's is felt to represent potentially more serious pathophysiology. Some of the earlier proposed etiologies of enuresis such as abnormally deep sleep, psychosocial stress, or atopic etiologies are felt to be possibly contributory but less than previously. There is a significant familial hereditary component to nocturnal enuresis. Children of one enuretic parent have an approximately 44% chance of having enuresis. Children with 2 enuretic parents have a 77% incidence.
Evaluation of enuresis typically includes a thorough history as well as physical exam and urinalysis (UA). If the history, physical exam, and UA are benign with the exception of primary (occurring since birth), monosymptomatic (no other associated symptoms of infections or hematuria or other neurologic symptoms), nocturnal (occurring at night with no daytime or diurnal enuresis) enuresis, the children require no further radiographic, urodynamic, or invasive evaluation. If, however, there is any association to diurnal enuresis or secondary enuresis, history of UTI's, or other neurologic symptoms or findings, then further referral and urologic evaluation is warranted.
The treatment of primary nocturnal enuresis involves both behavior modification and specific management. Behavior modification may involve an improved urinary voiding schedule as well as restriction of fluids after supper, with nocturnal bedtime voiding. Specific therapy includes use of the bed alarm, as well as medical therapy with either Tofranil or DDAVP spray or tablets. The bed alarm is felt to function through avoidance behavior conditioning. Tofranil affects anticholinergic relaxation and presumably increased functional storage capacity of the bladder. DDAVP medication supplements normal or diminished nocturnal production of ADH. Each therapy has its own specific logistics as well as risks and benefits and advantages and disadvantages, but all are felt to be safe and highly effective in the treatment of nocturnal enuresis.
The bed alarm can be obtained by mail order. The company seems to be very reputable. The bed alarm actually comes with a money back guarantee. If it does not work, you can return it and get your money back. I have had several families do this and they did in fact receive their money back. The company does not seem to be a fly-by-night organization. We would ask that you give the bed alarm at least a 6-week trial to see if it will become effective. Sometimes it takes a few days or a few weeks to see if it is really going to work or not. Certainly the biggest drawback to the bed alarm is that it may not wake your child up. It may wake you up or other family members or your dog or your next- door neighbor, but it may not wake your child up. If it does not, we will have to consider alternative treatment. If it is successful, however, we would typically continue this for about 6 months then stop its use and re-evaluate at that time to see if we need to continue it or not and proceed accordingly as described below.
Tofranil is an oral medication that can be used in the evenings to relax the bladder and help hold on to the urine and decrease bedwetting. It is an old fashioned medication that was originally used to treat depression. It was not very good for that. In fact, there are many other, much better anti-depressants that are used now. It is no longer used to treat depression. However, when it was used, it was discovered to have the benefit of decreasing bedwetting. We would again start with either 25mg or 50mg and use this for approximately 6 weeks to see if this will be effective and give this a fair try as it does take a few days or weeks to take effect. If it is working, we would continue again for about 6 months then taper off and re-evaluate and proceed accordingly. If it is not effective, we would increase the dosage to either 50mg or even, ultimately, up to 75mg each night. If the higher dose does not work, then we would have to consider another alternative treatment.
DDAVP was originally developed as a nasal spray. It has recently been formulated into a tablet as well. The spray and tablet both have some advantages and disadvantages, but both are easy to learn to use. We would typically start with 2 puffs of the nasal spray or 0.2mg of the tablet each night for approximately 2 weeks. If that were successful, we would continue that dosage. If it were not, we would increase to 3 puffs per night or 0.4mg tablets for another 2 weeks and re-evaluate. If successful, we would continue. If not, we would increase to 4 puffs nasally each evening or 0.6mg tablets. This is the highest recommended dosage. If this were successful, we would again continue for 6 months. If it were not, then we would have to consider alternative therapy.
Once we can discover a treatment which is working for you and which you like, we would typically continue the treatment for about 6 months. This allows some time for the body to grow and develop and for the bladder to grow and develop as well. At the end of 6 months, we would discontinue the therapy and see how you are doing. If you remain dry and have successfully outgrown the enuresis, you are all done and would not require any further management. If you begin to have resumption or recurrence of the bed wetting, we would typically resume the therapy and go another 6 months to give it a little more time. In many respects, we just continue working with the treatment until we can wear down the nocturnal enuresis and it will resolve. We will typically, therefore, continue treatment for 6 months then taper off and see you back in the office in about 7 months or approximately one month off the treatment to see how we are doing and how to proceed accordingly.
Education is provided to the family that therapy is a temporizing measure. Therapy ameliorates ongoing problems with nocturnal enuresis allowing normal delayed maturation of urinary control to progress at which time specific therapy can be discontinued. Successful therapy for primary nocturnal enuresis is a very gratifying process for the children, their family and the physician. It improves self-esteem and confidence allowing increased socialization and resumption of routine childhood activities.
In summary, successful management of primary nocturnal enuresis involves accurate diagnosis, successful therapy, and ultimate reassurance and patience. Diurnal enuresis, secondary enuresis or enuresis associated with UTI's or other neurologic symptomatology warrants further evaluation.
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