Nocturnal enuresis in children: Etiology and evaluation
- Naiwen D Tu, MD
Naiwen D Tu, MD
- Texas Children's Pediatrics - Pediatric Medical Group
- Laurence S Baskin, MD, FAAP
Laurence S Baskin, MD, FAAP
- Section Editor — Pediatric Urology
- Frank Hinman, Jr., MD, Distinguished Professorship in Pediatric Urology
- Chief Pediatric Urology
- Professor of Urology and Pediatrics
- UCSF Benioff Children's Hospital
- Anne M Arnhym, CPNP
Anne M Arnhym, CPNP
- Certified Pediatric Nurse Practitioner
- UCSF Pediatric Urology
- Section Editors
- Jan E Drutz, MD
Jan E Drutz, MD
- Section Editor — General Pediatrics
- Professor of Pediatrics
- Baylor College of Medicine
- Carolyn Bridgemohan, MD
Carolyn Bridgemohan, MD
- Section Editor — Developmental and Behavioral Pediatrics
- Assistant Professor of Pediatrics
- Harvard Medical School
Urinary incontinence is a common problem in children. At five years of age, 15 percent of children are incompletely continent of urine. Most of these children have isolated nocturnal enuresis (monosymptomatic nocturnal enuresis).
An overview of the causes and evaluation of nocturnal enuresis in children will be presented here. The management of nocturnal enuresis and bladder dysfunction are discussed separately. (See "Nocturnal enuresis in children: Management" and "Etiology and clinical features of bladder dysfunction in children" and "Evaluation and diagnosis of bladder dysfunction in children" and "Management of bladder dysfunction in children".)
The International Children's Continence Society (ICCS) has developed standardized terminology for lower urinary tract function and malfunction in children .
Enuresis (synonymous with intermittent nocturnal incontinence) refers to discrete episodes of urinary incontinence during sleep in children ≥5 years of age . Enuresis is divided into monosymptomatic and non-monosymptomatic forms.
Monosymptomatic enuresis is defined as enuresis in children without any other lower urinary tract symptoms and without a history of bladder dysfunction . Monosymptomatic nocturnal enuresis usually is divided into primary and secondary forms. Children who have never achieved a satisfactory period of nighttime dryness have primary enuresis. An estimated 80 percent of children with nocturnal enuresis have this form. Children who develop enuresis after a dry period of at least six months have secondary enuresis . Secondary enuresis often is ascribed to an unusually stressful event (eg, parental divorce, birth of a sibling) at a time of vulnerability in a child's life. Stool retention and suboptimal daytime voiding habits often play a role. However, the exact cause of secondary enuresis may remain unknown.
Subscribers log in hereLiterature review current through: Jun 2017. | This topic last updated: Jul 12, 2017.References
- Nevéus T, von Gontard A, Hoebeke P, et al. The standardization of terminology of lower urinary tract function in children and adolescents: report from the Standardisation Committee of the International Children's Continence Society. J Urol 2006; 176:314.
- von Gontard A, Mauer-Mucke K, Plück J, et al. Clinical behavioral problems in day- and night-wetting children. Pediatr Nephrol 1999; 13:662.
- Neveus T, Eggert P, Evans J, et al. Evaluation of and treatment for monosymptomatic enuresis: a standardization document from the International Children's Continence Society. J Urol 2010; 183:441.
- Koff S. Enuresis. In: Campbell's Urology, 7th ed, Walsh P, Retik A Jr, et al (Eds), WB Saunders, Philadelphia 1998. p.2055.
- Rushton HG. Wetting and functional voiding disorders. Urol Clin North Am 1995; 22:75.
- Fergusson DM, Horwood LJ, Shannon FT. Factors related to the age of attainment of nocturnal bladder control: an 8-year longitudinal study. Pediatrics 1986; 78:884.
- Bakker E, van Sprundel M, van der Auwera JC, et al. Voiding habits and wetting in a population of 4,332 Belgian schoolchildren aged between 10 and 14 years. Scand J Urol Nephrol 2002; 36:354.
- Howe AC, Walker CE. Behavioral management of toilet training, enuresis, and encopresis. Pediatr Clin North Am 1992; 39:413.
- Forsythe WI, Redmond A. Enuresis and spontaneous cure rate. Study of 1129 enuretis. Arch Dis Child 1974; 49:259.
- Klackenberg G. Nocturnal enuresis in a longitudinal perspective. A primary problem of maturity and/or a secondary environmental reaction? Acta Paediatr Scand 1981; 70:453.
- Esperanca M, Gerrard JW. Nocturnal enuresis: studies in bladder function in normal children and enuretics. Can Med Assoc J 1969; 101:324.
- Bloom DA, Seeley WW, Ritchey ML, McGuire EJ. Toilet habits and continence in children: an opportunity sampling in search of normal parameters. J Urol 1993; 149:1087.
- Michel RS. Toilet training. Pediatr Rev 1999; 20:240.
- Stadtler AC, Gorski PA, Brazelton TB. Toilet training methods, clinical interventions, and recommendations. American Academy of Pediatrics. Pediatrics 1999; 103:1359.
- Wille S. Primary nocturnal enuresis in children. Background and treatment. Scand J Urol Nephrol Suppl 1994; 156:1.
- Nørgaard JP, Djurhuus JC. The pathophysiology of enuresis in children and young adults. Clin Pediatr (Phila) 1993; Spec No:5.
- Nørgaard JP. Pathophysiology of nocturnal enuresis. Scand J Urol Nephrol Suppl 1991; 140:1.
- Dossche L, Walle JV, Van Herzeele C. The pathophysiology of monosymptomatic nocturnal enuresis with special emphasis on the circadian rhythm of renal physiology. Eur J Pediatr 2016; 175:747.
- Nevéus T. Pathogenesis of enuresis: Towards a new understanding. Int J Urol 2017; 24:174.
- Baker BL. Symptom treatment and symptom substitution in enuresis. J Abnorm Psychol 1969; 74:42.
- Young GC, Morgan RT. Conditioning techniques and enuresis. Med J Aust 1973; 2:329.
- Longstaffe S, Moffatt ME, Whalen JC. Behavioral and self-concept changes after six months of enuresis treatment: a randomized, controlled trial. Pediatrics 2000; 105:935.
- Järvelin MR. Developmental history and neurological findings in enuretic children. Dev Med Child Neurol 1989; 31:728.
- Light L. Children with enuresis. Most cases of primary nocturnal enuresis are caused by isolated developmental immaturity. BMJ 1998; 316:777.
- Koff SA. Cure of nocturnal enuresis: why isn't desmopressin very effective? Pediatr Nephrol 1996; 10:667.
- Järvelin MR, Moilanen I, Kangas P, et al. Aetiological and precipitating factors for childhood enuresis. Acta Paediatr Scand 1991; 80:361.
- von Gontard A, Freitag CM, Seifen S, et al. Neuromotor development in nocturnal enuresis. Dev Med Child Neurol 2006; 48:744.
- Iscan A, Ozkul Y, Unal D, et al. Abnormalities in event-related potential and brainstem auditory evoked response in children with nocturnal enuresis. Brain Dev 2002; 24:681.
- Freitag CM, Röhling D, Seifen S, et al. Neurophysiology of nocturnal enuresis: evoked potentials and prepulse inhibition of the startle reflex. Dev Med Child Neurol 2006; 48:278.
- Watanabe H, Azuma Y. A proposal for a classification system of enuresis based on overnight simultaneous monitoring of electroencephalography and cystometry. Sleep 1989; 12:257.
- Bakwin H. Enuresis in twins. Am J Dis Child 1971; 121:222.
- Bakwin H. The genetics of enuresis. In: Bladder Control and Enuresis, Kolvin RM, Meadows SR (Eds), Medical Books Ltd, London 1973. p.73.
- Eiberg H, Berendt I, Mohr J. Assignment of dominant inherited nocturnal enuresis (ENUR1) to chromosome 13q. Nat Genet 1995; 10:354.
- Loeys B, Hoebeke P, Raes A, et al. Does monosymptomatic enuresis exist? A molecular genetic exploration of 32 families with enuresis/incontinence. BJU Int 2002; 90:76.
- Koff SA. Estimating bladder capacity in children. Urology 1983; 21:248.
- MUELLNER SR. Development of urinary control in children: some aspects of the cause and treatment of primary enuresis. J Am Med Assoc 1960; 172:1256.
- Starfield B. Functional bladder capacity in enuretic and nonenuretic children. J Pediatr 1967; 70:777.
- Wu HH, Chen MY, Lee YH, et al. Urodynamic studies in primary nocturnal enuresis. Zhonghua Yi Xue Za Zhi (Taipei) 1988; 41:227.
- Jalkut MW, Lerman SE, Churchill BM. Enuresis. Pediatr Clin North Am 2001; 48:1461.
- VULLIAMY D. The day and night output of urine in enuresis. Arch Dis Child 1956; 31:439.
- Robson WL. Clinical practice. Evaluation and management of enuresis. N Engl J Med 2009; 360:1429.
- Troup CW, Hodgson NB. Nocturnal functional bladder capacity in enuretic children. Wis Med J 1971; 70:171.
- Kawauchi A, Tanaka Y, Naito Y, et al. Bladder capacity at the time of enuresis. Urology 2003; 61:1016.
- POULTON EM. Relative nocturnal polyuria as a factor in enuresis. Lancet 1952; 2:906.
- Rasmussen PV, Kirk J, Borup K, et al. Enuresis nocturna can be provoked in normal healthy children by increasing the nocturnal urine output. Scand J Urol Nephrol 1996; 30:57.
- Aikawa T, Kasahara T, Uchiyama M. The arginine-vasopressin secretion profile of children with primary nocturnal enuresis. Eur Urol 1998; 33 Suppl 3:41.
- Rittig S, Knudsen UB, Nørgaard JP, et al. Diurnal variation of plasma atrial natriuretic peptide in normals and patients with enuresis nocturna. Scand J Clin Lab Invest 1991; 51:209.
- Pomeranz A, Abu-Kheat G, Korzets Z, Wolach B. Night-time polyuria and urine hypo-osmolality in enuretics identified by nocturnal sequential urine sampling--do they represent a subset of relative ADH-deficient subjects? Scand J Urol Nephrol 2000; 34:199.
- Aceto G, Penza R, Delvecchio M, et al. Sodium fraction excretion rate in nocturnal enuresis correlates with nocturnal polyuria and osmolality. J Urol 2004; 171:2567.
- Rittig S, Schaumburg HL, Siggaard C, et al. The circadian defect in plasma vasopressin and urine output is related to desmopressin response and enuresis status in children with nocturnal enuresis. J Urol 2008; 179:2389.
- Yeung CK, Sit FK, To LK, et al. Reduction in nocturnal functional bladder capacity is a common factor in the pathogenesis of refractory nocturnal enuresis. BJU Int 2002; 90:302.
- George CP, Messerli FH, Genest J, et al. Diurnal variation of plasma vasopressin in man. J Clin Endocrinol Metab 1975; 41:332.
- Rittig S, Matthiesen TB, Pedersen EB, Djurhuus JC. Circadian variation of angiotensin II and aldosterone in nocturnal enuresis: relationship to arterial blood pressure and urine output. J Urol 2006; 176:774.
- Kawauchi A, Watanabe H, Nakagawa S, Miyoshi K. [Development of bladder capacity, nocturnal urinary volume and urinary behavior in nonenuretic and enuretic children]. Nihon Hinyokika Gakkai Zasshi 1993; 84:1811.
- Kawauchi A, Watanabe H, Miyoshi K. Early morning urine osmolality in nonenuretic and enuretic children. Pediatr Nephrol 1996; 10:696.
- Yeung CK, Chiu HN, Sit FK. Bladder dysfunction in children with refractory monosymptomatic primary nocturnal enuresis. J Urol 1999; 162:1049.
- Nørgaard JP, Hansen JH, Nielsen JB, et al. Simultaneous registration of sleep-stages and bladder activity in enuresis. Urology 1985; 26:316.
- Norgaard J. Urodynamic in enuretics: I. Reservoir function. Neurourol Urodynamics 1989; 8:199.
- Norgaard J. Urodynamics in enuretics: II. A pressure-flow study. Neurourol Urodynamics 1989; 8:213.
- Van Hoeck K, Bael A, Lax H, et al. Urine output rate and maximum volume voided in school-age children with and without nocturnal enuresis. J Pediatr 2007; 151:575.
- Nørgaard JP, Hansen JH, Nielsen JB, et al. Nocturnal studies in enuretics. A polygraphic study of sleep-EEG and bladder activity. Scand J Urol Nephrol Suppl 1989; 125:73.
- Nørgaard JP, Hansen JH, Wildschiøtz G, et al. Sleep cystometries in children with nocturnal enuresis. J Urol 1989; 141:1156.
- Broughton RJ. Sleep disorders: disorders of arousal? Enuresis, somnambulism, and nightmares occur in confusional states of arousal, not in "dreaming sleep". Science 1968; 159:1070.
- Wille S. Nocturnal enuresis: sleep disturbance and behavioural patterns. Acta Paediatr 1994; 83:772.
- Nevéus T, Hetta J, Cnattingius S, et al. Depth of sleep and sleep habits among enuretic and incontinent children. Acta Paediatr 1999; 88:748.
- Wolfish NM, Pivik RT, Busby KA. Elevated sleep arousal thresholds in enuretic boys: clinical implications. Acta Paediatr 1997; 86:381.
- Hunsballe JM. Increased delta component in computerized sleep electroencephalographic analysis suggests abnormally deep sleep in primary monosymptomatic nocturnal enuresis. Scand J Urol Nephrol 2000; 34:294.
- Yeung CK, Diao M, Sreedhar B. Cortical arousal in children with severe enuresis. N Engl J Med 2008; 358:2414.
- Ritvo ER, Ornitz EM, Gottlieb F, et al. Arousal and nonarousal enuretic events. Am J Psychiatry 1969; 126:77.
- Bader G, Nevéus T, Kruse S, Sillén U. Sleep of primary enuretic children and controls. Sleep 2002; 25:579.
- Nevéus T, Stenberg A, Läckgren G, et al. Sleep of children with enuresis: a polysomnographic study. Pediatrics 1999; 103:1193.
- Wille S, Anveden I. Social and behavioural perspectives in enuretics, former enuretics and non-enuretic controls. Acta Paediatr 1995; 84:37.
- Joinson C, Heron J, Butler R, et al. A United Kingdom population-based study of intellectual capacities in children with and without soiling, daytime wetting, and bed-wetting. Pediatrics 2007; 120:e308.
- Hägglöf B, Andrén O, Bergström E, et al. Self-esteem before and after treatment in children with nocturnal enuresis and urinary incontinence. Scand J Urol Nephrol Suppl 1997; 183:79.
- Baeyens D, Roeyers H, Hoebeke P, et al. Attention deficit/hyperactivity disorder in children with nocturnal enuresis. J Urol 2004; 171:2576.
- Mellon MW, Natchev BE, Katusic SK, et al. Incidence of enuresis and encopresis among children with attention-deficit/hyperactivity disorder in a population-based birth cohort. Acad Pediatr 2013; 13:322.
- Nevéus T. Diagnosis and management of nocturnal enuresis. Curr Opin Pediatr 2009; 21:199.
- Ullom-Minnich MR. Diagnosis and management of nocturnal enuresis. Am Fam Physician 1996; 54:2259.
- Robson WL, Leung AK. Secondary nocturnal enuresis. Clin Pediatr (Phila) 2000; 39:379.
- Readett DR, Morris JS, Serjeant GR. Nocturnal enuresis in sickle cell haemoglobinopathies. Arch Dis Child 1990; 65:290.
- Cinar U, Vural C, Cakir B, et al. Nocturnal enuresis and upper airway obstruction. Int J Pediatr Otorhinolaryngol 2001; 59:115.
- Firoozi F, Batniji R, Aslan AR, et al. Resolution of diurnal incontinence and nocturnal enuresis after adenotonsillectomy in children. J Urol 2006; 175:1885.
- Brooks LJ, Topol HI. Enuresis in children with sleep apnea. J Pediatr 2003; 142:515.
- Basha S, Bialowas C, Ende K, Szeremeta W. Effectiveness of adenotonsillectomy in the resolution of nocturnal enuresis secondary to obstructive sleep apnea. Laryngoscope 2005; 115:1101.
- Mayers CP, Purvis RJ. Manifestations of pinworms. Can Med Assoc J 1970; 103:489.
- Sachdev YV, Howards SS. Enterobius vermicularis infestation and secondary enuresis. J Urol 1975; 113:143.
- National Institute for Health and Care Excellence. Nocturnal enuresis - the management of bedwetting in children and young people. www.nice.org.uk/guidance/index.jsp?action=download&o=51367 (Accessed on February 28, 2011).
- Vande Walle J, Rittig S, Bauer S, et al. Practical consensus guidelines for the management of enuresis. Eur J Pediatr 2012; 171:971.
- McGrath KH, Caldwell PH, Jones MP. The frequency of constipation in children with nocturnal enuresis: a comparison with parental reporting. J Paediatr Child Health 2008; 44:19.
- Robson WL, Leung AK, Van Howe R. Primary and secondary nocturnal enuresis: similarities in presentation. Pediatrics 2005; 115:956.
- Rushton HG. Evaluation of the enuretic child. Clin Pediatr (Phila) 1993; Spec No:14.
- Kovacevic L, Wolfe-Christensen C, Mirkovic J, et al. Renal bladder ultrasound evaluation in monosymptomatic primary nocturnal enuresis: is it really necessary? Pediatr Nephrol 2014; 29:1189.
- Hodges SJ, Anthony EY. Occult megarectum--a commonly unrecognized cause of enuresis. Urology 2012; 79:421.
- Pippi Salle JL, Capolicchio G, Houle AM, et al. Magnetic resonance imaging in children with voiding dysfunction: is it indicated? J Urol 1998; 160:1080.
- Yeung CK, Sreedhar B, Sihoe JD, et al. Differences in characteristics of nocturnal enuresis between children and adolescents: a critical appraisal from a large epidemiological study. BJU Int 2006; 97:1069.
- EPIDEMIOLOGY AND NATURAL HISTORY
- BLADDER MATURATION
- Maturational delay
- Small bladder capacity
- Nocturnal polyuria
- - Role of ADH
- Detrusor overactivity
- Disturbed sleep
- ASSOCIATED CONDITIONS
- DIFFERENTIAL DIAGNOSIS
- - Voiding diary
- Physical examination
- SOCIETY GUIDELINE LINKS
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS