Enuresis

Patients can be seen by Texas Children's experts in Urology.

Causes & Risk Factors

A small proportion (about 2%) of daytime wetting is due to neurogenic causes, which impact the central nervous system or peripheral nerves involved in the control of urination. The rest (98%) of the cases have non-neurogenic causes. This means there is no problem with the nervous system or other nerves that lead to daytime wetting.Symptoms & Types

Types and causes of non-neurogenic enuresis include:

• Urge incontinence:  This is caused by an over-active bladder or detrusor instability (involuntary contraction of the detrusor muscle of the bladder).   A child often demonstrates urgency, frequency, and holding maneuvers, and urinates on the way to the restroom.
• Dysfunctional voiding (bladder-sphincter discoordination). This is caused by a disturbance in the voiding phase which blocks urinary flow. The child usually has an interrupted (“staccato”) flow and urine left in the bladder after peeing.
• Underactive bladder: This can result from persistent postponement of urinating and ignoring the urge to go. The child infrequently urinates, often leaving a large amount of urine in the bladder after voiding.
• Detrusor-sphincter dyssnergy: This is an extreme form of dysfunctional voiding that can lead to bladder and upper urinary tract problems. Symptoms include a large post-urination residual, bladder wall thickening, and can even result in extra fluid in the kidneys.
• Giggle incontinence: This is urine leakage associated only with laughter.
• Vaginal voiding: This occurs as a result of urine flowing into the vagina during voiding, then when the girl stands this urine dribbles into her underwear and she has “wetness.”  These girls complain of wetness after using the bathroom.

Often children with daytime wetting have other symptoms such as constipation, bladder spasms, abdominal pain and urinary tract infections (UTIs).

Diagnosis & Tests

Obtaining an accurate and thorough history is the primary way a diagnosis is made. Your child’s doctor will ask questions covering topics such as an elimination history, fluid intake and social history. A physical exam includes examination of the abdomen and external genitalia, and inspection of the lower back for abnormalities that would suggest underlying neurologic problems.

Your child’s urine will be tested in the office on the day of the appointment but usually further laboratory testing is not needed. Occasionally the doctor will order a renal bladder ultrasound or abdominal x-ray. On return visits an uroflow (graph of your child’s urine flow) and measurement of post-void residual may be performed.

Treatment & Care

Treatment begins with conservative management and behavioral modification. This may include:

• Urinating every 2-3 hours during the day on a schedule
• Treating any present constipation, often with the use of diet and fiber supplements
• Avoiding drinks which irritate the bladder, such as caffeinated drinks, carbonated drinks and citrus drinks
• Posture and relaxing techniques
• Hydration
• Management of perineal irritation (burning or itching after a bowel movement)

For children that do not respond to conservative management, your doctor may prescribe medicine. These include anticholinergics to help stabilize the bladder, low-dose daily antibiotics to help prevent recurrent UTIs, and medications to help with constipation.

Living & Managing

A high degree of motivation on the part of the child and family is key to successful management as treating daytime wetting is an ongoing process requiring a great deal of time and effort. Positive reinforcement should be a mainstay of treatment and there is no role for punishment. There is a spontaneous cure rate of daytime wetting of about 15% yearly, and 20% of children will achieve dryness with behavioral modifications alone.