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Paediatric Urology
Nocturnal Enuresis Management – How to Achieve Dry Nights
a report by
Didier Aubert
1
and Anne Moro-Enemuwe
2
1. Professor of Paediatric Surgery, and Head of Department; 2. Senior Paediatric Surgeon, Department of Paediatric Surgery, University Hospital Besançon
Nocturnal enuresis has been studied and published in the literature Management of Children with Primary
worldwide. In November 2007, a group of French experts performed a Monosymptomatic Bed-wetting
meta-analysis to provide practical recommendations to the French Health
Authority (HAS) on the management of primary nocturnal enuresis (PNE) First Step – Evaluation of the Primary Nocturnal Enuresis
using evidence-based medicine and the latest recommendations of the At the clinic the first consultation is essential and should be
International Children’s Continence Society (ICCS).
1,2
comprehensive. The goals of this consultation are set out below.
Definition, Prevalence and Pathophysiology Rule Out All Other Voiding Dysfunctions
Monosymptomatic PNE is defined as isolated primary nocturnal bed- Other possible explanations include:
wetting without any other urinary symptoms in children over five years
of age. Physiologically, at approximately 36–42 months of age there is a • overactive bladder, which is associated with urgency, increased
correlation between an increase in the capacity of the bladder and a frequency, squatting and daytime incontinence;
decrease in nocturnal diuresis, which results in nocturnal continence. In • functional lazy bladder due to poor toilet habits (infrequent voiding,
enuretic children there is a mismatch between nocturnal bladder faecal retention and/or encopresis and cystitis); and
capacity and nocturnal urinary volume production.
3
The prevalence of • other causes of daytime incontinence, such as urethral obstruction,
PNE is approximately 10% in children seven years of age.
4,5
The ectopic urethra and neurogenic disorders (occult dysraphism and others).
spontaneous resolution rate is 15% per year,
6
but 3% of adults still
suffer from PNE.
1,5
In-depth questioning and a physical examination are necessary
to diagnose monosymptomatic PNE once all other symptoms have
PNE is a multifactorial condition; however, three components are been excluded.
essential to its development: an excess of nocturnal urine production
during sleep due to abnormal antidiuretic hormone (ADH) circadian Family Background
rhythm and abnormal solute metabolism; small bladder capacity and an A positive family history of bed-wetting can be observed in 30–60% of
overactive bladder, which are are identified in 30% of cases; and a high enuretic children. In 45% of patients the mode of transmission is
level of threshold arousal during sleep due to brain immaturity. Each autosomal-dominant with high penetrance (90%).
12
patient should have a meticulous assessment of each component in order
to provide an accurate analysis. Evaluation of the Condition
The precise definitions of PNE intensities are defined as follows:
5,13
PNE is a true social concern for children and their families.
7
Low self-
esteem is a frequent psychological symptom,
4,8
and can be improved by • low intensity: less than one episode per week on average;
basic information and counselling before medical treatment is started.
9–11
• moderate intensity: one or two episodes per week on average; and
• severe intensity: at least three episodes per week.
Didier Aubert is a Professor of Paediatric Surgery (Urology)
and Head of the Department of Paediatric Surgery at the
Behavioural Disorders, Co-morbidity,
University Hospital Besançon. He is Past President of the Motivation and Family Environment
French Paediatric Urology Association and the Paediatric
PNE may be associated with attention-deficit–hyperactivity disorder
Section of the French Association of Urology (AFU), and a
member of the scientific committee of the International
(ADHD). About 20% of children with ADHD have associated enuresis,
French-speaking Urodynamic Society.
while 10% of enuretic children suffer from ADHD.
14
This co-morbidity
E: daubert@chu-besancon.fr
should be assessed during the first visit. Subclinical neurological
immaturity can also be observed.
15–17
Anne Moro-Enemuwe is a Senior Paediatric Surgeon at the
University Hospital Besançon. She is enrolled on a PhD
programme in developmental biology at the University of
Sleep disturbance has been demonstrated in enuretic children and
Franche-Comte, Besançon. She received surgical training at
until recently these children were believed to be deep sleepers, but
the University of Bordeaux and Westmead Hospital, Sydney.
She also completed a research fellowship at the Sick Kids one study has demonstrated that they are light sleepers with frequent
Hospital, Toronto.
cortical arousal and are unable to wake up. High cortical arousal could
be stimulated by an overactive bladder, thereby decreasing the
wakening threshold.
18
122 © TOUCH BRIEFINGS 2008