Enuresis

Enuresis is a repeated inability to control urination. Use of the term is usually limited to describing people old enough to be expected to exercise such control. Involuntary urination is also known as urinary incontinence. The term "enuresis" comes from the .

Enuresis has been previously viewed as a psychiatric condition, however, scientific evidence has shown this view to be unsupported through current understanding of the condition and its underlying causes. It may be accompanied by bladder dysfunction during the day which is termed non-mono symptomatic enuresis. Day time enuresis, also known as urinary incontinence, may also be accompanied by bladder dysfunction.

The symptoms of bladder dysfunction include:

Causes

Bedwetting children are often normal emotionally and physically, although enuresis can be caused by other health conditions.

Enuresis can be caused by one or more of the following:

Caffeine consumption

Caffeine is a diuretic, which means that it increases urine production. Reports from those who have failed enuresis treatment say that they were not recommended to limit caffeine and that they mostly consume 2 to 4 mg/kg/day. It is characterized by an obstruction of the bladder as a result of a non-neurogenic cause, which is due to the muscles controlling urine flow that do not completely relax. Symptoms may include daytime wetting, night wetting, urgency, a feeling that the bladder is always full, and straining to urinate.

Urinary tract infection

It is uncommon for nocturnal enuresis, in the absence of other symptoms, to be caused by an infection. Pinworms have been linked with sudden onset enuresis in young girls.

Sleep disorders

The inability to wake from sleep has been understood as one cause of nocturnal enuresis, however studies focused on the importance of the time of night in which enuresis episodes occur have shown inconsistent results. Parents often report that their bedwetting children are very difficult to awaken from sleep, therefore research regarding enuresis has also aimed to elucidate why children with enuresis do not awaken from the sensation of a full bladder. Although several genes are considered of interest in relation to enuresis, lack of a single gene that may cause enuresis means that individuals of a family may have differing genetic mechanisms resulting in the condition.

Current DSM-5 criteria:

Repeated voiding of urine into bed or clothes (whether involuntary or intentional)
Behavior must be clinically significant as manifested by either a frequency of twice a week for at least three consecutive months or the presence of clinically significant distress or impairment in social, academic (occupational), or other important areas of functioning.
Chronological age is at least 5 years of age (or equivalent developmental level).
The behavior is not due exclusively to the direct physiological effect of a substance (such as a diuretic) or a general medical condition (such as diabetes, spina bifida, a seizure disorder, etc.).

All these criteria must be met in order to diagnose an individual. Generally, healthcare providers may further investigate for bladder control issues if a child is still enuretic in the daytime by age 4, or if they are still enuretic at nighttime by age 5 or 6.

Primary enuresis refers to children who have never been successfully trained to control urination.

There are 2 categories of enuresis:

Monosymptomatic enuresis (MNE) – Does not include bladder dysfunction during daytime. Other conditions, or comorbidities, that commonly accompany enuresis may be expected to be more common with NMNE.

thumb|308x308px|Enuresis Alarm

Behavioral therapy

Simple behavioral interventions may prove to be superior in comparison to no ongoing form of treatment and are recommended as initial treatment.

Nighttime fluid limitation
Enuresis alarm – includes sleeping mats with electrical circuits; alarms with sensors placed in child's underwear; alarms that are wired or wireless and produce noise, vibration, or light; and alarm clocks or mobile phones for older individuals
Motivational therapy
Bladder training – training the bladder to hold more urine
Reward systems – give star charts for dry nights
Lifting – carrying the child, who is still asleep, away from the bed to an appropriate place to urinate

Waking a child up at night is not a medically supported long-term cure or solution for nocturnal enuresis, and may just be a one-time solution even if it appears to resolve enuresis. Neurostimulation of the sacral nerve is an option for children in which all other therapies have failed. Neurostimulation treatment of adult enuresis may be considered prior to pursuing surgical methods. For adult enuresis, sacral nerve stimulation can be administered to decrease bladder muscle activity so that the bladder muscles are not constantly in a contracted state to help improve enuresis symptoms.

Hypnotherapy

Hypnotherapy is often performed under the guidance of a licensed clinician or hypnotherapist. It is a guided state of relaxation, concentration and focused attention, and is often where the individual is in a guided trance-like state to treat conditions such as pediatric enuresis. However, some studies have shown that the utilization of enuresis alarm may be more effective than hypnotherapy. On the other hand, certain types of hypnotherapy may be more effective compared to no treatment of enuresis, but evidence is insufficient. There is good short-term success rate; however, there is difficulty in keeping the bed dry after medication is stopped. An additional third-line alternative shown to be effective is the tricyclic antidepressant imipramine, however the use of tricyclic antidepressants carries the risk of cardiotoxicity and is not recommended to be given without evaluating a person's risk factors for certain heart diseases.

Acupuncture

There are multiple studies examining the efficacy of acupuncture in treating nocturnal enuresis in children, but the evidence is generally of low quality and has multiple limitations. Therefore, there is not strong evidence to suggest that acupuncture is useful for treating enuresis.

Epidemiology

Approximately 10% of six- to seven-year-olds around the world experience enuresis. While 15% to 20% of five‐year‐old children experience nocturnal enuresis which usually goes away as they grow older, approximately 2% to 5% of young adults experience nocturnal enuresis. About 3% of teenagers and 0.5% to 1% of adults experience enuresis or bedwetting, with the chance of it resolving being lower if it is considered frequent. Furthermore, in the eighteenth century, children with enuresis were subjected to a variety of chemical and mechanical treatments including fluid restriction, enemata, the use of an alarm clock, cold baths, warm baths, cold dashes to the perineum and douches to the lower spine. During World War II, bedwetting was considered as part of neuropsychiatric evaluation of a soldier for discharge.