Enuresis is nighttime urinary incontinence in children aged ≥5 years (girls) or ≥6 years (boys). It is classified as primary (never achieved bladder control) or secondary (loss of bladder control after ≥3 months of continence). It affects approximately 5–7 million children, most commonly boys, and may occasionally occur in adults with sleep apnea.

Pathophysiology

Enuresis results from the interaction of several physiologic, neurologic, and psychological factors:

• Detrusor muscle immaturity or hyperactivity: Involuntary bladder contractions cause urgency and nocturnal voiding.

• Deep sleep patterns: Difficulty arousing during bladder fullness may contribute.

• Psychological stress: Stressful events (birth of sibling, bereavement, divorce, rigorous toilet training) increase enuresis risk.

• Organic disorders: Structural or functional abnormalities of the urinary tract or neurologic system.

• Hormonal factors: Nocturnal antidiuretic hormone (ADH) deficiency can lead to excess nighttime urine production.

Signs and Symptoms

• Nighttime bed-wetting (primary or secondary)

• Daytime urinary symptoms (urgency, frequency, incontinence) in some cases

• Pain, dysuria, or abnormal voiding patterns (if UTI or obstruction present)

• Behavioral or emotional signs: embarrassment, anxiety, or stress

• Occasional systemic signs: thirst, polyuria, fatigue (if diabetes present)

Clinical Assessment

History

• Frequency and duration of bed-wetting

• Family history of enuresis

• Fluid intake, timing of last drink before bedtime

• Sleep patterns and depth

• Daytime urinary symptoms: urgency, frequency, incontinence

• Recent stressors, illness, or trauma

• History of constipation or encopresis

• Prior bladder control and toilet training history

Physical Examination

• Observe gait and lower limb sensory function (neurologic assessment)

• Inspect urethral meatus for erythema or discharge

• Obtain a urine specimen for urinalysis and culture

• Rectal exam if indicated to assess sphincter control

• Check for signs of systemic illness, dehydration, or endocrine disorders

Medical causes of Enuresis

Special Considerations

• Bladder training programs may improve detrusor muscle control

• Moisture alarms (for children ≥8 years) can condition nighttime arousal

• Limit fluid intake 2–3 hours before bedtime

• Pharmacologic therapy: desmopressin (ADH analog) or anticholinergics if indicated

• Emotional support and reassurance are crucial

Patient Counseling

• Encourage supportive parenting and avoid punishment for bed-wetting

• Explain underlying causes and treatment options

• Provide strategies for home management, including toilet routines and fluid regulation

• Discuss use of alarms and medications if prescribed

Pediatric Pointers

• Most common in boys

• Primary enuresis is more frequent than secondary

• Assess for constipation, encopresis, or underlying neurologic disorders

• Emotional stress may exacerbate or trigger secondary enuresis

References

1. Kwak KW, Lee YS, Park KH, Baek M. Efficacy of desmopressin and enuresis alarm as first and second line treatment for primary monosymptomatic nocturnal enuresis: Prospective randomized crossover study. J Urol. 2010;184(6):2521–2526.

2. Melnyk BM, Fineout-Overholt E. Evidence-based practice in nursing and healthcare: A guide to best practice, 2nd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2011.

3. Nevéus T. Nocturnal enuresis: etiology and management. Pediatr Nephrol. 2007;22:109–116.

4. Franco I, van Gool JD, Nijman RJM. Pediatric Urology: Bedwetting and urinary incontinence in children. Springer; 2012.