Genitourinary Defects, Disorders, and Infections in the Pediatric Patient

Enuresis, also known as bedwetting, refers to involuntary urination in children who have passed the age of toilet training, which is typically around five years of age. Enuresis can be primary, which is when involuntary urination occurs in individuals who have never developed bladder control; or secondary, which is when involuntary urination occurs in individuals who had previously developed bladder control. If the involuntary urination occurs mainly during the day, it is called diurnal enuresis; and if it mainly occurs at night, it is called nocturnal enuresis.

Now, the exact pathological process of enuresis remains unclear, though there are several factors that contribute to its development, and the cause is likely multifactorial.

So, enuresis can be associated overproduction of urine, like with polydipsia and polyuria due to diabetes mellitus; or central diabetes insipidus, where there’s a lack of antidiuretic hormone, or ADH, which helps regulate the amount of water released by the kidneys into the urine.

Then, sleep disorders, like obstructive sleep apnea can interrupt normal sleep patterns and prevent the child from waking up in response to a full bladder.

Enuresis can also occur due to delays in motor or social functioning which can be associated with delayed bladder maturation and reduced functional capacity.

In addition, psychosocial stressors, like abuse and family disruptions, like divorce or birth of a sibling, can be associated with enuresis. Other factors include medications, like valproate; infections, like cystitis, which can cause bladder inflammation leading to uncoordinated contractions; and constipation, which can reduce bladder capacity.

The most important clinical manifestation of enuresis is recurrent, involuntary urination in bed or on clothes.

Diagnosis of enuresis is based on detailed history and physical assessment and is confirmed using the Diagnostic and Statistical Manual for Mental Disorders fifth edition, or DSM-5, criteria. The four main criteria that must be met to confirm the diagnosis of primary enuresis include: voluntary or involuntary urination into the bed or clothes; episodes occur at least 2 times per week for three consecutive months or episodes cause significant distress; the patient is at least 5 years old; and the symptoms cannot be explained by another condition or medication.

Treatment options for enuresis are reserved for children older than 7 years of age and can be nonpharmacologic or pharmacologic.

Nonpharmacologic treatments include bladder training and use of bedwetting alarms. Bladder training establishes a regular voiding schedule by assisting the child to empty their bladder on a set schedule, instead of waiting for the urge to urinate. This can include scheduled awakenings during the night for a child with nocturnal enuresis.