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. Bedwetting alarms, also known as the bell and pad technique, consist of a moisture-sensitive pad, which is placed on the bed, attached to an alarm.

When the pad senses moisture, it triggers the alarm to wake the child in order to stop the stream of urine. On the other hand, pharmacologic treatment includes medications such as synthetic ADH analogues, like desmopressin, and tricyclic antidepressants, like imipramine.

Alright, let’s look at the nursing care you’ll be providing for a child with enuresis. Your priority nursing goals are to provide psychosocial support and patient and family teaching.

Start by asking the child’s caregivers about their child’s voiding pattern and encourage them to talk about its impact on family life.

Also assess their degree of motivation to begin treatment and ability to provide behavioral interventions for their child.

Be sure to determine if the child is experiencing low self-esteem due to their condition, and refer the family to pediatric mental health counseling, as needed.

Lastly, remember to remind them bedwetting is not the child’s fault and stress the importance of not punishing their child when bedwetting occurs.

Then, provide the patient and family with age-appropriate teaching regarding treatments. Begin by reviewing strategies they can do to help their child establish a normal voiding pattern, including emptying their bladder just before bedtime.

Encourage them to keep a voiding diary to track their child’s patterns including wet and dry nights and amount of fluid consumed daily.

Instruct them to limit nighttime fluid intake and avoid sources of caffeine, like soda or chocolate, which can lead to increased urine production and bladder hyperactivity.

If a bedwetting alarm is used, demonstrate how to properly use the device. If their child is prescribed medication, be sure to provide information about how the medication helps with the problem and instruct them to administer the medication exactly as directed.

During treatment, recommend they use a fitted plastic sheet to protect the mattress. All right, as a quick recap….

Enuresis, also known as bedwetting, refers to involuntary urination in children who have passed the age of toilet training.

It can be primary or secondary. When it occurs mainly during the day, it is called diurnal enuresis; and when it occurs mainly during the night, it is called nocturnal enuresis.

The cause of enuresis is not exactly known but can include physiologic and psychological stressors. Diagnosis includes a patient history, physical exam, and criteria in the DSM-5.

Treatment includes nonpharmacological interventions like bladder training and bedwetting alarms; and pharmacologic interventions like synthetic ADH.

Goals of nursing care for a patient with enuresis include providing psychosocial support and patient and family teaching.