Primary and Secondary Enuresis: Pathophysiology, Diagnosis, and Treatment.

CONTEXT: Enuresis is a common and possibly underestimated condition. While 5-10% of school-aged children suffer from the condition, a lack of background knowledge may impede timely child-adapted and successful therapy. OBJECTIVE: To provide a comprehensive overview of the pathophysiology, diagnosis, and treatment of enuresis. EVIDENCE ACQUISITION: Guideline and position papers from the European Society of Pediatric Urology, the European Association of Urology, and the International Children's Continence Society were acquired. PubMed was searched for literature on enuresis, and all papers published in the last 5 yr were considered. The most relevant information from the papers with the highest level of evidence was extracted and incorporated into the review. EVIDENCE SYNTHESIS: An altered antidiuretic hormone profile, arousal failure, and delayed bladder maturation are the main pathophysiological factors in primary enuresis. Coexisting constipation, obstructive airway disease, attention deficit hyperactivity disorder, obesity, and genetic preconditions influence its prevalence. Diagnosis relies on history-taking and simple noninvasive examinations to differentiate monosymptomatic enuresis and patients with daytime symptoms. It is essential to exclude daytime voiding symptoms, overactive bladder, dysfunctional voiding, and urinary tract infections. Further imaging is indicated in complex cases with a suspicion of underlying congenital malformations or systemic or endocrine diseases and in children refractory to initial therapy. In secondary enuresis, psychological causes should also be taken into consideration. While desmopressin melt tablets and alarm systems constitute the mainstays of treatment in monosymptomatic enuresis, anticholinergics and urotherapy play an additional role in nonmonosymptomatic enuresis. For therapy-refractory cases, after a thorough re-investigation to identify any missed comorbidities and anatomical or functional causes of enuresis, combination therapy and stationary urotherapy might be promising options. CONCLUSIONS: While enuresis seems to be an often underestimated condition in terms of the suffering that children and their families, there are efficacious therapy options once a correct and full diagnosis is made. PATIENT SUMMARY: This article reviews primary and secondary nocturnal enuresis, which is the medical term for the condition whereby children wet their beds regularly after their first birthday. We describe the background of enuresis,including its complex underlying mechanisms, as well as diagnosis and treatment in the light of current scientific publications. We conclude that while enuresis seems to be an often underestimated condition in terms of the suffering that children and their families may undergo, there are efficacious therapy options once a correct and full diagnosis is made.

Enuresis and more.

We describe Pervasive Refusal Syndrome, an important but rare, debilitating condition that may present to paediatric services. Although previous reports have described improvement seen with care delivered in the mental health setting, we have demonstrated treatment predominately delivered in a paediatric ward environment associated with successful recovery.

An 8-year-old boy with treatment-resistant encopresis.

CASE: Paul is an 8-year-old boy with a long-standing history of encopresis and enuresis. Potty training was initiated when he was 2(1/2) years old. At this time, his mother was absent from the home for 6 weeks when she cared for her ill father in a different city. The process of teaching Paul to use the bathroom was described as "inconsistent" due to multiple caretakers.Paul never successfully mastered bowel and bladder control. He continues to wet and soil his clothes on a daily basis at home and school. According to his parents, he does not accept responsibility and comments about his soiling such as, "I didn't do it; someone else must have put it there." One of Paul's teachers commented that she could tell at the beginning of the school day whether he would maintain bowel and bladder control. If he was "agitated and talkative" in the early morning, he would often soil that day.He had a pediatric gastroenterological evaluation at the age of 5 years when he was having daily episodes of stool soiling. Physical examination revealed normal anal tone, normal placement of the anus, and moderate stool in the rectal vault. An abdominal radiograph revealed moderate stool throughout the colon. He was treated with Miralax and instructed to sit on the toilet twice daily. Paul did not respond to these interventions and was diagnosed with "overflow incontinence secondary to stool withholding." When he was taking Miralax, he had a normal barium enema radiograph. He was admitted to the hospital for a clean out with a polyethylene glycol/electrolyte solution. Although abdominal radiographs demonstrated absence of colonic stool for the following 5 months, he continued to soil his clothing. Play therapy and biofeedback did not change the chronic soiling and wetting pattern. An evaluation at the Continence Clinic resulted in a rigorous program including stooling after each meal, wearing a vibrating watch reminding him to void every 2 hours, drinking 60 ounces of water per day, tracking elimination patterns on a calendar, and a daily laxative (polyethylene glycol). A neuropsychological evaluation revealed a superior aptitude associated with unresolved early childhood issues of self-control, self-care, and frustration tolerance. Family therapy was initiated. However, daily fecal soiling and wetting persisted.Paul was born full-term without prenatal or perinatal complications. He was breast fed for 1 year and described as an easy baby. He achieved motor, social, and language milestone on time. Paul had difficulty with separation and aggression in preschool (e.g., biting). In school, teachers report inattention, fidgetiness, and difficulty following directions. He has been obese since age 3 years; his current body mass index is 29.

Nocturnal enuresis: behavioral treatments.

Nocturnal enuresis is a common problem. Physiologic and environmental factors are thought to have a role in the etiology and treatment of this condition. This article discusses the association between enuresis and behavioral or emotional problems. Common behavioral treatments are described, and evidence for their efficacy is reviewed. A brief discussion of hypnosis and acupuncture is included.

Prevalence and perception of nocturnal enuresis in children of a rural community in southwestern Nigeria.

Nocturnal enuresis after the fifth year of life is a distressing problem. In Nigeria, there is a dearth of information about the condition. This cross-sectional study was carried out to determine the prevalence and perception of the condition among children in Igbo-Ora, a rural community in southwestern Nigeria. Four hundred parents/guardians were interviewed and information obtained on 644 children aged 6-12 years. Overall enuresis prevalence was 17.6% (19.9% among boys and 14.9% among girls). The reported causes of nocturnal enuresis included urinary tract infection (33.5%), excessive play (27.5%) and deep sleep (25%). A majority (74.5%) of the respondents would use herbs or traditional medicine to treat enuresis, while only 6.8% of the respondents sought orthodox healthcare facilities for its management. Only 18 (25%) of the 71 parents/guardians with enuretic children had ever consulted a health worker. The misconceptions and inappropriate enuresis management methods among the parents/guardians require health education intervention.

Síndrome de Smith Magenis: un caso de abordaje multidisciplinar / Smith Magenis síndrome: a multidisciplinar approached

M.R., niña de 9 años diagnosticada de síndrome de Smith Magenis que es derivada a salud mental infantil por su pediatra porque desde hace varios meses presenta alteraciones heterogéneas del comportamiento, autoagresividad, insomnio global y enuresis primaria nocturna. Describimos la clínica y las exploraciones realizadas. Discutimos el diagnóstico y la orientación terapéutica empleada, destacando la necesidad de realizar un abordaje multidisciplinar que incluya profesores, pediatras y profesionales de la salud mental infantil (AU)

Bases psicológicas del biofeedback / Psychological basis of biofeedback

En la relación estímulo-respuesta, en ocasiones, resulta necesario el reforzamiento o premio. Así, de todo el repertorio de conductas que proporciona un sujeto, aquella que reduzca los estímulos impulsores a la vez que se enlace con el patrón de inicio será la que más frecuentemente se verá recompensada. Este hecho constituye la base explicativa de la retroalimentación biológica: las respuestas autónomas pueden condicionarse instrumentalmente y los procesos fisiológicos pueden someterse a sistemas de control voluntario. En definitiva, el funcionamiento de un sistema puede cambiar al suminstrarle información desde una fuente externa y este hecho tiene importantes implicaciones en el manejo educativo de los transtornos miccionales, especialmente de la micción no coordinada (AU)

Biofeedback and electrical stimulation therapy for treating urinary incontinence and voiding dysfunction: one center's experience.

Urinary incontinence affects 13 million Americans at a cost of $11.2 billion annually to the community. With an aging population, these numbers are expected to increase substantially in coming years. At the Bladder Control Center in Cincinnati, staff have completed over 3,600 biofeedback sessions with encouraging results.

Living with a young person who wets the bed: the families' experience.

After allergic disorders, bed-wetting is the most common chronic condition of childhood. It can seriously diminish the quality of life of young people and their families, having an impact on day-to-day activities, family holidays and the young person's willingness and ability to stay away from home with friends and wider family. In this ethnographic study, family members describe the practical and social consequences of bed-wetting, both for themselves and for the family, and the methods that they have employed to encourage the bed-wetting to stop. Most of these methods have little chance of success. Many families' feelings of helplessness and isolation are reinforced by lack of help from healthcare professionals, although the professional's intention to be helpful is rarely questioned. The nature of the families' experiences illustrates the urgent need for adopting a new professional approach to the support of these families, which is based on the principles of 'family nursing'.

[Urodynamics in diagnosis and therapy of "enuresis"--relevance for child and adolescent psychiatry]. / Urodynamik in der Diagnostik und Therapie der "Enuresis"--Relevanz für die Kinder- und Jugendpsychiatrie.

Enuresis and functional urinary incontinence are clinically and pathophysiologically heterogeneous disorders. They differ with regard to their urodynamics, i.e. with regard to the function or dysfunction of the urinary tract. In addition to general measures such as history, physical examination, urinalysis, questionnaires and flow charts, noninvasive sonography and uroflowmetry with pelvic-floor EMG play an important role in diagnosis and therapy. Rates of pathological findings are especially high among day-wetting children and nocturnal enuretics with micturition problems. This group requires a detailed diagnosis, especially children with detrusor-sphincter discoordination, which can be treated effectively by means of uroflow-biofeedback. The relevance of these methods in child and adolescent psychiatry are discussed in detail and practical recommendations are made.

[Child psychiatry aspects of enuresis nocturna]. / Kinderpsychiatrische Aspekte der Enuresis nocturna.

Nocturnal enuresis is associated with emotional suffering. Psychoanalytic claims of a psychogenic aetiology are not tenable. The rate of behavioural disorders is significantly higher among wetting children, especially among day wetters and secondary nocturnal enuretics. Still, most wetting children are not psychiatrically disturbed. A symptom-oriented therapy with an alarm can raise the self-concept and feelings of self-worth. Play-therapies are indicated only when emotional disorders co-exist. A case of a sandplay therapy is presented, which demonstrates that in addition to empirical methodology, a hermeneutic approach is needed to understand the child's subjective experience and meaning.

Sleep disorders.

Sleep disorders carry a high risk of morbidity and mortality, yet they receive little medical attention. This article outlines the clinical features, aetiology, diagnosis and management of some common sleep disorders.

Biofeedback in the treatment of voiding disorders in childhood.

Voiding disorders are a common problem in pediatric urology. Biofeedback is a non-invasive method in the treatment of voiding disorders in childhood. Biofeedback takes aim at the learning or relearning of influencing involuntary functions. We report about our preliminary results of biofeedback training in the treatment of the enuretic syndrome in children. Out of 26 children with pseudo-detrusor-sphincter-dyssynergy 17 could be completely cured and 5 improved considerably. Out of 21 children with motor urgency 9 could be completely cured and 7 children improved. Biofeedback is a successful method to treat children with the enuretic syndrome.

Chiropractic management of primary nocturnal enuresis.

OBJECTIVE: To evaluate chiropractic management of primary nocturnal enuresis in children. DESIGN: A controlled clinical trial for 10 wk preceded by and followed by a 2-wk nontreatment period. SETTING: Chiropractic clinic of the Palmer Institute of Graduate Studies and Research. PARTICIPANTS: Forty-six nocturnal enuretic children (31 treatment and 15 control group), from a group of 57 children initially included in the study, participated in the trial. INTERVENTION: High velocity, short lever adjustments of the spine consistent with the Palmer Package Techniques; or a sham adjustment using an Activator at a nontension setting administered to the examiner's underlying contact point. Two 5th-year chiropractic students under the supervision of two clinic faculty performed the adjustments. MAIN OUTCOME MEASURES: Frequency of wet nights. RESULTS: The post-treatment mean wet night frequency of 7.6 nights/2 wk for the treatment group was significantly less than its baseline mean wet night frequency of 9.1 nights/2 wk (p = 0.05). For the control group, there was practically no change (12.1 to 12.2 nights/2 wk) in the mean wet night frequency from the baseline to the post-treatment. The mean pre- to post-treatment change in the wet night frequency for the treatment group compared with the control group did not reach statistical significance (p = 0.067). Twenty-five percent of the treatment-group children had 50% or more reduction in the wet night frequency from baseline to post-treatment while none among the control group had such reduction. CONCLUSIONS: Results of the present study strongly suggest the effectiveness of chiropractic treatment for primary nocturnal enuresis. A larger study of longer duration with a 6-month follow-up is therefore warranted.

[Enuresis as an individual symptom and systemic manifestation--considerations on using hypnotherapy in family dynamic interventions]. / Bettnässen als individuelles Symptom und systemisches Ereignis--Uberlegungen zur Verwendung hypnotherapeutischer Methoden unter familiendynamischen Aspekten.

Hypotherapeutic and family therapeutic technic of systemic therapy in treating enuresis nocturia and diuria will be discussed under diagnostic and therapeutic aspects. The integration and exclusion of family members in treatment is seen as a central issue. Questions of indication and contraindication are viewed from a family-dynamic perspective.

[Pyromania and enuresis. Multifactorial causes require multidimensional treatment concepts]. / Pyromanie und Enuresis. Multifaktorielle Ursachen erfordern mehrdimensionale Behandlungskonzepte.

The abilities to control the voiding of the bladder and to act competently in dealing with fire are important factors of the normal development of children. Unfavourable conditional constellations in the socio-emotional, cognitive, or physical realm can cause developmental defects which manifest themselves in certain target symptoms, for instance Pyromania and Enuresis. The importance of multifactorial etiological models will be illustrated by a case report of a boy displaying symptoms of Pyromania and Enuresis nocturna. The analysis of the specific conditions of the case studied results in the appropriate multidimensional treatment concept.