{
 "topic": "Nocturnal Enuresis",
 "slug": "nocturnal-enuresis",
 "category_id": 15716,
 "passage_count": 14,
 "source_chars": 11224,
 "enough_material": true,
 "references": [
  {
   "title": "MedStudy Pediatrics Core 11th Edition 2024-2025",
   "author": null,
   "pages": [
    594,
    595
   ]
  },
  {
   "title": "Kliegman R. Nelson Textbook of Pediatrics 2-Volume Set 22ed 2024",
   "author": null,
   "pages": [
    3330
   ]
  },
  {
   "title": "Cover",
   "author": "Vitalsource Download",
   "pages": [
    6689
   ]
  },
  {
   "title": "Algorithms in Pediatrics",
   "author": null,
   "pages": [
    525,
    528
   ]
  },
  {
   "title": "Berkowitz's Pediatrics",
   "author": "Berkowitz, Carol D.;",
   "pages": [
    392
   ]
  },
  {
   "title": "CURRENT Diagnosis and Treatment Pediatrics, Twenty-Fourth Edition",
   "author": "Hay, William W., Levin, Myron J., Deterding, Robin R., Abzug, Mark J.",
   "pages": [
    108
   ]
  },
  {
   "title": "Ghai Essential Pediatrics, 9e (Vinod K Paul, Arvind Bagga)",
   "author": "CamScanner",
   "pages": [
    505
   ]
  },
  {
   "title": "Pediatric Decision-Making Strategies",
   "author": "Pomeranz, Albert J.",
   "pages": [
    132,
    136
   ]
  }
 ],
 "passages": [
  {
   "source": "MedStudy Pediatrics Core 11th Edition 2024-2025, p. 595",
   "text": "[Figure OCR, page 595, figure 1] The causes of nocturnal enuresis can be multiple: delayed maturation control of continence, emotional stresses, small bladder capacity, and disordered sleep arousal. The majority of children have no organic or functional cause. Ina child who was previously continent, consider sexual, physical, or emotional abuse. Ask if the patient snores; obstructive apnea can cause nocturnal enuresis. In making the diagnosis, it is important to take into account daytime voiding patterns, as well as the physi- cal examination. You can rule out infection with U/A and culture. Concentrated urine (i.e., high specific gravity) can rule out a renal concentrating defect. Imaging stud- ies (an U/S and a VCUG) are not routinely recommended unless a child > 10 years of age has continued enuresis. Treatment of enuresis includes the use of \u201cpotty alarms,\u201d which work fairly well in younger children. Medications are effective for older children and include"
  },
  {
   "source": "MedStudy Pediatrics Core 11th Edition 2024-2025, p. 594",
   "text": "detrusor and perianal musculature coordination during voiding. Refer to a urologist for suspected anatomic abnormalities such as ectopic ureter. Prevent or treat constipation in all children with daytime incontinence. Nocturnal Enuresis Nocturnal enuresis is the involuntary loss of urine during sleep. It can be primary, meaning these children have never had a prolonged period of nighttime dryness, or secondary, due to some new factor in a child with a his- tory of previous dry spells. Nocturnal enuresis occurs in approximately 15% of 5-year-olds and spontaneously resolves at a rate of about 15% per year. Boys are more commonly affected. If one parent had nocturnal enuresis, there is a 40% risk to the child of having the condition; this increases to 70% if both parents had nocturnal enuresis as children. Note the importance of a detailed family history\u2014these usu- ally are not questions you ask parents. No physical harm occurs because of nocturnal enuresis, but the emotional impact can be great."
  },
  {
   "source": "Kliegman R. Nelson Textbook of Pediatrics 2-Volume Set 22ed 2024, p. 3330",
   "text": "## **NOCTURNAL ENURESIS** By 5 years of age, 90\u201395% of children are nearly completely continent during the day, and 80\u201385% are continent at night. Nocturnal enuresis refers to the occurrence of involuntary voiding at night after 5 years old, the age when volitional control of micturition is expected. Enuresis ~~Table 580.3 Nocturnal Enuresis~~ ## CAUSES Delayed maturation of the cortical mechanisms that allow voluntary control of the micturition reflex Defective sleep arousal Reduced antidiuretic hormone production at night, resulting in an increased urine output (nocturnal polyuria) Genetic factors, with chromosomes 12 and 13q the likely sites of the gene for enuresis Bladder factors (lack of inhibition, reduced capacity, overactive) Constipation Organic factors, such as urinary tract infection, obstructive uropathy, or sickle cell anemia nephropathy Sleep disorders"
  },
  {
   "source": "Cover, p. 6689",
   "text": "The evaluation of children with nocturnal enuresis begins with a complete history that includes determining the number of wet nights per week, the longest period of dry nights, fluid intake in the late afternoon and evening, voiding"
  },
  {
   "source": "Algorithms in Pediatrics, p. 525",
   "text": "## **Enuresis** ![](/tmp/pdf-images/pdf-0525-02.png) _Jyoti Sharma_ ## **INTRODUCTION** Enuresis refers to intermittent incontinence in discrete episodes while asleep; sometimes called nocturnal enuresis (NE) to add extra clarity. It is essential to subgroup these children as having monosymptomatic (MNE) and nonmonosymptomatic enuresis (NMNE). The latter refers to children who have concomitant symptoms of lower urinary tract (LUT) malfunction, i.e., increased (>eight times) or decreased (<three times) voiding frequency, daytime incontinence, urgency, hesitancy, straining, a weak stream, intermittency, holding maneuvers, a feeling of incomplete emptying, postmicturition dribble, and genital or LUT pain. ## **Clinical Pearl** - Nonmonosymptomatic enuresis is more common; when a detailed history is obtained, the majority of children have at least subtle daytime symptoms - Children and adult perceptions of daytime voiding symptoms differ. Hence, careful questioning of the child is recommended."
  },
  {
   "source": "Berkowitz's Pediatrics, p. 392",
   "text": "The term _primary nocturnal enuresis_ is used when children have never achieved sustained dryness, and _secondary enuresis_ is used when urinary incontinence recurs after 3 to 6 months of dryness. Monosymptomatic nocturnal enuresis means that nighttime wetting is the only symptom. Children who experience urgency, frequency, dribbling, or other symptoms have _polysymptomatic enuresis._ Such symptoms may be related to inappropriate muscle contraction, are often associated with constipation, and are termed _dysfunctional elimination syndrome_ or _bowel/bladder dysfunction._"
  },
  {
   "source": "Berkowitz's Pediatrics, p. 392",
   "text": "_Enuresis_ is defined as involuntary or intentional urination in children whose age and development suggest achievement of bladder control. Voiding into the bed or clothing occurs repeatedly (at least twice a week for at least 3 consecutive months). On average, urinary continence is reached earlier in girls than in boys, and the diagnosis of enuresis is reserved for girls older than 5 years and boys older than 6 years. The term _diurnal enuresis,_ wetting that occurs during the day, has been replaced by _daytime incontinence._ The International Children\u2019s Continence Society promotes a standardization for enuresis-related terminology. It prefers the use of the term _incontinence_ to denote uncontrollable leakage of urine, intermittent or continuous, that occurs after continence should have been achieved. _Nocturnal_ or _sleep enuresis_ refers to involuntary urination or incontinence that occurs during the night. The term _primary nocturnal enuresis_ is used when children have never achieved sustained dryness,"
  },
  {
   "source": "Algorithms in Pediatrics, p. 528",
   "text": "## **CONClUSION** Nocturnal enuresis is very common and has the potential for an appreciable negative emotional impact on affected children. It is important to differentiate MNE from NMNE and pathological conditions associated with enuresis. Behavioral modification promoting good bladder and bowel habits and alarm therapy is the mainstay of management of NE. Pharmacological therapy is indicated when there are additional symptoms and when behavioral and alarm therapy fail. Treatment for comorbid conditions, like constipation and ADHD, must be offered simultaneously. ## ~~**KEy POINTS**~~ - ) A detailed history including a voiding diary are essential for the diagnosis of primary nocturnal enuresis - ) Urinalysis and ultrasonography with a full bladder help rule out pathological conditions with which enuresis may be associated"
  },
  {
   "source": "CURRENT Diagnosis and Treatment Pediatrics, Twenty-Fourth Edition, p. 108",
   "text": "## **ENURESIS** _Enuresis_ is defined as repeated urination into the clothing during the day and into the bed at night by a child who is chronologically and developmentally older than 5 years; this pattern of urination must occur at least twice a week for 3 months. Enuresis has been categorized by the International Children\u2019s Continence Society as monosymptomatic or non-monosymptomatic. Monosymptomatic enuresis is uncomplicated nocturnal enuresis (NE; must never have been dry at night for over 6 months with no daytime accidents); it is a reflection of a maturational disorder and there is no underlying organic problem. Complicated or nonmonosymptomatic enuresis often involves NE and daytime incontinence and often reflects an underlying disorder. The evaluation of both forms needs to take into consideration both the medical and psychological implications of these conditions. Monosymptomatic enuresis reflects a delay in achieving nighttime continence and reflects a delay in the **76** **CHAPTER 3**"
  },
  {
   "source": "Ghai Essential Pediatrics, 9e (Vinod K Paul, Arvind Bagga), p. 505",
   "text": "or slightly higher in girls. Enuresis is called primary when the child has never been dry and secondary when bed wetting starts after a minimum period of 6 months of dryness at night. It is termed monosymptomatic, if it is not accompanied by any lower urinary tract symptoms and nocturnal, if it occurs only during sleep. Children with monosymptomatic nocturnal enuresis require no further evaluation. Etiology Maturational delay is the most likely cause of nocturnal enuresis, suggested by high spontaneous cure rates with increasing age. Other reasons that have been attributed include a lack of circadian rhythm of secretion of the antidiuretic hormone (ADH), inadequate sleep arousal, urinary tract infections, bladder bowel dysfunction and stressful events. Evaluation Less than 5% patients with nocturnal enuresis have an organic basis. A careful history helps determine whether the enuresis is primary or secondary, whether any daytime symptoms are present and whether any voiding difficulty"
  },
  {
   "source": "Pediatric Decision-Making Strategies, p. 132",
   "text": "history of snoring and mouth breathing may indicate sleep apnea. Hypertension or growth failure may indicate chronic renal disease. A careful GU examination should be done to look for meatal stenosis, labial fusion, or other abnormalities. In patients with urethral obstruction, the bladder and kidneys may be enlarged."
  },
  {
   "source": "Pediatric Decision-Making Strategies, p. 136",
   "text": "2[A positive reagent strip (dipstick) in the absence of ] RBCs indicates the presence of Hgb or myoglobin. Hemoglobinuria occurs with hemolysis. It may occur in hemolytic anemias, hemolytic-uremic syndrome, mismatched transfusions, freshwater drowning, septicemia, and paroxysmal nocturnal hemoglobinuria. It is also associated with carbon monoxide, fava beans, venoms, mushrooms, naphthalene, quinine, and many other substances. A CBC with smear will often show fragmented cells, and the reticulocyte count may be elevated. Myoglobinuria occurs with rhabdomyolysis after viral myositis and in children with inborn errors of energy metabolism, often after exercise. The clinical picture as well as elevated muscle enzyme levels may aid in distinguishing myoglobinuria from hematuria. If needed, Hgb and myoglobin may be measured in the urine."
  },
  {
   "source": "Cover, p. 6689",
   "text": "Enuresis may be nocturnal (bed-wetting) or diurnal (daytime wetting) or both. Nocturnal enuresis is much more common than diurnal enuresis. Approximately 10% of children with nocturnal enuresis will have daytime wetting as well, whereas 50% of children with daytime wetting will have nocturnal enuresis. _Primary enuresis_ refers to children who have never achieved dryness for an extended period of time and is more common than secondary enuresis and less likely to be associated with disease. _Secondary enuresis_ refers to the appearance of enuresis in a child who has been dry for at least 6 months. ## **Nocturnal Enuresis**"
  },
  {
   "source": "AAP Developmental and Behavioral Pediatrics, p. 145",
   "text": "## **\u2013 Elimination Disorders** _Enuresis_ refers to the repeated passage of urine into bed or clothes, whether involuntary or intentional, in a child whose developmental level is at least 5 years of age.[5] Children with enuresis experience episodes of incontinence at least twice a week, for a period of at least 3 consecutive months, and experience clinically significant distress or impairment in important areas of functioning.[5] Enuresis can be specified as diurnal (passage of urine during waking hours), nocturnal (passage of urine only during nighttime sleep), or combined nocturnal-diurnal.[5] In **125** Chapter 8: Development and Disorders of Feeding, Sleep, and Elimination addition, it is important to note whether the enuresis is primary (child was not previously continent) or secondary (child was continent for at least 6 months), as this can inform the differential diagnosis."
  }
 ]
}