Author's details
Reviewer's details
Enuresis in Children
Enuresis is the voluntary or involuntary repeated discharge of urine on clothes or bed after a developmental age when bladder control should have been established. This is commonly known as bedwetting, remains one of the most frequent pediatric concerns and can be a source of distress and embarrassment for both children and their caregivers. While typically self-limiting, it requires a thorough understanding of normal bladder development, continent mechanisms, and potential underlying causes to guide effective management.
Normal Voiding and Toilet Training
Bladder control in children develops gradually. Newborns typically void 15–20 times a day, but as they age, bladder capacity increases and voiding frequency decreases. A rough estimate of millilitre bladder capacity is calculated as 30 × (age in years + 2).
Bladder control usually develops between 2–4 years of age, with girls attaining continence earlier than boys. Key contributors to continence include bladder growth, the child’s awareness of bladder fullness, voluntary control of the external sphincter, and motivation to remain dry. Notably, bowel control typically precedes bladder control.
Diurnal Incontinence and Its Causes
Diurnal (daytime) incontinence is common in children and is often due to overactive bladder or bladder-bowel dysfunction. Most children achieve dryness during the day by age five (95%) and nearly all by age twelve (99%).
Causes of diurnal incontinence include:
- Overactive or underactive bladder
- Giggle or overflow incontinence
- Voiding postponement
- Vaginal voiding
- Detrusor-sphincter discoordination
- Obstructive uropathy (e.g., posterior urethral valves)
- Psychological trauma or sexual abuse
- Chronic constipation
Assessment involves a careful history focusing on frequency, timing, volume of leakage, and associated symptoms like urgency or urinary tract infection (UTI). Investigations may include urinalysis, urine culture, ultrasound, and bladder diaries.
Nocturnal Enuresis: Definition and Classification
Nocturnal enuresis refers to involuntary urination during sleep in children aged five years and above. It is categorized by:
-
- Time of Onset:
- Primary: When nighttime dryness has never been achieved.
- Secondary: When enuresis recurs after at least six months of dryness, often triggered by stress or medical conditions.
- Time of Occurrence:
- Nocturnal Only (75% of cases)
- Daytime Only (rare)
- Mixed Day and Night (25%)
- Symptom Type:
- Monosymptomatic NE (MNE): Bedwetting without daytime urinary symptoms.
- Time of Onset:
- Non-monosymptomatic NE (NMNE): Associated with daytime urgency, frequency, or incontinence
PATHOGENESIS AND CONTRIBUTING FACTORS
Enuresis is rarely due to a single cause. Several factors often interact:
- Maturational Delay: Slow development of bladder control and central nervous system (CNS) arousal.
- Genetic Predisposition: Positive family history in 50% of cases, with higher concordance in monozygotic twins.
- Nocturnal Polyuria: Reduced secretion or sensitivity to antidiuretic hormone (ADH) leads to excessive nighttime urine.
- Small Bladder Capacity: Common in enuretic children; results in frequent voiding and urgency.
- Detrusor Overactivity: Involuntary bladder contractions, often seen in polysymptomatic cases.
- Sleep Disorders: Deep or fragmented sleep may impair the child's ability to awaken when the bladder is full.
SYMPTOMS
Key Features
- Primary NE (80% of cases): Never achieved 6+ months of nighttime dryness.
- Secondary NE: Recurrence after a prolonged dry period (often triggered by stress, constipation, or UTI).
- Red Flags (Suggest NMNE or Organic Cause):
- Daytime incontinence, urgency, straining.
- Dysuria, foul-smelling urine (UTI).
- Polydipsia, polyuria (diabetes).
PHYSICAL EXAMINATION
General
Growth parameters: (failure to thrive → chronic kidney disease).
Blood pressure: (hypertension → renal pathology).
Abdominal
- Palpable stool (constipation).
- Distended bladder (post-void residual).
Neurological
- Spinal dysraphism clues: Sacral dimple, tuft of hair, gluteal asymmetry.
- Lower limb reflexes (spasticity → spinal cord abnormality).
ENT
Tonsillar hypertrophy (Obstructive Sleep Apnoea risk).
- Laboratory Tests:
- Urinalysis: To detect infection (Nitrite, leucocyte), diabetes (glycosuria, ketone), or diabetes insipidus (urine osmolality which is more specific than low specific gravity).
- Ultrasound: Evaluate post-void residual (PUV) and structural anomalies(obstructive lesions).
- VCUG (Voiding Cystourethrogram): For suspected neurogenic bladder or posterior urethral valves.
- Urodynamic Studies: In refractory or complex cases to assess bladder function.
TREATMENT
- Reassurance and Conservative Measures
Most cases resolve with time.
Before age seven, active treatment is often not necessary.
Conservative measures include:
- Limiting evening fluid intake
- Voiding before bedtime
- Avoiding sugary or caffeinated drinks in the evening
- Behavioural Therapies
- Motivational therapy: Use of reward charts for dry nights.
- Moisture alarms: Highly effective; train the child to wake up when wetting begins.
IF ABOVE MEASURES FAIL, REFER TO PAEDIATRIC NEPHROLOGIST
- Pharmacologic Interventions
- Desmopressin: An ADH analog; reduces urine production.
- Oxybutynin/Tolterodine: Anticholinergics used for overactive bladder.
- Imipramine: A tricyclic antidepressant with anticholinergic and alpha-adrenergic effects (used cautiously).
- Combination Therapy
For treatment-resistant cases, a combination of alarms and medications may be employed. - Addressing Underlying Conditions
Constipation and UTI should be identified and managed concurrently.
REFERRAL IS STRONGLY INDICATED FOR:
- Suspected neurogenic or obstructive uropathy
- Persistent daytime symptoms
- Neurological signs or abnormal imaging
- Suspected sleep-disordered breathing (ENT or sleep specialist referral)
PROGNOSIS AND FOLLOW-UP
Enuresis improves with age, with a spontaneous annual resolution rate of about 15%. Regular follow-up helps monitor progress, reinforce behavioural strategies, and adjust therapy as needed.
While nocturnal enuresis is common and typically self-limiting, it warrants structured evaluation and individualised care.
Addressing both medical and psychosocial aspects ensures better outcomes for affected children and their families.
Parents should be guided with empathy and reassurance, and clinicians should remain vigilant for signs of underlying pathology.
We have managed a couple of patients aged 8 to < 18years of age. They were mostly managed as outpatients. Some were in primary and secondary schools, while some were in the universities. This condition had prevented some of the children from sleeping outside their homes or attending boarding school.
Most of the patients did well on conservative measures, and this is highly recommended. The few that required pharmacologic therapy mostly complained of a feeling of hotness (anticholinergic effect). Most of them were usually lost to follow-up, probably due to resolution with age, in addition to the medication
Public enlightenment is highly recommended to :
- Explain this condition that usually undergoes spontaneous resolution with age, especially the non-organic type.
- Reduce the associated psychological problem in children, especially adolescent
A 7-year-old boy is brought to the primary health clinic by his mother due to persistent bedwetting. The mother reports that he wets the bed almost every night, despite efforts such as limiting evening fluids and waking him up at night to urinate. There is no history of daytime incontinence or urinary tract infection symptoms. The family has been using traditional remedies without improvement. The child is otherwise healthy and performing well in school but is starting to withdraw socially due to teasing from his siblings. After counselling, reassurance, and advice on bladder training techniques, the mother is encouraged to remain patient and supportive while follow-up is scheduled.
- Kilongo LG, Furia FF. Nocturnal enuresis among children in Morongo Region in Tanzania. A Cross-sectional survey. East Afr Health res J. 2020; 4(2): 154-61
- Aliyu A, Ocheke AN, Bode-Thomas F. Enuresis among primary school children in Jos, Plateau state. Niger J Paeditr. 2016; 43(4): 248-52
- Lewinson RT, Adewuya AO, Obimakinde A, Ola BA. Prevalence and predictors of childhood enuresis in southwest Nigeria: Findings from a cross-sectional population study. J Paediatr Urol 2015; 11 (1): 38e1-6
- Etuk IS, Ikpeme O, Essiet GA. Nocturnal enuresis and its treatment among primary school children in Calabar. Niger J Paediatr 2011; 38(2):
- Nzamu IM. Prevalence of Nocturnal Enuresis and associated factors among 6-14-year-olds in rural Kenya[Thesis]. University Nairobi 2012
- Abdel-latif AM, Osman E, Abdelaziz A, Shaker S, Nageib N. Pattern of primary nocturnal enuresis in primary school children in Assiut, Egypt. Afr J Urol 2004; 10 (1): 22-29
- McLaughlin JF, Murray M, Van Zandt K, Carr M. Clean intermittent catheterization and self-catheterisation in children with neurogenic bladder: a comprehensive team approach. Pediat Rahabil 1995; 98 (6): 446-454
- Abiodun OA, Tunde-Ayinmode MF, Adegunloye OA, Ayinmode BA, Sulyman D, Unaogu NN et al. Psychiatric morbidity in paediatric primary care clinic in Ilorin, Nigeria. J Trop Pediatr 2011; 57( 3): 173-178
- Baker BL. Symptom treatment and symptom substitution in enuresis. J Abnorm Psychol 1969; 74:42.
- Young GC, Morgan RT. Conditioning techniques and enuresis. Med J Aust 1973; 2:329.
- Baker BL. Symptom treatment and symptom substitution in enuresis. J Abnorm Psychol 1969; 74:42.
- Young GC, Morgan RT. Conditioning techniques and enuresis. Med J Aust 1973; 2:329.
- Baker BL. Symptom treatment and symptom substitution in enuresis. J Abnorm Psychol 1969; 74:42.
- Young GC, Morgan RT. Conditioning techniques and enuresis. Med J Aust 1973; 2:329.
Author's details
Reviewer's details
Enuresis in Children
Enuresis is the voluntary or involuntary repeated discharge of urine on clothes or bed after a developmental age when bladder control should have been established. This is commonly known as bedwetting, remains one of the most frequent pediatric concerns and can be a source of distress and embarrassment for both children and their caregivers. While typically self-limiting, it requires a thorough understanding of normal bladder development, continent mechanisms, and potential underlying causes to guide effective management.
Normal Voiding and Toilet Training
Bladder control in children develops gradually. Newborns typically void 15–20 times a day, but as they age, bladder capacity increases and voiding frequency decreases. A rough estimate of millilitre bladder capacity is calculated as 30 × (age in years + 2).
Bladder control usually develops between 2–4 years of age, with girls attaining continence earlier than boys. Key contributors to continence include bladder growth, the child’s awareness of bladder fullness, voluntary control of the external sphincter, and motivation to remain dry. Notably, bowel control typically precedes bladder control.
Diurnal Incontinence and Its Causes
Diurnal (daytime) incontinence is common in children and is often due to overactive bladder or bladder-bowel dysfunction. Most children achieve dryness during the day by age five (95%) and nearly all by age twelve (99%).
Causes of diurnal incontinence include:
- Overactive or underactive bladder
- Giggle or overflow incontinence
- Voiding postponement
- Vaginal voiding
- Detrusor-sphincter discoordination
- Obstructive uropathy (e.g., posterior urethral valves)
- Psychological trauma or sexual abuse
- Chronic constipation
Assessment involves a careful history focusing on frequency, timing, volume of leakage, and associated symptoms like urgency or urinary tract infection (UTI). Investigations may include urinalysis, urine culture, ultrasound, and bladder diaries.
Nocturnal Enuresis: Definition and Classification
Nocturnal enuresis refers to involuntary urination during sleep in children aged five years and above. It is categorized by:
-
- Time of Onset:
- Primary: When nighttime dryness has never been achieved.
- Secondary: When enuresis recurs after at least six months of dryness, often triggered by stress or medical conditions.
- Time of Occurrence:
- Nocturnal Only (75% of cases)
- Daytime Only (rare)
- Mixed Day and Night (25%)
- Symptom Type:
- Monosymptomatic NE (MNE): Bedwetting without daytime urinary symptoms.
- Time of Onset:
- Non-monosymptomatic NE (NMNE): Associated with daytime urgency, frequency, or incontinence
- Kilongo LG, Furia FF. Nocturnal enuresis among children in Morongo Region in Tanzania. A Cross-sectional survey. East Afr Health res J. 2020; 4(2): 154-61
- Aliyu A, Ocheke AN, Bode-Thomas F. Enuresis among primary school children in Jos, Plateau state. Niger J Paeditr. 2016; 43(4): 248-52
- Lewinson RT, Adewuya AO, Obimakinde A, Ola BA. Prevalence and predictors of childhood enuresis in southwest Nigeria: Findings from a cross-sectional population study. J Paediatr Urol 2015; 11 (1): 38e1-6
- Etuk IS, Ikpeme O, Essiet GA. Nocturnal enuresis and its treatment among primary school children in Calabar. Niger J Paediatr 2011; 38(2):
- Nzamu IM. Prevalence of Nocturnal Enuresis and associated factors among 6-14-year-olds in rural Kenya[Thesis]. University Nairobi 2012
- Abdel-latif AM, Osman E, Abdelaziz A, Shaker S, Nageib N. Pattern of primary nocturnal enuresis in primary school children in Assiut, Egypt. Afr J Urol 2004; 10 (1): 22-29
- McLaughlin JF, Murray M, Van Zandt K, Carr M. Clean intermittent catheterization and self-catheterisation in children with neurogenic bladder: a comprehensive team approach. Pediat Rahabil 1995; 98 (6): 446-454
- Abiodun OA, Tunde-Ayinmode MF, Adegunloye OA, Ayinmode BA, Sulyman D, Unaogu NN et al. Psychiatric morbidity in paediatric primary care clinic in Ilorin, Nigeria. J Trop Pediatr 2011; 57( 3): 173-178
- Baker BL. Symptom treatment and symptom substitution in enuresis. J Abnorm Psychol 1969; 74:42.
- Young GC, Morgan RT. Conditioning techniques and enuresis. Med J Aust 1973; 2:329.
- Baker BL. Symptom treatment and symptom substitution in enuresis. J Abnorm Psychol 1969; 74:42.
- Young GC, Morgan RT. Conditioning techniques and enuresis. Med J Aust 1973; 2:329.
- Baker BL. Symptom treatment and symptom substitution in enuresis. J Abnorm Psychol 1969; 74:42.
- Young GC, Morgan RT. Conditioning techniques and enuresis. Med J Aust 1973; 2:329.
Content
Author's details
Reviewer's details
Enuresis in Children
Background
Enuresis is the voluntary or involuntary repeated discharge of urine on clothes or bed after a developmental age when bladder control should have been established. This is commonly known as bedwetting, remains one of the most frequent pediatric concerns and can be a source of distress and embarrassment for both children and their caregivers. While typically self-limiting, it requires a thorough understanding of normal bladder development, continent mechanisms, and potential underlying causes to guide effective management.
Normal Voiding and Toilet Training
Bladder control in children develops gradually. Newborns typically void 15–20 times a day, but as they age, bladder capacity increases and voiding frequency decreases. A rough estimate of millilitre bladder capacity is calculated as 30 × (age in years + 2).
Bladder control usually develops between 2–4 years of age, with girls attaining continence earlier than boys. Key contributors to continence include bladder growth, the child’s awareness of bladder fullness, voluntary control of the external sphincter, and motivation to remain dry. Notably, bowel control typically precedes bladder control.
Diurnal Incontinence and Its Causes
Diurnal (daytime) incontinence is common in children and is often due to overactive bladder or bladder-bowel dysfunction. Most children achieve dryness during the day by age five (95%) and nearly all by age twelve (99%).
Causes of diurnal incontinence include:
- Overactive or underactive bladder
- Giggle or overflow incontinence
- Voiding postponement
- Vaginal voiding
- Detrusor-sphincter discoordination
- Obstructive uropathy (e.g., posterior urethral valves)
- Psychological trauma or sexual abuse
- Chronic constipation
Assessment involves a careful history focusing on frequency, timing, volume of leakage, and associated symptoms like urgency or urinary tract infection (UTI). Investigations may include urinalysis, urine culture, ultrasound, and bladder diaries.
Nocturnal Enuresis: Definition and Classification
Nocturnal enuresis refers to involuntary urination during sleep in children aged five years and above. It is categorized by:
-
- Time of Onset:
- Primary: When nighttime dryness has never been achieved.
- Secondary: When enuresis recurs after at least six months of dryness, often triggered by stress or medical conditions.
- Time of Occurrence:
- Nocturnal Only (75% of cases)
- Daytime Only (rare)
- Mixed Day and Night (25%)
- Symptom Type:
- Monosymptomatic NE (MNE): Bedwetting without daytime urinary symptoms.
- Time of Onset:
- Non-monosymptomatic NE (NMNE): Associated with daytime urgency, frequency, or incontinence
Further readings
- Kilongo LG, Furia FF. Nocturnal enuresis among children in Morongo Region in Tanzania. A Cross-sectional survey. East Afr Health res J. 2020; 4(2): 154-61
- Aliyu A, Ocheke AN, Bode-Thomas F. Enuresis among primary school children in Jos, Plateau state. Niger J Paeditr. 2016; 43(4): 248-52
- Lewinson RT, Adewuya AO, Obimakinde A, Ola BA. Prevalence and predictors of childhood enuresis in southwest Nigeria: Findings from a cross-sectional population study. J Paediatr Urol 2015; 11 (1): 38e1-6
- Etuk IS, Ikpeme O, Essiet GA. Nocturnal enuresis and its treatment among primary school children in Calabar. Niger J Paediatr 2011; 38(2):
- Nzamu IM. Prevalence of Nocturnal Enuresis and associated factors among 6-14-year-olds in rural Kenya[Thesis]. University Nairobi 2012
- Abdel-latif AM, Osman E, Abdelaziz A, Shaker S, Nageib N. Pattern of primary nocturnal enuresis in primary school children in Assiut, Egypt. Afr J Urol 2004; 10 (1): 22-29
- McLaughlin JF, Murray M, Van Zandt K, Carr M. Clean intermittent catheterization and self-catheterisation in children with neurogenic bladder: a comprehensive team approach. Pediat Rahabil 1995; 98 (6): 446-454
- Abiodun OA, Tunde-Ayinmode MF, Adegunloye OA, Ayinmode BA, Sulyman D, Unaogu NN et al. Psychiatric morbidity in paediatric primary care clinic in Ilorin, Nigeria. J Trop Pediatr 2011; 57( 3): 173-178
- Baker BL. Symptom treatment and symptom substitution in enuresis. J Abnorm Psychol 1969; 74:42.
- Young GC, Morgan RT. Conditioning techniques and enuresis. Med J Aust 1973; 2:329.
- Baker BL. Symptom treatment and symptom substitution in enuresis. J Abnorm Psychol 1969; 74:42.
- Young GC, Morgan RT. Conditioning techniques and enuresis. Med J Aust 1973; 2:329.
- Baker BL. Symptom treatment and symptom substitution in enuresis. J Abnorm Psychol 1969; 74:42.
- Young GC, Morgan RT. Conditioning techniques and enuresis. Med J Aust 1973; 2:329.
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