Enuresis affects 10 to 20 percent of first-grade boys and 8 to 17 percent of first-grade girls. Diurnal enuresis (daytime incontinence) usually is not diagnosed until age 5 or 6. Nocturnal enuresis (bedwetting) usually is not diagnosed until age 7.

Finding the cause

Laura Weissman, MD, a specialist in Developmental and Behavioral Pediatrics at Children's Hospital Boston, says that in most cases, the key to enuresis assessment is a comprehensive history and thorough physical exam. "In most cases, if a child presents with monosymptomatic nocturnal enuresis and otherwise unremarkable history and physical exams, the cause of the enuresis is generally not pathological and can be treated with behavioral therapy."

It's helpful to classify the symptoms of enuresis to guide evaluation. Questions to aid in the process should include the onset of symptoms, timing of symptoms and whether the symptoms are continuous or intermittent.

Assessing a voiding schedule can also be helpful. Questions can include: When does the child urinate and how often? Does the child seem to wet large or small volumes? Does the wetting occur before or after urination?

Taking a medical history should assist in identifying organic causes, including birth defects, such as spina bifida, neurologic disorders, renal disorders, diabetes and history of UTIs. Extremely important causes or exacerbating factors that are an essential part of the history include constipation, UTI and sleep apnea.

Children should also be screened for the possibility of sexual abuse and family history of enuresis should be noted, since children whose parents or siblings experienced enuresis are at increased risk.

Treatment

Treatment should be targeted toward any underlying cause that is identified. In particular, it's important to treat constipation if present. Stool retention caused by constipation can press on the bladder and exacerbate the symptoms of enuresis even if it is not the primary cause.

Nocturnal enuresis

Nocturnal enuresis is thought to be multifactorial in origin, and although the etiology is not entirely clear, it is thought to be related to slower physical development, an overproduction of urine at night or a child's lack of ability to recognize his bladder filling when asleep.

The most effective long-term strategy for treatment of bedwetting without other symptoms is a bed-wetting alarm. Success rates can be as high as 70 percent when children are motivated to end the enuresis and the family is able to adhere. Most cases resolve within four months.

Medications such as desmopressin (DDAVP) can also decrease night time wetting episodes, but the effects only last as long as the medication is taken, and children's symptoms often return when the medication is discontinued.

Diurnal enuresis

For cases of daytime wetting, it's also important to treat underlying constipation. Information from a voiding diary can also help identify opportunities for intervention. General measures include:

  *Urgency containment exercises: Children are told to go to the bathroom as soon as they feel the urge to urinate. They then hold the urine as long as they can and, when they can no longer hold it, start to urinate and then stop and start the urinary stream. The object is to strengthen the sphincter and give the child confidence that he can control the urinary stream.

  *Scheduled urination: Children wear an alarm (such as a wrist watch) that beeps every two hours to remind them to urinate. This is preferable to having a parent in the reminder role.

  *Proper voiding methods to discourage retention of urine in the vagina: Girls are directed to sit backward on toilet or with knees wide apart.

  * Medication: Can be helpful but is not typically first-line therapy.

Family education

According to Kim Dunn, PNP, nurse practitioner in the Pains and Incontinence Program (PIP) at Children's, an important factor in managing enuresis is family involvement and education. Parents need to know that incontinence is a common problem in children and is usually not a sign of emotional or psychological dysfunction. To preserve the child's self-esteem, parents should be instructed to avoid punitive approaches.

The child's commitment is also essential, says Sherry Tsai, CPNP, a PIP nurse practitioner. "Any technique that gives him ownership of the problem, like wearing a reminder watch, can be a motivating factor," she says.

When to refer

Refer when a physical cause has been identified that cannot be treated by the pediatrician, including sleep apnea, spinal dysraphism, diabetes, neurogenic bladder, sexual abuse or a urological abnormality. Referral may also be appropriate when a case is refractory to behavioral management or if the pediatrician is not comfortable making a diagnosis.

Copyright 2008- American Society of Registered Nurses (ASRN.ORG)-All Rights Reserved