• periodic involuntary passage of feces beyond age when continence should have been achieved (usually 4)

 

General Information (including ICD-9/-10 Codes)

Description :

• enuresis should be considered a symptom, not a disease
• definition variable
  • involuntary passage of urine during sleep
  • in one study, enuresis defined as repeated voiding of urine during the day and night into bed or clothes, whether involuntary or intentional, at least 2 times/week for 3 consecutive months, age at least 5 years, and not related to a physical disorder (J Dev Behav Pediatr 1996 Apr;17:90 in QuickScan Reviews in Fam Pract 1996 Oct;21(7):17)

ICD-9 Codes :

• 307.6 enuresis [used for nonorganic causes]
• 788.30 urinary incontinence, unspecified
• 788.36 nocturnal enuresis

ICD-10 Codes :

• F98.0 nonorganic enuresis
• R32 unspecified urinary incontinence

Types :

• primary vs. secondary
  • primary more common
  • secondary if previously continent at least 6-12 months, 8-10% cases, related to psychological stressors
  • classification in DSM-III-R but no longer used in DSM-IV
• 85% nocturnal, 5% diurnal, 10% mixed

Who is most affected :

• males

Incidence/Prevalence :

• 3% teenagers (developmental delay more common than organic disease), 1% adults
• incidence of bed-wetting in parental survey of > 10,000 children aged 5-17 years
  • 33% for children aged 5 years
  • 18% at age 8 years
  • 7% age 11 years
  • 0.7% at age 17 years
  • more likely to be infrequent (1-6 times/year)
  • associated with increased rates of behavior problems
  • Reference - Pediatrics 1996 Sep;98:414 in QuickScan Reviews in Fam Pract 1997 Mar;21(12):24
• 25% overall prevalence of enuresis at ages 5-6 years
  • based on longitudinal study in Quebec, Canada
  • number of families interviewed were 1,997 at age 29 months, 1,950 at age 41 months, 1,944 at age 4 years, 1,759 at age 5 years and 1,492 at age 6 years
  • prevalence of enuresis was 21.4% at age 5 years and 16.1% at age 6 years (considered not applicable before age 5 years)
  • Reference - Pediatrics 2007 May;119(5):e1016

Causes and Risk Factors

Causes :

• physiologic (age 2-3 years, up to 5-6 years)
• functional (psychosocial stressors)
• sleep disorder - many during stage 3 and 4 of first sleep cycle
• ? abnormal ADH cycles
• delayed neuromuscular maturation
• genetic - possibly autosomal dominant with > 90% penetrance
• 1-5% organic disease - urinary tract infection, outflow obstruction (distal urethral stenosis in girls, posterior urethral valves in boys), neurogenic bladder (lumbosacral meningomyelocele), diabetes mellitus, diabetes insipidus, sickle cell disease, chronic stool retention

Pathogenesis :

• bladder control varies with age with a lot of variability
  • 0-6 months - frequent uninhibited voiding, bladder fills and empties completely, hypothalamic control, spinal cord reflex
  • 6-12 months - decreased frequency, some CNS inhibition of detrusor reflex
  • 1-2 years - increased bladder capacity, neural maturation of frontal and parietal lobes, sensation of bladder fullness precedes ability to postpone voiding
  • 3-5 years - unconscious and voluntary inhibition of desire to void, normal filling sensation
• usual sequence of control
  • bowel control asleep
  • bowel control awake
  • bladder control awake
  • bladder control asleep (variable time to develop)
• maturational lag - hypothesis for primary enuresis
  • delayed development of inhibitory control consistent with delayed functional maturation of CNS (e.g. minor developmental delay - late walking, delayed fine + gross motor skills)
  • normal bladder capacity but decreased functional bladder capacity with early urge to void
  • up to 85% have "detrusor instability" on cystometrogram
• alternative hypothesis
  • decreased functional bladder capacity as result of child's voiding habits
  • may result from inadequate cortical inhibition
    • cortical arousals appears more common in children with severe enuresis
      • case-control study of 35 children (mean age 9.6 years) with severe refractory nocturnal enuresis and 21 controls were analyzed by polysomnography
      • cortical arousals and arousal index significantly correlated with unstable bladder contractions (p < 0.01)
      • Reference - N Engl J Med 2008 May 29;358(22):2414
• negative reinforcement factors
  • transient period of stress at critical period of development, e.g. sibling birth, move, being bullied
  • increased prevalence of enuresis in lower socioeconomic groups, dysfunctional families, divorce
• nocturnal diuresis
  • ADH levels increased in control subjects at night but constant in enuretics
  • high urine output results from lack of ADH, basis for DDAVP therapy
• enuretic event predominantly during non-rapid eye movement sleep (Pediatrics 1999 Jun;103(6):1193); study suggests that enuretic children tend to be very sound sleepers (Pediatric Notes 1999 Jul 1;23(26):102)

Likely risk factors :

• birth of sibling, move
• genetic factors
  • 70% children when both parents enuretic
  • 40% when 1 parent enuretic
  • 15% when neither parent enuretic

Possible risk factors :

• may be associated with being bullied in children; based on interviews of 2,848 children ages 7-10 years, 22.4% reported having been bullied and this was associated with reporting not sleeping well, bed wetting, feeling sad, and more than occasional headaches and tummy aches; increasing risk of symptoms with increased frequency of bullying (Br Med J 1996 Jul 6;7048(313):17)

Complications and Associated Conditions

Associated conditions :

• constipation associated with enuresis
  • based on cohort of 277 children aged 4.8-17.5 years with nocturnal enuresis
  • 95 (36.1%) had constipation based on clinician scoring method
  • 14.1% had constipation based on parental reporting
  • Reference - J Paediatr Child Health 2008 Jan;44(1-2):19
• mental disorders in only 20% enuretic children, especially girls, those with nocturnal and diurnal symptoms and older children
• 2 times risk of developmental delays in longitudinal study
• bed-wetting at age 53 months associated with delay in developmental milestones in study of 1,666 children in Quebec (Arch Pediatr Adolesc Med 2005 Dec;159(12):1129 in JAMA 2006 Feb 15;295(7):741)
• ADHD more common in enuretics > 10 years old
• ADHD and enuresis associated; based on questionnaires from 153 parents of ADHD patients and 142 parents of controls; children with ADHD 2.7 times more likely to have nocturnal enuresis and 4.5 times more likely to have diurnal enuresis (South Med J 1997 May;90:503 in QuickScan Reviews in Fam Pract 1997 Nov;22(8):14)

History

Chief Concern (CC) :

• enuresis

History of Present Illness (HPI) :

• considered polysymptomatic if frequency, urgency, urge incontinence, dysuria, dribbling, difficulty with starting or stopping stream (if so, observe), sensation of incomplete voiding
• pattern (nocturnal, diurnal, both), number of wet nights per week or month, number of episodes per night, time of episodes, number of daytime voids, longest interval between voids
• 24-hour fluid intake
• toilet training methods, behavior problems at time of toilet training
• about 80% have never had dryness for 1 year (80% primary enuresis), secondary enuresis usually begins at age 5-8 years; secondary enuresis after 8 years should suggest organic cause, especially diabetes
• organic features more common if both nocturnal and diurnal enuresis, plus urinary frequency and urgency
• normal development of bowel and bladder control is nocturnal fecal continence, then diurnal fecal continence, then diurnal bladder control, then nocturnal bladder control

Past Medical History (PMH) :

• urinary tract infections, sickle cell disease or trait, allergies, seizures, constipation, encopresis

Family History (FH) :

• 70-75% have first-degree relative who was enuretic, concordance rate higher for monozygotic twins than for dizygotic twins
• ask about age when parents achieved bladder control

Social History (SH) :

• impulse disordered child, birth of sibling, parental divorce, other stressors
• based on interviews of 2,848 children ages 7-10, 22.4% reported having been bullied and this was associated with reporting not sleeping well, bed wetting, feeling sad, and more than occasional headaches and tummy aches; increasing risk of symptoms with increased frequency of bullying (BMJ 1996 Jul 6;313(7048):17)

Review of Systems (ROS) :

• ask about constipation and encopresis; in series of 234 children 5-18 years old with chronic constipation and encopresis, 29% had daytime enuresis, 34% had nocturnal enuresis and 11% had urinary tract infection; at 12 mos, treatment relieved constipation successfully in 52%; among those with relief of constipation, daytime enuresis resolved in 89%, nocturnal enuresis resolved in 63% and recurrent urinary tract infections disappeared in all patients without anatomic abnormalities (Pediatrics 1997 Aug;100(2):228), commentary can be found in Pediatrics 1998 Jul;102(1):158

Physical

General Physical :

• height, weight, blood pressure; examine external genitalia

Abdomen :

• abdominal and genitourinary exam

Back :

• look for lumbar spine abnormalities or sacral dimpling

Neuro :

• thorough exam

Rectal :

• check rectal and perineal sensation

Diagnosis

Making the diagnosis :

• DSM-IV-TR criteria
  • repeated voiding of urine into bed or clothes, involuntary or intentional
  • frequency 2 times/week at least 3 consecutive months or significant distress or impairment in social, academic, occupational or other important areas of functioning
  • chronological or developmental age at least 5 years
  • not due to direct physiological effect, substance or general medical condition

Rule out :

• urinary tract infection, diuretic, diabetes mellitus, spina bifida, seizure disorder, up to 3% structural obstructive anomalies, neurologic disorders, cystitis, diabetes insipidus, intoxication, sleepwalking, antipsychotic side effect, detrusor instability, neurogenic bladder, posterior urethral valves, ectopic ureter, chronic renal failure, renal tubular disorders, sexual abuse
• organic features more common if both nocturnal and diurnal enuresis, plus urinary frequency and urgency

Testing to consider :

• urinalysis (including specific gravity [early morning is most concentrated], glucose, protein, blood, WBC) and urine culture sufficient if normal stream
• dipstick urinalysis and urine culture not useful in primary nocturnal enuresis, based on series of 121 reviewed charts (Pediatric Notes 1997 Jul 17;21(29):114)
• because urethral stenosis is rare, females with enuresis should not be subjected to cystoscopy and urethral dilation
• consider uroradiography study (if UTI or obstruction) or urodynamic study (if severe diurnal symptoms)

Urine studies :

• bacteruria
  • treatment with antibiotics may resolve secondary enuresis
  • in monosymptomatic primary nocturnal enuresis, 5% girls and 0 boys had bacteruria on urinalysis
  • in polysymptomatic enuresis, 50% girls and 5% boys had bacteruria

Prognosis

Prognosis :

• excellent response to treatment, high spontaneous remission rate (10%/year)
• relapse rate high, but may be curbed by tapering treatment after nighttime continence established, retreatment periods tend to be shorter
• certain abnormal behaviors at age 3 years associated with criminal offences in adulthood; based on study of 828 people; factors at age 3 years associated with adult criminal offences included soiling, daytime enuresis, and activity level and management difficulties (Br J Psychiatry 2001 Sep;179(3):197 in BMJ 2001 Sep 22;323(7314):702)

Treatment

Treatment overview :

• enforce that problem is "no one's fault"
• involve both child and parent in treatment plan
• motivational counseling and reassurance, appropriate toilet training with parental reinforcement, symptom diary, star charting (form of reward)
• committee review of European trials (but not North American trials) found that treatment of first choice should be the one most acceptable to the family, e.g. alarm system, desmopressin or combination (Acta Paediatr 1999 Jun;88(6):679 in Pediatric Notes 1999 Jul 29;23(30);117)

Diet :

• eliminating certain foods works in small minority, e.g. chocolate, soda, citrus juices, eggs, dairy

Activity :

• simple behavioral treatments may be preferred as first-line therapy to medications or alarm therapy, but evidence limited
  • systematic review of 13 trials with 702 children, but each outcome only addressed by single trials
  • reward systems (e.g. star charts with stars given for dry nights) associated with fewer wet nights, higher cure rates and lower relapse rates
  • lifting or waking the children at night to urinate associated with fewer wet nights, higher cure rates and lower relapse rates
  • insufficient evidence to evaluate retention control training (bladder training)
  • cognitive therapy may have lower failure and relapse rates than star charts, based on 1 small trial
  • imipramine more effective than fluid deprivation and avoidance of punishment in 1 small trial
  • Reference - systematic review last updated 2004 Feb 19 (Cochrane Library 2004 Issue 2:CD003637)

Counseling :

• psychotherapy expensive, impractical and limited to obvious psychopathology

Medications :

• medications rarely needed but can be used when dryness essential
  • imipramine (Tofranil) 50-75 mg at night
    • approved for childhood enuresis especially short-term
    • dose 0.9-1.5 mg/kg/day, maximum 2.5 mg/kg, 25 mg at age 5-8 years, 50-75 mg at > 12 years old
    • 30-50% success rate, up to 85% improved symptoms, 30% relapse rate
    • tolerance after 6 weeks, high relapse rate on discontinuation usually within mos
    • no clear efficacious therapeutic range, increased dose often creates more side effects than benefit
    • costs $14-32/month
    • anticholinergic effect on bladder tone, decreased depth of sleep
    • tricyclic drugs (imipramine, amitriptyline, viloxazine, nortriptyline, clomipramine and desipramine) reduce number of wet nights per week by 1 in children with nocturnal enuresis and no organic causes, mianserin effect did not reach statistical significance in 1 small trial; about 20% children became dry on treatment, but most children relapased after stopping tricyclics or desmopressin, while only half the children relapse after alarm treatment; insufficient data to compare tricyclic drugs, except imipramine more effective than mianserin; evidence comparing tricyclics with desmopression or alarm treatment was unreliable or conflicting; systematic review of 54 randomized trials (many of poor quality) with 3,379 children last updated 2003 May 28 (Cochrane Library 2003 Issue 3:CD002117)
  • desmopressin
    • intranasal desmopressin (DDAVP, DDVP, Minirin, Stimate Nasal Spray) no longer indicated for treatment of primary nocturnal enuresis and should not be used in patients with hyponatremia or history of hyponatremia
      • increased risk of severe hyponatremia (possibly resulting in seizures and death) in certain patients (including children) treated with intranasal desmopressin for primary nocturnal enuresis
      • desmopressin tablets should be interrupted during acute illnesses that may lead to fluid and/or electrolyte imbalance
      • all formulations should be used cautiously in patients at risk for water intoxication with hyponatremia
      • Reference - FDA MedWatch 2007 Dec 4
    • desmopressin rapidly reduces number of wet nights per week in children with nocturnal enuresis, but response not sustained after treatment stopped; limited evidence suggests desmopressin as effective as tricyclic antidepressants with less side effects, and less effective than bed alarms; avoid drinking > 240 ml (8 oz) during desmopressin treatment to avoid water intoxication; systematic review of 41 trials with 2,760 children last updated 2002 May 29 (Cochrane Library 2002 Issue 3:CD002112)
    • desmopressin 20-60 mcg increases "cure" rates defined as 14 consecutive dry nights during treatment (NNT 5-6) based on meta-analysis of 3 trials (J Urol 2001;166:2427); insufficient evidence to compare nasal vs. oral desmopressin (Clinical Inquiries in J Fam Pract 2003 Jul;52(7):568)
    • desmopressin (DDAVP) nasal spray recently approved
      • 50-70% cure rate for primary nocturnal enuresis
      • high relapse rate
      • 10-40 mcg intranasally at night
      • useful for fast results and special occasions (e.g. sleepovers)
      • increases urine concentration and decreases urine output during sleep
      • costs $116 per 5 ml inhaler
      • oral tablet has poor bioavailability
      • very few side effects
      • monosymptomatic, nocturnal enuresis responds better than mixed enuresis
      • hyponatremia is potential problem affecting patients with nocturnal enuresis treated with DDAVP, so patients should ingest < 8 oz fluid on any night that DDAVP is administered; 11 case reports of patients who developed seizure or altered level of consciousness during treatment with DDAVP for nocturnal enuresis, presumably due to water intoxication; in 6 of 11 case reports, excess fluid intake was identified as cause (Eur J Pediatr 1996 Nov;155(11):959 in QuickScan Reviews in Fam Pract 1997 May;22(2):23)
      • now available in nasal spray formulation which can be stored at room temperature (Monthly Prescribing Reference 1997 Aug;A-18)
      • responders tend to void during early or late part of night, based on study of 25 enuretic children (Pediatrics 1999 Jun;103(6):1193)
    • desmopressin (DDAVP) now available in tablet form for children at least 6 with primary nocturnal enuresis (Monthly Prescribing Reference 1998 May;A-25)
    • oral DDAVP modestly effective; study of children 6-16 with primary nocturnal enuresis given DDAVP 200, 400 or 600 mcg/day vs. placebo x 14 wks, DDAVP dose increased if not completely dry after 2 wks; at 8 wks, 24% vs. 3% had excellent response, 7% vs. 0 completely dry (Pediatric Notes 1998 May 28;22(22):85)
  • oxybutynin (Ditropan)
    • antispasmodic
    • used for small bladder capacity, diurnal frequency, urge incontinence
    • 5 mg PO 2-3 times daily
    • Ditropan XL now available in 5 and 10 mg doses for once daily dosing, approved for treatment for overactive bladder (Monthly Prescribing Reference 1999 Feb;A-26)
    • no clear role for primary nocturnal enuresis
• drugs which have had poor results
  • diuretics (for relative dehydration at night)
  • Valium (to suppress stage 4 sleep)
  • belladonna alkaloids, ephedrine (anticholinergic)
• no evidence to support use of drugs other than desmopressin or tricyclics for nocturnal enuresis; review of all randomized trials of drugs (excluding desmopressin or tricyclics) for nocturnal enuresis in children; conclusions generally limited by small trials or poor methodological quality; most of the 28 drugs evaluated were no better than placebo; indomethacin and diclofenac were each better than placebo, but desmopressin better than either of these drugs; systematic review of 32 trials with 1,613 children last updated 2003 Aug 25 (Cochrane Library 2003 Issue 4:CD002238)

Consultation and referral :

• urologic workup if wetting in daytime, other urologic symptoms, or enuresis persists beyond age 5-6 years
• psychotherapy alone not effective in controlled studies, but may be useful for coexisting psychiatric problems and family difficulties resulting from enuresis
• referral for mental health evaluation not necessary in children with primary nocturnal enuresis unless child's clinical presentation is unusual, as they do not have significant behavioral comorbidity (Arch Pediatr Adolesc Med June 1998;152:537 in Am Fam Physician 1998 Nov 1;58(7):1667)

Other management :

• conditioning therapy - enuresis alarm
  • considered by many to be treatment of choice
  • voiding triggers buzzer to wake child
  • goal to awaken before voiding
  • 60-80% success rate
  • intermittent use (vs. continuous use) decreases 20-30% relapse rate
  • costs about $70
  • difficult, slow to work, and best for motivated families
  • alarm superior to other treatments for nocturnal enuresis and should be considered for recalcitrant cases; 294 children 5-18 years old with nocturnal enuresis and previous unsuccessful treatments, patients and parents chose treatments, cure at 12 months defined as consecutive dry nights for at least 1 month; 31% chose alarm with 56% cure rate, 22% chose DDAVP with 18% cure rate, 21% chose combination therapy with oxybutynin with 16% cure rate, 24% chose no therapy with 28% cure rate (Pediatric Notes 1998 May 28;22(22):85)
  • alarm interventions effective for treating nocturnal bedwetting in children (level 1 [likely reliable] evidence); systematic review of 55 randomized trials with 3,152 children; alarms appear more effective than desmopressin or tricyclic antidepressants by end of treatment and after cessation of treatment; overlearning (giving extra fluids at bedtime after becoming dry), dry bed training and avoiding penalties may further reduce relapse rate; systematic review last updated 2005 Feb 22 (Cochrane Library 2005 Issue 2:CD002911), Cochrane for Clinicians summary can be found in Am Fam Physician 2002 May 1;65(9):1798; commentary can be found in Evidence-Based Medicine 2004 Jan-Feb;9(1):22
• fluid restriction before bed of limited value + may be counterproductive, forced fluids may actually help bladder training
• night awakening 1.5 hours after sleep onset
  • enuretic boys more difficult to awaken from sleep than age-matched controls, study of 15 boys 7-12 years old with enuresis at least 3 years vs. 18 controls, 9% vs. 40% successful attempts to wake at night (Acta Paediatr 1997 Apr;86:381 in QuickScan Reviews in Fam Pract 1997 Nov;22(8):20)
• assign adolescent to change sheets and do laundry
• encourage parents to eliminate negative remarks and punishments, provide positive reinforcement for dryness
• dry bed training
  • 85-100% cure rate
  • signal alarm
  • night waking
    • wake every hour until 1 am on first night, then once each night and shorten wake time gradually from 3 hours after bedtime
    • ask to void once awake, praise for dry bed
    • if child wets > 2 times/week, start over
  • cleanliness (clean wet laundry, remake bed)
  • child goes to bed, counts to 50, attempts to void in bathroom, repeat 20 times nightly and with each enuretic event
  • addition of dry bed training (DBT) to alarm may increase success rates, but use of DBT alone not as effective as alarm (level 2 [mid-level] evidence)
    • based on Cochrane review of trials with unclear or inadequate allocation concealment
    • systematic review of 18 randomized or quasi-randomized trials evaluating complex behavioral or educational interventions in 1,174 children with nocturnal enuresis
    • 3 trials had inadequate allocation concealment (quasi-randomization), 15 trials had unclear allocation concealment
    • for outcome of 14 consecutive dry nights
      • 85.2% with alarm only vs. 25.9% with DBT only in analysis of 2 trials with 54 children (p = 0.00067, NNT 2 favoring alarm only)
      • 98.6% with DBT plus alarm vs. 23.3% with DBT only in analysis 2 trials with 100 children (p < 0.00001, NNT 2 favoring DBT plus alarm)
      • 83.8% with DBT plus alarm vs. 62.3% with alarm only in sensitivity analysis of 4 trials with 186 children (p = 0.026, NNT 5 favoring DBT plus alarm), results may be limited by heterogeneity (p = 0.09) and this sensitivity analysis excluded 1 trial using different types of alarms
    • DBT plus alarm associated with lower rates of failure or relapse
      • 27.7% with DBT plus alarm vs. 62.5% with alarm only in analysis of 2 trials with 104 children (p = 0.0038, NNT 3)
      • 25.7% with DBT plus alarm vs. 70% with DBT only in analysis of 2 trials with 100 children (p < 0.00001, NNT 3)
    • Reference - Cochrane Database Syst Rev 2008 Jul 16;(3):CD004668
• hypnosis - 70% cure rate, not popular, not well documented in literature, used when specific stressors identified
• bladder stretching exercises (encouragement or reward for delaying micturition for increasing duration)
• bladder retention training
  • 35% cure rate, 60% improvement rate
  • bladder capacity can be estimated as oz = age in years + 2
  • works best for older children
  • drink large amount of water, postpone void for increasing amounts in 3 min intervals, reward for delayed voids
• enemas for constipation, distended rectum compresses bladder, some children with enuresis have constipation and soiling that need to be treated before enuresis treated
• alarm system with minimal wetness, e.g. bell and pad apparatus
• continue treatment 3 weeks after dryness achieved
• use of alarm or medication only justified with consent of teenager
• review of 49 questionnaires from 125 physicians; most preferred psychobehavioral to pharmacologic treatment methods, different from prior studies; rewards for dry nights + reassurance were most typical methods used; other methods included fluid restriction, medication, bladder stretching, waking for toilet use, enuresis alarm, + hypnotherapy; in no case was punishment or shaming utilized; 80% reported using "bell and pad" conditioning (5% in previous studies); 53% reported using medication for functional nocturnal enuresis, which was considered inappropriate since little supporting evidence exists; medication may sometimes be helpful, e.g. sleep-over party (J Dev Behav Pediatr 1996 Apr;17:90 in QuickScan Reviews in Fam Pract 1996 Oct;21(7):17)
• weak evidence supporting hypnosis, psychotherapy, acupuncture and chiropractic (level 2 [mid-level] evidence)
  • systematic review of 15 randomized or quasi-randomized trials of complementary and other miscellaneous interventions for nocturnal enuresis in 1,389 children
  • trials had poor overall quality, 4 were quasi-randomized, 5 had baseline differences, 10 lacked follow-up data
  • for outcome of failure or relapse after stopping treatment
    • hypnosis associated with lower risk than imipramine in 1 trial
    • psychotherapy associated with lower risk than alarm or rewards in 1 trial
    • acupuncture associated with lower risk than sham acupuncture in 1 trial
    • active chiropractic adjustment associated with lower risk than sham adjustment in 1 trial
    • data regarding diet and faradization considered unreliable
    • no trials of homeopathy or surgery
  • Reference - systematic review last updated 2005 Feb 21 (Cochrane Library 2005 Issue 2:CD005230)

Follow-up :

• regular follow-ups by single enthusiastic practitioner

Prevention and Screening

Prevention :

• breastfeeding may be associated with reduced risk for enuresis (level 2 [mid-level] evidence)
  • case-control study comparing 55 children ages 5-13 years with lifetime involuntary urine voiding during nighttime sleep at least 2 times per week and 117 matched controls
  • breastfeeding history reported in 45.5% cases vs. 81.2% controls
  • Reference - Pediatrics 2006 Jul;118(1):254, commentary can be found in Pediatrics 2006 Oct;118(4):1802, 1803

References including Reviews and Guidelines

Reviews :

• evidence-based review of treatment of nocturnal enuresis can be found in BMJ 2001 Nov 17;323(7322):1167, commentary can be found in BMJ 2002 Mar 16;324(7338):677
• Clinical Evidence Concise review (search date 2005 Mar) of nocturnal enuresis can be found in Am Fam Physician 2006 May 1;73(9):1611
• review can be found in Am Fam Physician 2003 Apr 1;67(7):1499
• review can be found in J Fam Pract 2005 Oct;54(10):905
• review can be found in Am Fam Physician 1999 Mar 1;59(5):1205
• review can be found in West J Med 2001 Aug;175;108, summary can be found in Am Fam Physician 2002 Feb 15;65(4):690
• review can be found in Mayo Clin Proc 1996 Sep;71(9):857
• review can be found in Am Fam Physician 1996 Nov 15;54(7);2259
• Ambulatory Child Health 1997;3(2);130 in QuickScan Reviews in Fam Pract 1998 Feb;22(11);8
• editorial review can be found in J Urol 1998 Apr;159;1338 (Pediatric Notes 1998 Apr 2;22(14);55)
• review of sleep disorders in childhood can be found in Am Fam Physician 2001 Jan 15;63(2):277
• review of psychopharmacological, psychoscoial and combined interventions for childhood disorders from American Psychological Association Working group on Psychotropic Medications for Children and Adolescents 2006 Aug PDF

Guidelines :

• American Academy of Child and Adolescent Psychiatry (AACAP) practice parameter for assessment and treatment of children and adolescents with enuresis can be found in J Am Acad Child Adolesc Psychiatry 2004 Dec;43(12):1540 or at National Guideline Clearinghouse 2005 Jun 6:6510

Patient Information

Patient information :

• handout from EBSCO Publishing Health Library PDF or in Spanish PDF
• handout from American Academy of Family Physicians
• handout can be found in Am Fam Physician 2003 Apr 1;67(7):1509
• handout can be found in Am Fam Physician 1999 Mar 1;59(5):1219
• handouts from Patient UK
  • bedwetting (enuresis)
  • bedwetting alarms
  • bedwetting reward systems
  • bedwetting medications