Makindo Medical Notes

Related Subjects: |Encopresis in Children |Enuresis/Bedwetting in Children |Acute Glomerulonephritis in Children |Nephrotic Syndrome in Children |Acute Appendicitis in Children |Gastro-oesophageal reflux in Children |Intussusception in Children |Panayiotopoulos Syndrome in Children |Reflex anoxic attacks in Children

🌙 Enuresis (bedwetting) is common in young children and often resolves naturally as the child matures. Early behavioural support, reassurance, and selective medical therapy can reduce anxiety for both child and family. With a patient, consistent approach, most children will eventually achieve full dryness.

💧 Introduction

• Enuresis refers to the involuntary passage of urine during sleep (night-time enuresis) in children beyond the age of expected bladder control.
• 💤 Occurs in about 15% of 5-year-olds and 5% of 10-year-olds; only 1–2% persist into adolescence or adulthood.
• 👨‍👩‍👧 Often has a strong familial tendency — one or both parents may have had enuresis in childhood.
• 👧 Girls typically achieve bladder control earlier than boys.
• 🕐 Defined clinically as bedwetting beyond age 5 (girls) or age 6 (boys), in the absence of organic disease.

🧠 Causes and Risk Factors

• 🧬 Delayed maturation of bladder control: Most common cause. Nocturnal vasopressin release and bladder capacity are immature, leading to overnight urine accumulation.
• ⚕️ Underlying medical issues: Consider UTIs, diabetes mellitus, chronic kidney disease, or urinary tract abnormalities if presentation is atypical.
• 💭 Secondary enuresis: Recurrence after ≥6 months of dryness — may indicate emotional or behavioural stressors, bullying, parental separation, or abuse.
• 🌡️ Sleep-related factors: Deep sleep patterns and reduced arousal response to bladder fullness.
• 🚽 Constipation: Faecal loading compresses the bladder, reducing capacity and control.

🔎 Clinical Features

• 💤 Night-time wetting — frequency and timing are key: assess number of nights per week and volume.
• 🌞 Daytime symptoms: Frequency, urgency, or urge incontinence suggest overactive bladder — may benefit from oxybutynin or bladder training.
• 🥛 Fluid habits: Inadequate daytime fluids or excessive evening drinks worsen symptoms.
• 🚫 Constipation or stool withholding can exacerbate bladder instability.
• ⏳ Secondary enuresis: Reappearance of wetting after prior dryness warrants investigation for UTI, diabetes, or psychosocial stress.

🧪 Diagnosis

Diagnosis is clinical, supported by a detailed history and simple investigations where indicated.

• 🩺 History: Frequency of wetting, toilet training history, family history, and psychosocial context.
• 🔬 Urine dipstick: Check for glycosuria (diabetes), leucocytes/nitrites (UTI), or proteinuria (renal pathology).
• 💩 Assess bowel habits: Chronic constipation is common and treatable.
• 🧠 Secondary causes: Consider emotional distress or trauma if onset follows stress or regression.

🩺 Management Overview

Most children will improve with reassurance, behavioural intervention, and gradual bladder training. Punishment should never be used — it increases anxiety and perpetuates symptoms.

• 💬 Reassurance: Explain that enuresis is common, benign, and self-limiting in most children.
• 🥤 Fluid timing: Encourage adequate hydration during the day; limit fluids 1–2 hours before bedtime.
• ☕ Avoid caffeine: Chocolate, cola, and tea irritate the bladder.
• 🚽 Toilet routine: Encourage urination 4–7 times daily and always before sleep.
• 🌈 Reward charts: Reinforce effort-based goals (e.g. using the toilet before bed), not dry nights.
• 💩 Address constipation: Treat proactively with diet, fluids, or stool softeners (e.g. PEG 3350).

⚙️ Advanced Management for Persistent Cases

• ⏰ Bedwetting alarms: Motion or moisture alarms (e.g. Drinite®) condition the child to wake at the first sign of wetness. Success rate ~55–60% after one year; relapse reduced by continued use after dryness achieved.
• 💊 Desmopressin (DDAVP): Reduces nocturnal urine output. Use for children ≥5 years (120–240 mcg at bedtime). Ideal for occasional use (e.g. sleepovers). Relapse common after discontinuation. Avoid in renal impairment, CF, or low sodium states.
• 🧑‍⚕️ Specialist referral: To paediatric continence or child mental health services if resistant to first-line therapy, or if secondary causes suspected.

💞 Support and Parental Guidance

Bedwetting can cause embarrassment, guilt, and frustration. Parents need reassurance that this is not “bad behaviour.” Supportive, consistent routines reduce shame and anxiety. Emotional warmth and patience are more effective than punishment. Encourage empathy and practical strategies — such as waterproof bedding and quiet nighttime cleanup plans.

🧩 Key Points for Parents

• 💬 Reassure: Enuresis is common and rarely signifies a serious problem.
• ❤️ Be patient: Most children will naturally achieve dryness as the bladder and central control mature.
• 🧠 Address stressors: School, family, or emotional difficulties can contribute to relapse.
• 🔄 Consistency: Follow structured routines; avoid mixed messages or punitive responses.
• 🌟 Prognosis: Excellent — about 15% of affected children become dry each year without specific treatment.

✅ Conclusion

Enuresis reflects a delay in the normal maturation of bladder control rather than pathology. Most cases resolve spontaneously, but behavioural interventions and reassurance form the cornerstone of care. In resistant cases, bedwetting alarms or desmopressin may be helpful. Above all, a calm, supportive, and shame-free environment fosters confidence, normal development, and family harmony.