Katie S. Murray, DO
Tomas L. Griebling, MD, MPH, FACS
BASICS
DESCRIPTION
• Enuresis is repeated inability to control urine
– Primary: Starts in childhood and never resolves and continues into adulthood
– Secondary: New onset in adulthood
• Nocturnal enuresis (NE) is involuntary urination while asleep after the age at which bladder control usually occurs
EPIDEMIOLOGY
2.3% of adult population affected (1)[A]
RISK FACTORS
• Family history of NE
– If both parents have NE, children have 80% chance
Genetics
• Possibly hereditary
• Related to site on chromosome 13
PATHOPHYSIOLOGY
• Unknown in most situations
• Recognized hypotheses
– Obstructive sleep apnea causing diminished vasopressin secretion
– Disturbance in sensation, cortical arousal, or urinary sphincter function
– Decreased bladder capacity initiating involuntary voiding reflex
– Nocturnal polyuria because vasopressin secretion or reduction in renal sensitivity to the antidiuretic (2)[B]
– Detrusor instability during filling phase
– Urine production increased in recumbent position in patients with peripheral edema or congestive heart failure
• Normal physiology decreases nighttime, relative to daytime, urinary output. Excess production of urine at night, in the setting of a normal 24-hr urine output, is termed nocturnal polyuria
– Nocturnal polyuria is nighttime excretion of >35% of a 24-hr urine volume
ASSOCIATED CONDITIONS
• Benign prostatic hypertrophy
• Daytime urinary incontinence
• Psychological disorders including depression
• Sleep apnea
GENERAL PREVENTION
• Timed voiding
• Complete bladder emptying
• Avoidance of caffeine and alcohol
• Adjust timing of fluid intake
DIAGNOSIS
HISTORY
• Have never achieved nocturnal continence of urine
• Nonspecific urinary symptoms
• Ask about known or potential medical history
• Complete surgical and trauma/incident history
• Obtain record of fluid intake habits
• Review medications and times of administration
• Voiding diaries to evaluate frequency, volume, and patterns
• International prostate symptom score (IPSS) in men
PHYSICAL EXAM
• Full urologic exam (pelvic exam in women and DRE in men)
• Full neurologic exam
DIAGNOSTIC TESTS & INTERPRETATION
Lab
• Urinalysis and urine culture: Rule out urinary tract infection, hematuria, proteinuria, glycosuria
• Creatinine: Rule out renal insufficiency
• Urine cytology (if other symptoms such as irritative voiding symptoms make carcinoma a concern)
Imaging
• Post-void residual bladder scan
• Renal/ureteral imaging to evaluate for abnormalities such as ectopic ureters
– CT urogram
– Renal ultrasound
Diagnostic Procedures/Surgery
• Bladder diaries/frequency–volume charts
• Cystoscopy with retrograde pyelograms to evaluate bladder and ureters
• Urodynamic testing (3)[B]
– Identify anatomical urethral abnormalities
– Identify anatomical bladder abnormalities
– Evaluate bladder function for possible neurogenic bladder findings
– May find abnormalities in up to 90% of patients (4)[B]
• Consider sleep medicine consultation and/or polysomnography if clinical concern for sleep apnea
Pathologic Findings
N/A
DIFFERENTIAL DIAGNOSIS
• Obstructive sleep apnea
• Anxiety or psychological disorders
• Anatomic abnormalities
• Idiopathic detrusor instability
• Neurologic disorders
TREATMENT
GENERAL MEASURES
• Conservative measures have varying success rates
• Education is key when attempting to improve enuresis without medical therapy
• Timed voiding
• Complete bladder emptying
• If associated with BPH in men management with α-blockers for 5α-reductase inhibitors
• Avoidance of caffeine and alcohol
• Adjust timing of fluid intake
– Restrict fluid intake in evening to reduce urine output at night
– Take diuretic medications early in a day
MEDICATION
First Line
• If due to prostatic hypertrophy: See Section I “Bladder Outlet Obstruction (BOO).”
• Antimuscarinics or β3-agonists (3)[B]
– Inhibit the effect of acetylcholine at postjunc-tional muscarinic receptors on detrusor muscle cells
– β3-Adrenergic agonist promotes detrusor muscle relaxation
– Varying results (5–40%), depends on whether detrusor instability is root cause of enuresis
– Side effects: Dry mouth, constipation, blurred vision, confusion
• Antimuscarinics
– Tolterodine (2–4 mg/d)
– Trospium XR (60 mg/d)
– Darifenacin (7.5–15 mg/d)
– Solifenacin(5–10 mg/d)
– Oxybutynin (IR 7.5–20 mg/d, XL 5–30 mg/d, patch twice weekly)
– Fesoterodine (4–8 mg/d)
• β3-adrenergic agonist
– Mirabegron (25–50 mg/d)
Second Line
• DDAVP (Desmopressin) (5)[B]
– Not currently FDA approved for this clinical indication (has European regulatory approval)
– Analog of vasopressin
– Decreases urine production for about 5 hr
– Decreases number of enuresis events but may not eliminate it completely
Oral 0.2 mg at bedtime; increase to 0.6 mg to response
Intranasal formulations are no longer indicated for the treatment of primary NE due to risk for severe hyponatremia with seizures and death
Side effects: Nasal irritation, dry mouth, sleep disruption, water intoxication, seizures, heart failure, electrolyte disturbances, hyponatremic coma
Use with extreme caution if at all in geriatric patients (>65 yr) due to risk of severe hyponatremia and other adverse events
• Imipramine (5)[B]
– Tricyclic antidepressant
– Mild anticholinergic effect and α-action to increase internal sphincter tone
– Side effects: Sleep abnormalities, decrease appetite, personality disturbances
SURGERY/OTHER PROCEDURES
• Consideration after all conservative and pharmacologic measures have failed
• If urodynamic testing shows detrusor overactivity, may consider additional interventions
– Botulinum toxin injections
– Sacral neuromodulation
– Posterior tibial neuromodulation
– Augmentation cystoplasty
– Urinary diversion
ADDITIONAL TREATMENT
Radiation Therapy
N/A
Additional Therapies
• Psychological counseling
– Assist with coping mechanisms and finding any potential underlying issues
Complementary & Alternative Therapies
• Enuresis (bedwetting) alarms
• Timed voiding through the day and night
• Decrease fluid hydration prior to bed
• Empty bladder to completion prior to bed
ONGOING CARE
PROGNOSIS
• Many patients may eventually become dry
– This is more likely in children
COMPLICATIONS
• Urea dermatitis
• Skin breakdown and superficial ulcers from direct contact of urine on skin
• Psychological effects
– Job changes/decreased work performance
– Depression
– Low self-esteem
– Decreased social activities
FOLLOW-UP
Patient Monitoring
• Long-term follow-up until resolution or satisfaction by the patient
• Psychological counseling and follow-up if necessary
Patient Resources
• The Simon Foundation for Continence (simonfoundation.org)
• National Association for Continence (www.nafc.org)
REFERENCES
1. Yeung CK, Sihoe JD, Sit FK, et al. Characteristics of primary nocturnal enuresis in adults: An epidemiological study. BJU Int. 2004;93:341–345.
2. Natsume O, Kaneko Y, Hirayama A, et al. Fluid control in elderly patients with nocturia. Int J Urol. 2009;16:307–313.
3. Yucel S, Kutlu O, Kukul E, et al. Impact of urodynamics in treatment of primary nocturnal enuresis persisting into adulthood. Urology. 2004;64:1020–1025.
4. Yeung CK, Sihoe JD, Sit FK, et al. Urodynamic findings in adults with primary nocturnal enuresis. J Urol. 2004;171:2595–2598.
5. Vandersteem DR, Husmann DA. Treatment of primary nocturnal enuresis persisting into adulthood. J Urol. 1999;161:90–92.
ADDITIONAL READING
http://www.nafc.org/bladder-bowel/bedwetting-2/adult-bedwetting/
See Also (Topic, Algorithm, Media)
• Bladder Outlet Obstruction (BOO)
• Enuresis Algorithm 
• Enuresis, Pediatrics
• Incontinence, Adult Male
• Nocturia
• Urge Incontinence
• Urgency, Urinary (Frequency and Urgency)
CODES
ICD9
• 307.6 Enuresis
• 788.30 Urinary incontinence, unspecified
• 788.36 Nocturnal enuresis
ICD10
• F98.0 Enuresis not due to a substance or known physiol condition
• N39.44 Nocturnal enuresis
• R32 Unspecified urinary incontinence
CLINICAL/SURGICAL PEARLS
• Evaluating for underlying conditions is important in new onset enuresis.
• Social implications are common.
• Enuresis raised the risk for nighttime falls in elderly.