By Chiara Ghetti, MD
Associate Professor, Obstetrics and Gynecology, Division of Female Pelvic Medicine and Reconstructive Surgery, Washington University School of Medicine, St. Louis
Dr. Ghetti reports no financial relationships relevant to this field of study.
SYNOPSIS: Nocturnal enuresis was prevalent in women seen in a urogynecology setting and can be associated with nocturia, overactive bladder symptoms, and stress incontinence.
SOURCE: Campbell P, Li W, Money-Taylor J, et al. Nocturnal enuresis: Prevalence and associated LUTS in adult women attending a urogynaecology clinic. Int Urogynecol J 2017;28:315-320. doi: 10.1007/s00192-016-3099-0.
The objective of this study was to assess the prevalence of nocturnal enuresis (NE) and its association with other lower urinary tract symptoms (LUTS) in a urogynecologic population. This was an observational study of 2,302 women attending a urogynecologic practice for the first time between 2012-2015. All subjects completed the ePAQ-PF, a validated, web-based, 120-item questionnaire that assesses pelvic floor symptoms and their effect on quality of life. This study focused primarily on the following domains: overactive bladder (OAB), nocturia, and stress urinary incontinence (SUI). The authors evaluated prevalence of NE and used logistic regression modeling to explore the association of NE with symptoms of OAB, nocturia, and SUI. In addition, a subgroup analysis was performed in 84 women who underwent tension-free vaginal tape (TVT) for SUI during 2012-2015 and completed the ePAQ-PF at baseline and three months. This subanalysis compared NE symptoms before TVT and three months postoperatively.
The mean age of the 2,302 women was 54 years (range 18-89 years). Of these women, 23% (n = 536) reported NE. Symptoms of OAB, SUI, and nocturia were associated independently with NE. Patients with three or more episodes of nocturia were more likely to have NE compared to those without nocturia (odds ratio, 2.99; 95% confidence interval, 1.94-4.61). NE was reported preoperatively by 49% of the 84 women undergoing TVT (n = 41). Women with NE (n = 41) reported slightly lower improvement in SUI compared to women without NE (76% and 93%, respectively). While patients who underwent TVT showed improvement in SUI, OAB, and nocturia, only the improvements in SUI were associated with a significant improvement of NE.
COMMENTARY
The literature provides several definitions pertaining to NE and nocturia. The International Continence Society defines NE as the complaint of involuntary urinary loss occurring during sleep.1 Primary NE is defined as occurring in children ≥ 5 years of age. Persistent primary NE is defined as primary NE that does not resolve by adulthood. Secondary NE in children is defined as NE arising after a period of nighttime dryness of at least six months, while secondary NE in adults refers to symptoms arising after one year of dryness. Nocturia is defined as the complaint of interruption of sleep one or more times due to a need to void.
Most of us think about NE in the context of children. NE in adults is very poorly studied. A 1997 Scandinavian study of 13,081 community adults (18-64 years of age) found a 0.5% prevalence of NE.2 In this cohort, 12% of men and 29% of women also reported daytime incontinence. The authors noted that the majority of adult women who reported NE had secondary enuresis, with only 20% having persistent primary NE. The authors reported a significant effect of enuresis on quality of life. In a 2001 database study of 3,277 consecutive patients, 0.02% had adult-onset NE without daytime incontinence as a primary complaint.3 However, subjects with daytime incontinence were excluded.3 A 2004 telephone survey of 8,534 male and female respondents (ages 16-40 years) found an overall prevalence of NE of 2.3%.4 The authors found a significantly higher incidence of depression, low self-esteem, and sleep disturbances in NE subjects, with significant social and psychological effects on these individuals. A 2017 study of 12,795 women undergoing urodynamic testing for LUTS found a 14.4% prevalence of secondary NE.5 Authors found that women with secondary NE typically presented with OAB symptoms. NE was associated with higher body mass index, cigarette smoking, antidepressant use, and neurological conditions, and did not seem to be associated with stress incontinence.
Campbell et al found a 23% prevalence of NE in 2,302 women attending a urogynecologic clinic. The populations studied and the measures used in other studies are very different. The prevalence of NE in a general population of women is unknown. NE likely is much more common in adult women than we might think, and especially so in women with daytime lower urinary symptoms.
As in prior studies, Campbell et al found an association between NE and urge incontinence symptoms. However, this is the first study to find an association with stress incontinence symptoms. In their small cohort of 84 women undergoing TVT, almost half reported symptoms of NE and 60% noted improvement in their enuresis postoperatively.
A limitation of this study, beyond its study design, is the lack of information regarding onset and natural history of NE. The authors were unable to differentiate between persistent NE and secondary enuresis. It is likely that the etiology of NE in adult women differs between these types and, therefore, that the associations between NE and LUTS, such as OAB and SUI, may vary by type. In addition, the strong relationship between NE and nocturia was not explored fully. Modifiable risk factors for nocturia, such as sleep apnea, constipation, and nocturnal diuresis, also may be associated with NE.
NE is common in women with daytime lower urinary symptoms and incontinence, and it has a significant effect on sleep and quality of life. Asking patients with daytime urinary symptoms about NE may help providers better understand the severity of patients’ symptoms and may affect both treatment and desired outcomes.
REFERENCES
- Haylen BT, de Ridder D, Freeman RM, et al. An International Urogynaecological Association (IUGA)/International Continence Society (ICS) joint report on the terminology for female pelvic floor dysfunction. Int Urogynecol J 2010;21:5-26.
- Hirasing RA, van Leerdam FJ, Bolk-Bennick L, Janknegt RA. Enuresis nocturia in adults. Scand J Urol Nephrol 1997;31:533-536.
- Sakamoto K, Blaivas JG. Adult onset nocturnal enuresis. J Urol 2001;165(6 Pt 1):1914-1917.
- Yeung CK, Sihoe JD, Sit FK, et al. Characteristics of primary nocturnal enuresis in adults: An epidemiological study. BJU Int 2004;93:341-345.
- Madhu CK, Hashim H, Enki D, Drake MJ. Risk factors and functional abnormalities associated with adult onset secondary nocturnal enuresis in women. Neurourol Urodyn 2017;36:188-191.
Nocturnal enuresis was prevalent in women seen in a urogynecology setting and can be associated with nocturia, overactive bladder symptoms, and stress incontinence.
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