Special Report
Childhood Enuresis Association
By Thomas L. Kennedy, MD, FAAP
Two recently published studies address commonly asked questions regarding children with enuresis. The study by von Gontard and associates from Germany conducted a prospective nonblinded evaluation of 167 consecutive children referred to an "outpatient enuresis clinic" as a result of pediatrician referral or in response to newspaper and radio advertisements.1 The children ranged in age from 5 to 11 years with a mean age of 7¾. Seventy-three percent were males. Sixty-six percent had nocturnal enuresis, 4% had daytime wetting, and 30% had both. All were evaluated for psychiatric diagnosis by a team of child psychiatrists and a pediatrician. All were also screened for behavioral problems by a parent-completed questionnaire. One-third of wetting children had significant behavioral problems and/or psychiatric ICD-10 diagnoses. However, in children with primary, nocturnal enuresis the incidence of these problems was no greater than expected in the general population. In order to determine if subgroups of enuretic children are at increased risk for the behavior/psychiatric disorders, children with nocturnal enuresis were divided into subgroups defined as primary (never dry at night) and secondary (relapse after a period of dryness of 6 months ³). The children with daytime incontinence were divided into subgroups characterized by urge incontinence, postponement syndrome, and detrusor-sphincter dyscoordination (dysfunctional voiding). Von Gontard et al found that the 49 children with isolated, primary nocturnal enuresis had no greater rate of psychiatric and/or behavior disturbances than expected in the general population. Other subgroups of enuretic children, however, had a significantly increased risk of problems. For example, in children with secondary nocturnal enuresis, 39% and 75% had behavior problems and psychiatric diagnoses, respectively. Similarly, children with daytime wetting due to postponement syndrome were at significant risk, while those with urge incontinence were at low risk. Overall, one-third of the enuretic children had clinically relevant behavioral problems.
Neveus and colleagues, in a study from Sweden, examined depth of sleep and other sleep-associated problems and voiding patterns in children with enuresis in an attempt to evaluate the widely held belief that children with enuresis are often "deep sleepers."2 Their aim was to clarify the role of sleep in the pathogenesis of nocturnal enuresis. Additionally, they wanted to "test the hypothesis that enuresis may be a result of the coexistence of several separately inherited abnormalities in the same individual." The study was constructed as a questionnaire distributed in Swedish schools for the parents and children (ages 6-10 years) to complete together at home. There was a 74% response rate. Eight percent of children had nocturnal enuresis, including 10% of boys and 5% of girls. Approximately 4½% had daytime incontinence. Results showed that children with enuresis are more difficult to arouse from sleep and are three times more likely to be "deep sleepers." Nocturia is an important risk factor for both past and current enuresis. Family history of enuresis in parents or siblings is also an important risk factor. Additionally, children with past and/or current enuresis appear to have a higher incidence of bruxism, somnambulism, and hypnagogic myoclonus. The study also found that children with daytime incontinence have a greater likelihood of having a sleep disturbance, including bedtime fears, insomnia, and nocturia. The greatest risk factor for daytime wetting is urgency. Neveus et al conclude that enuretic children have impaired sleep arousal responses, and children with daytime wetting most frequently have bladder instability.
It has long been the impression of many pediatricians that children with nocturnal enuresis are deep sleepers. Data supporting this impression have been almost totally lacking. A 1997 study did look at the intensity of auditory cues required to arouse children from sleep and found that children with enuresis required a higher sound stimulus to awake.3 The current Swedish study uses an arbitrary rating scale on an anonymous, parent/child-completed questionnaire and comes to the same conclusion. Although there are some aspects of the study design that are open to criticism and Wolfish and colleagues try to take on too much by attempting to investigate disordered sleep in children with daytime wetting, the finding of triple the risk of enuresis among "deep sleepers" is a "keeper" for pediatricians who are discussing a child’s enuresis with the family.
Along these same lines, when we evaluate a child with urinary incontinence, there has always been the impression that emotional disorders are almost never a factor in a child with primary, monosymptomatic, nocturnal enuresis. On the other hand, children who develop nocturnal enuresis after a prolonged period of being dry, and children who are daytime wetters are frequently suspect for emotional and/or behavioral disturbances. The results of the study seem to confirm these impressions and make it a valuable addition to our resources regarding children with enuresis. The study is perhaps a bit too informative in its reporting of types of emotional disorders and psychiatric diagnosis. Nevertheless, knowing that a child with daytime setting has a 35% likelihood of a behavioral problem and a 53% likelihood of having at least one psychiatric disorder is helpful when we see this child in the office. This likelihood is even higher if the child has postponement of urination with or without stool retention and encopresis. It is less if the daytime wetting is secondary to urge incontinence.
References
1. von Gontard A, et al. Clinical behavioral problems in day- and night-wetting children. Pediatr Nephrol 1999; 13:662-667.
2. Neveus T, et al. Depth of sleep and sleep habits among enuretic and incontinent children. Acta Paediatr 1999;88:748-752.
3. Wolfish NM, et al. Elevated sleep arousal thresholds in enuretic boys: Clinical implications. Acta Paediatr 1997;86:381-384.
Enuresis in children:
a. is more common in girls than in boys.
b. emotional disorders are common in children with primary nocturnal enuresis.
c. behavioral and psychiatric disorders are common in children with daytime enuresis.
d. depth of sleep is not associated with nocturnal enuresis.
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