Nocturnal Enuresis Normal Up Until Age 6
By: Miriam E. Tucker, Senior Writer
[Pediatric News 32(2):34, 1998. © 1998 International Medical News Group.]

NEW ORLEANS -- Investigation and treatment of enuresis need not begin until a child reaches age 6, pediatric urologist Frank R. Cerniglia Jr. advised at the annual meeting of the American Academy of Pediatrics.
Typically, girls will gain control of urination by age 5 and boys, by age 6. However, nocturnal enuresis is still common in children between the ages of 6 and 8, said Dr. Cerniglia, chief of pediatric urology at the Ochsner Clinic in New Orleans.

Primary nocturnal enuresis (nighttime wetting in a child who has never been dry for any extended period) affects 5-7 million children in the United States. About 15% per year resolve without any intervention.

Only a third of parents consult a physician about a child who wets the bed. More than a third of parents punish their child for wet nights--something they should be strongly urged not to do, he said.

There appears to be a genetic link to bed-wetting: It occurs in 77% of children when both parents had wet the bed at one time in their lives, in 44% of children with one parent who had wet the bed, and in 15% of those whose parents had never wet the bed.

Simple maturational delay is felt by some to be the most common cause of enuresis. Although most children will outgrow bed-wetting with time, treatment may be warranted if the problem is really bothering the parent or child.

Decreased bladder capacity "gets too much credit" as a cause of enuresis and is not the problem in a child who only wets during the night. Similarly, children with only nocturnal enuresis are unlikely to have low levels of antidiuretic hormone, urinary tract disorders, or neurologic disorders. All of those problems would cause daytime wetness as well, he pointed out.

There is no role for cystoscopy or x-ray in a child with isolated primary nocturnal enuresis. If everything else on the history and physical is normal, the chance of finding anything on these tests is about 5 in 1 million, Dr. Cerniglia said.

Nonpharmacologic treatments, including behavior modification (see below), bladder stretching, and alarms, can be effective. Bladder stretching, based on the theory that bed wetters have small bladder capacities, will work only in the 30% of children who also have daytime wetting. The child is taught to hold his or her urine for longer periods each day.

Enuresis alarms are effective in about 70% of patients, but they take a few weeks to work and require a commitment from the parent and the child. The idea is to teach the child's brain to respond to a full bladder by waking the child up. Several companies now make these alarms, which cost about $40-$55.

Drugs may work when nonpharmacologic treatments are unsuccessful. Imipramine is effective in about 50% of patients. It's easy to use (one pill a day at bedtime) and is relatively cheap. However, relapses can occur, and there is a very small toxic window with a large side effect profile.

Desmopressin acetate (DDAVP nasal spray) is successful in about 50% of children with enuresis who have failed other therapies and can be used long term, but it is costly. DDAVP now is available in oral form, and the nasal DDAVP no longer needs to be kept refrigerated, Dr. Cerniglia said.