In some children the causes of enuresis are pri-
marily behavioral, such as ignoring the urge to
urinate until it becomes overwhelming, not emp-
tying the bladder immediately before going to bed,
or drinking large quantities of fluids throughout
the day and especially in the three to four hours
preceding bedtime. Generally these behaviors are
easy for parents to modify through positive rein-
forcement and diligent monitoring of the child’s
drinking and URINATION patterns. Psychological
enuresis typically occurs due to profound emo-
tional distress and is not the result of conscious
behavior.
Enuresis becomes a significant embarrassment
to most who have it after they reach about the age
of 8 to 10 and especially for teens and adults. Chil-
dren may refuse to spend the night with friends or
have friends spend the night with them and may
avoid overnight activities such as camping or
vacationing in motels. Their refusal may be overt
or they may express unreasonable fears.
Symptoms and Diagnostic Path
The symptom of enuresis is inappropriate urina-
tion, often during naps or when sleeping at night,
but it may occur any time. The diagnostic path
consists of a careful history of eating, drinking,
urination, and bowel habits as well as patterns of
enuresis (such as all the time or only during
sleep). The urologist may conduct diagnostic pro-
cedures such as urinalysis, ULTRASOUNDof the blad-
der, voiding CYSTOURETHROGRAM, or CYSTOSCOPY,
depending on the suspected underlying cause. In
most situations in which the urinalysis is normal,
however, the urologist delays extensive diagnostic
procedures until after a trial of basic treatment
and behavioral interventions.
Treatment Options and Outlook
Treatment may combine medical interventions
with behavioral approaches such as limiting fluids
in the evening and fully emptying the bladder
right before going to bed. Enuresis alarms (mois-
ture-sensitive devices) are especially effective for
children. Medication therapy may include desmo-
pressin (DDAVP), which decreases urine produc-
tion, or oxybutynin (Ditropan) or tolterodine
(Detrol), medications that slow smooth muscle
stimulation.
Risk Factors and Preventive Measures
Nocturnal enuresis appears to run in some fami-
lies, though researchers are not sure what
accounts for this. The key risk factors for enuresis
are organic causes such as congenital anomalies or
physiologic dysfunctions and severe emotional
stress. Health experts stress that neither punish-
ment nor the so-called bladder training method
(holding a full bladder for a determined amount of
time, ostensibly to strengthen sphincter control) is
effective in ending enuresis. These approaches fail
to address the causes of enuresis, result in further
embarrassment and discomfort, and may exacer-
bate the underlying cause of the enuresis. Time,
patience, and positive reinforcement (such as
praise and small rewards) as well as appropriately
addressing any physiologic dysfunctions, result in
ending enuresis about 98 percent of people.
See also ANURIA; CONGENITAL ANOMALY; DYSURIA;
HEMATURIA; NEURAL TUBE DEFECTS; NOCTURIA; OLIGURIA;
SLEEP DISORDERS; URINARY INCONTINENCE; URINARY
URGENCY.epispadias A random CONGENITAL ANOMALY in
which the URETHRAforms incorrectly. Epispadias
often occurs as an element within a constellation
of congenital malformations involving the pelvic
structures (including the pelvic bones) and the
GENITALIA.
In boys the urethra may exit the PENISother than
at the tip or appear as an open channel that runs
the length of the PENIS, and often occurs in conjunc-
tion with CHORDEE(a deformity in which the penis
curves sharply). In girls the urethra may exit any-
where between the neck of the BLADDERand the
upper labial fold, and typically occurs in conjunc-
tion with genital deformities such as bifid (two-fold
or split) CLITORISand abnormalities of the VULVA.
Epispadias is rare in either sex though much
more so in girls, and typically apparent at birth.
Early surgery is the preferred means to correct the
defects, which preserves FERTILITYand sexual func-
tion, restores the genitalia to normal appearance,
and helps establish urinary continence (the ability
to control the flow of URINE). Prenatal ULTRASOUND
sometimes can detect epispadias before birth.
There are no measures to prevent epispadias.
See also BIRTH DEFECTS; BLADDER EXSTROPHY;
HYPOSPADIAS; PRENATAL CARE.188 The Urinary System