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2 One third of nocturnal enuresis involves bladder over-activity or in-
stability. Pointers to this include: small wet patches; daytime urgency;
frequent daytime urination (over seven times per day); or daytime
wetting. Bladder training and anticholinergic medication may reduce
excessive and unstable activity of the bladder wall (see below).
3 Though an epileptic seizure may involve urinary incontinence, there
is no evidence that ordinary enuresis is anepileptic equivalent. Children
with enuresis are no more likely than other children to have an abnor-
mal EEG.
Assessment
It is always necessary to obtain a detailed history of the wetting and any
other urological symptoms. Urine testing is indicated when the onset of the
enuresis is recent or combined with daytime urinary problems. Physical
examination and urological investigation are not necessary if straightfor-
ward enuresis is unaccompanied by any other urological symptom. Ask
about any associated psychiatric problems, and remember to ask specifi-
cally about faecal soiling. It is important to enquire about factors that may
influence choice of treatment. What has the family already tried? How mo-
tivated is the child or adolescent to get dry? Are the parents motivated to
participate in treatment, for example, getting up in the middle of the night
to supervise their child changing sheets and resetting an enuresis alarm?
Is the main concern about nights spent away from home? If so, temporary
suppression of enuresis (with medication) may be all that is needed.
Prognosis
Continuing nocturnal enuresis is predicted by: male sex, low socio-
economic status, secondary rather than primary enuresis, and wetting the
bed every night. The prevalence of enuresis is still 2–5% at the onset of
puberty and continues to drop thereafter, leaving some 1–3% of adults
with intractable enuresis.
Treatment
Since uncomplicated enuresis is best seen as a developmental rather than
a mental disorder, it is entirely appropriate that professional help usually
comes from health visitors, general practitioners and paediatricians rather
than from child mental health professionals. Whichever professional is
involved, if the child is under the age of 5 or 6, it is often sufficient
to reassure the parents that nocturnal enuresis is common and usually
outgrown.
Parents have often tried ‘common-sense’ measures such as taking their
still-sleeping or half-awake child to use the toilet in the late evening or
restricting fluids before bedtime. It is not clear, though, whether these
measures help or hinder: lifting could be seen as a way of training the
child to urinate while asleep or half asleep (exactly what you don’t want!)
and fluid restriction may promote bladder over-activity.