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Enuresis--background and treatment
T Nevéus1, G Läckgren, T Tuvemo
1Dept of Women's and Children's Health, Uppsala University Children's Hospital, Sweden.
Insights
Nocturnal enuresis (bedwetting) in children stems from issues with nighttime urine production, bladder control, or sleep arousal. Understanding these factors helps differentiate between diuresis-dependent and detrusor-dependent enuresis for effective treatment.
Area of Science:
- Pediatric Urology
- Sleep Medicine
- Neuroscience
Background:
- Nocturnal urinary continence relies on balanced nocturnal urine production, bladder function, and sleep arousal mechanisms.
- Nocturnal enuresis occurs when urine output exceeds bladder capacity or the detrusor muscle is overactive, without arousal from sleep.
- Dysregulation in renal, hormonal, and neural pathways significantly impacts urine production and bladder control.
Purpose of the Study:
- To elucidate the pathogenetic factors contributing to nocturnal enuresis in children.
- To differentiate between the primary subtypes of nocturnal enuresis based on underlying mechanisms.
- To inform therapeutic strategies by understanding the heterogeneity of nocturnal enuresis.
Main Methods:
- Review of established physiological mechanisms governing nocturnal continence.
- Analysis of contributing factors including urine production, detrusor function, and arousal pathways.
- Classification of enuretic children into distinct pathogenetic subgroups.
Main Results:
- Nocturnal enuresis is pathologically heterogeneous, with two main types identified: diuresis-dependent and detrusor-dependent enuresis.
- Diuresis-dependent enuresis is characterized by excessive nocturnal urine production and impaired arousal.
- Detrusor-dependent enuresis involves nocturnal detrusor hyperactivity and impaired arousal; desmopressin is less effective in this subtype.
Conclusions:
- Effective management of nocturnal enuresis requires identifying the specific pathogenetic subtype.
- First-line treatments include enuresis alarms and desmopressin, with second-line options like anticholinergics and urotherapy.
- Understanding the interplay between urine production, bladder function, and sleep arousal is crucial for treating childhood enuresis.
Abstract:
Nocturnal urinary continence is dependent on 3 factors: 1) nocturnal urine production, 2) nocturnal bladder function and 3) sleep and arousal mechanisms. Any child will suffer from nocturnal enuresis if more urine is produced than can be contained in the bladder or if the detrusor is hyperactive, provided that he or she is not awakened by the imminent bladder contraction. Urine production is regulated by fluid intake and several interrelated renal, hormonal and neural factors, foremost of which are vasopressin, renin, angiotensin and the sympathetic nervous system. Detrusor function is governed by the autonomic nervous system which under ideal conditions is under central nervous control. Arousal from sleep is dependent on the reticular activating system, a diffuse neural network that translates sensory input into arousal stimuli via brain stem noradrenergic neurons. Disturbances in nocturnal urine production, bladder function and arousal mechanisms have all been firmly implicated as pathogenetic factors in nocturnal enuresis. The group of enuretic children are, however, pathogenetically heterogeneous, and two main types can be discerned: 1) Diuresis-dependent enuresis - these children void because of excessive nocturnal urine production and impaired arousal mechanisms. 2) Detrusor-dependent enuresis - these children void because of nocturnal detrusor hyperactivity and impaired arousal mechanisms. The main clinical difference between the two groups is that desmopressin is usually effective in the former but not in the latter. There are two first-line therapies in nocturnal enuresis: the enuresis alarm and desmopressin medication. Promising second-line treatments include anticholinergic drugs, urotherapy and treatment of occult constipation.