night,and frequency of urination during the daytime.Reduced functional capacity compared to EBC,in addition to decreased sleep arousal, is a common finding in bedwetting children and can make treatment more complicated.

12.1.4.5  Psychological/Behavioral

Psychological stressors do not cause nocturnal enuresis but may play a role in secondary enuresis, or the relapse of physiologic enuresis. These children often display daytime symptoms as well, including daytime incontinence, urgency, encopresis, decreased school performance, and social withdrawal. Associations have been made between nocturnal enuresis and psychological or behavioral problems and have been attributed to low self-esteem of bedwetters and an overrepresentation of children suffering from ADHD in the enuretic group. Once these physiological and psychological causes have been addressed, the enuresis can be treated with the same methods as children with primary enuresis. Another possible association is that children suffer from psychosocial problems because of poor sleep quality secondary to detrusor overactivity at night, which is another reason to consider early and efficient therapy for bedwetters.

12.1.5  Nonmonosymptomatic (Organic) Enuresis

12.1.5.1  Urological Conditions: Urgency of Urination

and Dysfunctional Elimination

The detrusor muscle contracts to signal the initial urge to urinate. Some children may have difficulty suppressing this urge by inhibiting the detrusor contraction until they can get to the bathroom. These children may show daytime urgency but maintain continence by using the bathroom more often. Children who have severe bladder contractions often have associated daytime (urge) incontinence and may have difficulty suppressing this urge at night while sleeping. These children usually have a normal bladder capacity, but a small

126 A.M. Behr

functional bladder capacity, and waking in time to void at night can be difficult.4

Bladder irritation can also lead to urgency and incontinence. One of the most common causes of bladder irritation is a urinary tract infection (UTI). Urinary tract infections can decrease bladder function and inflame the normal bladder tissue making it difficult to expand and contract normally. Antibiotics can heal infections, but the secondary enuresis may not automatically improve. Once the irritation and wetting starts, it seems to become a cycle. If children present with enuresis after a period of being dry, UTI should be ruled out or treated before the enuresis is addressed.

Children with nocturnal enuresis may be affected by elimination disorders that can cause irritation of the lower urinary tract. Elimination disorders include delayed voiding or incomplete bladder emptying and irregular or infrequent bowel movements. These children prolong urination during the daytime, void only partially, and do no empty their bladders before bedtime. These habits increase the possibility for nocturnal enuresis (Table 12.1).

Irregular and infrequent stooling can also affect the ability of the bladder to fill and empty properly. A full rectum can put pressure on the bladder, preventing it from functioning well. During bladder filling, expansion of the bladder may be

TABLE 12.1.  Causative conditions for secondary enuresis.

restricted by a full rectum. The limited expansion causes the bladder to contract even though there may be room for additional urine. Then, instead of contracting smoothly and uniformly, the bladder will spasm, causing wetting to occur. Additionally, when the rectum chronically intrudes upon the bladder, it can decrease the sensation of bladder fullness and lead to day and nighttime enuresis.9

12.1.5.2  Polyuria

Excessive urine production may cause the bladder to fill one or more times during the night, requiring the child to wake to urinate. If the child does not arouse from sleep with the sensation to void, he or she will likely wet the bed. Polyuria can arise from several disease states, including diabetes mellitus, diabetes insipidus, and isothenuria associated with sickle cell anemia. It can exist in the absence of disease in children who drink excessive amounts of fluid in the evening hours or get up to drink overnight. Habit polydipsia is the most common cause of polyuria. Children or parents should be asked to report the amount of fluids at dinnertime, before bedtime, and if fluids are consumed in the middle of the night. It is important to ask about the intake of caffeine and any medications in the evening, as these factors can cause transient polyuria.

12.1.5.3  ADH Secretion

Normally, antidiuretic hormone (ADH) production increases at night causing the kidneys to concentrate urine and the bladder to fill more slowly. Some children do not secrete adequate amounts of ADH and their kidneys continue to produce dilute urine in quantities consistent with daytime amounts, overfilling the bladder and causing nocturia or enuresis. These children may benefit from the addition of desmopressin (DDAVP), the synthetic version of this hormone. Children who have normal ADH levels can still respond to DDAVP administration, which further reduces their urine production and may allow them to be dry at night.