Symptom Finder - Enuresis ( Bed Wetting)
ENURESIS (BEDWETTING)
By following the innervation of the bladder from its termination to the spinal cord, brain, and “supratentorium,” one can develop an extensive list of possibilities for this mischievous condition. Thus, anatomy is the key and the mnemonic MINT is the door.
Termination: The bladder and entire urinary tract should be suspect for pathology in any case of enuresis beyond the age of 6.
M—Malformations include phimosis, small urinary meatus, and vesicoureteral reflux.
I—Inflammatory conditions form the largest group and include balanitis, urethritis, cystitis, and pyelonephritis. If a child develops chronic nephritis at an early age, his or her bladder simply may be too small to retain the polyuria during sleep.
N—Neoplasms are an unlikely cause in children, but they occur in adults.
T—Trauma from a vesical calculus or other foreign bodies inserted into the bladder must also be considered. Postprostatectomy enuresis should be considered here in the adult.
Spinal cord: The following are included in this group:
M—Malformations such as spina bifida.
I—Inflammatory conditions such as poliomyelitis and transverse myelitis.
N—Neoplasms such as spinal cord tumors.
T—Traumatic conditions such as fracture, hematomyelia, and herniated discs.
Brain: This is an important group of conditions to consider, if only briefly, because if the patient has a form of epilepsy, a cure may be easily obtained. Other neurologic conditions include mental retardation, multiple sclerosis, general paresis, brain tumors, and chronic encephalitides.
Supratentorium: A child may react violently to the pressure of toilet training by deliberately wetting the bed; this bedwetting may also be a way of getting back at generally strict parents or a way of getting their attention. Recent studies show that a child should not be considered a bedwetter until after the age of 6. Parents who put that label on a child too early may assure that the enuresis will continue for emotional
reasons. Labeling the child as a bedwetter at any age is not a solution to, but an aggravation of, the problem.
Approach to the Diagnosis
From the above discussion it should be obvious that simple bedwetting prior to age 6 may not require a workup at all. Look for a positive family history and beware of enuresis that develops after at least 6 months of remission (secondary enuresis). This may be a sign of sexual abuse. After that age a careful examination of the urine, including smear and culture for bacteria, should be done. An intravenous pyelogram and voiding cystogram are usually necessary. If these suggest a congenital lesion such as an ectopic ureter or are negative, cystoscopy may need to be done. An x-ray film for spina bifida and a sleep electroencephalogram (EEG) are probably worthwhile if urologic investigation is negative. If the workup is negative, reassure the patient that most children outgrow the problem by age 12.
Other Useful Tests
1. Urology consult
2. Psychiatry consult
3. Examination of urinary sediment (urinary tract infection [UTI])
4. Sonogram (test for residual urine)
5. Cystometric tests (neurogenic bladder)
6. Psychometric testing (psychiatric disorder)
ENURESIS (BEDWETTING)
By following the innervation of the bladder from its termination to the spinal cord, brain, and “supratentorium,” one can develop an extensive list of possibilities for this mischievous condition. Thus, anatomy is the key and the mnemonic MINT is the door.
Termination: The bladder and entire urinary tract should be suspect for pathology in any case of enuresis beyond the age of 6.
M—Malformations include phimosis, small urinary meatus, and vesicoureteral reflux.
I—Inflammatory conditions form the largest group and include balanitis, urethritis, cystitis, and pyelonephritis. If a child develops chronic nephritis at an early age, his or her bladder simply may be too small to retain the polyuria during sleep.
N—Neoplasms are an unlikely cause in children, but they occur in adults.
T—Trauma from a vesical calculus or other foreign bodies inserted into the bladder must also be considered. Postprostatectomy enuresis should be considered here in the adult.
Spinal cord: The following are included in this group:
M—Malformations such as spina bifida.
I—Inflammatory conditions such as poliomyelitis and transverse myelitis.
N—Neoplasms such as spinal cord tumors.
T—Traumatic conditions such as fracture, hematomyelia, and herniated discs.
Brain: This is an important group of conditions to consider, if only briefly, because if the patient has a form of epilepsy, a cure may be easily obtained. Other neurologic conditions include mental retardation, multiple sclerosis, general paresis, brain tumors, and chronic encephalitides.
Supratentorium: A child may react violently to the pressure of toilet training by deliberately wetting the bed; this bedwetting may also be a way of getting back at generally strict parents or a way of getting their attention. Recent studies show that a child should not be considered a bedwetter until after the age of 6. Parents who put that label on a child too early may assure that the enuresis will continue for emotional
reasons. Labeling the child as a bedwetter at any age is not a solution to, but an aggravation of, the problem.
Approach to the Diagnosis
From the above discussion it should be obvious that simple bedwetting prior to age 6 may not require a workup at all. Look for a positive family history and beware of enuresis that develops after at least 6 months of remission (secondary enuresis). This may be a sign of sexual abuse. After that age a careful examination of the urine, including smear and culture for bacteria, should be done. An intravenous pyelogram and voiding cystogram are usually necessary. If these suggest a congenital lesion such as an ectopic ureter or are negative, cystoscopy may need to be done. An x-ray film for spina bifida and a sleep electroencephalogram (EEG) are probably worthwhile if urologic investigation is negative. If the workup is negative, reassure the patient that most children outgrow the problem by age 12.
Other Useful Tests
1. Urology consult
2. Psychiatry consult
3. Examination of urinary sediment (urinary tract infection [UTI])
4. Sonogram (test for residual urine)
5. Cystometric tests (neurogenic bladder)
6. Psychometric testing (psychiatric disorder)