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Practice Essentials

The word enuresis is derived from a Greek word (enourein) that means to void
urine. It can occur either during the day or at night (though some restrict the
term to bedwetting that occurs at night). Enuresis can be divided into primary
and secondary forms.

Kata enuresis berasal dari kata Yunani (enourein) yang berarti "mengosongkan
urin." Hal ini dapat terjadi baik di siang hari atau di malam hari (meskipun
beberapa membatasi istilah untuk mengompol yang terjadi pada malam hari).
Enuresis dapat dibagi menjadi bentuk primer dan sekunder.

Signs and symptoms

The history is essential in making the proper diagnosis and should address the following:

Hydration history

Daytime voiding pattern

Toilet training history

Number and timing of episodes of bedwetting

Sleep history

Family history of nocturnal enuresis

Nutrition history

Behavior, personality, and emotional status

Alertness should be maintained for symptoms of common underlying problems such as the
following:

Overactive bladder or dysfunctional voiding

Cystitis and urinary tract infections (UTIs)

Constipation

Neurogenic bladder

Sleep-disordered breathing

Urethral obstruction
Major motor seizure

Ectopic ureter

Diabetes mellitus or diabetes insipidus

A comprehensive physical examination should include the following:

Measurement of blood pressure

Inspection of external genitalia

Palpation in the renal and suprapubic areas

Palpation of the abdomen

Thorough neurologic examination of the lower extremities, including gait, muscle


power, tone, sensation, reflexes, and plantar responses

Assessment of the anal wink

Inspection and palpation of the lumbosacral spine

Sejarah sangat penting dalam membuat diagnosis yang tepat dan harus
menangani hal berikut:

Sejarah hidrasi
Pola penguraian siang hari
Sejarah pelatihan toilet
Jumlah dan waktu episode mengompol
Sejarah tidur
Riwayat keluarga enuresis nokturnal
Sejarah gizi
Perilaku, kepribadian, dan status emosional

Kewaspadaan harus dipelihara untuk gejala masalah mendasar yang mendasar


seperti berikut ini:

Kandung kemih terlalu aktif atau disfungsional voiding


Sistitis dan infeksi saluran kemih (ISK)
Sembelit
Neurogenic kandung kemih
Napas tidak teratur
Obstruksi Uretral
Perampasan motor utama
Ureter ektopik
Diabetes mellitus atau diabetes insipidus
Pemeriksaan fisik menyeluruh harus mencakup hal-hal berikut:

Pengukuran tekanan darah


Pemeriksaan genital eksternal
Palpasi di daerah ginjal dan suprapubik
Palpasi perut
Pemeriksaan neurologis menyeluruh pada ekstremitas bawah, termasuk gaya
berjalan, kekuatan otot, nada, sensasi, refleks, dan respons plantar.
Penilaian anal "mengedipkan mata"
Inspeksi dan palpasi tulang belakang lumbosakral

Abnormal physical findings are not usually present in children when enuresis is the sole
symptom and are not necessarily present in children with overactive bladder or dysfunctional
voiding. Abnormal findings might be present in patients with cystitis, constipation,
neurogenic bladder, urethral obstruction, ectopic ureter, or obstructive sleep apnea (OSA).

Temuan fisik yang abnormal biasanya tidak ada pada anak-anak saat enuresis
adalah satu-satunya gejala dan tidak harus hadir pada anak-anak dengan
kandung kemih terlalu aktif atau kekisruhan disfungsional. Temuan abnormal
mungkin ada pada pasien dengan sistitis, konstipasi, kandung kemih neurogenik,
obstruksi uretra, ureter ektopik, atau apnea tidur obstruktif (OSA).

Lihat Presentasi untuk lebih detail

Diagnosis

If an underlying problem is identified and successfully treated and the enuresis persists, the
enuresis should be considered a separate problem. Adverse effects of medications should be
considered as possible causes.

Laboratory studies that may be helpful include the following:

Urinalysis (the most important screening test in a child with enuresis)

Ensure the urinalysis is performed on a concentrated urine specimen. Dilute


specimens with a specific gravity under 1.010 might not reveal infection.

If the urinalysis findings suggest cystitis, urine culture and sensitivity testing

Blood tests usually are not needed

Other studies that may be considered are as follows:


Uroflowmetry with bladder scanning (helpful in screening patients suspected of
having voiding dysfunction, neurogenic bladder and urthrakl obstruction)

Ultrasonography of the bladder and kidneys, both before and after voiding

Voiding cystourethrography (only if either the bladder wall is thickened or


trabeculated on ultrasonography or a significant postvoid residual volume of urine
[>50 mL) is noted or if neurogenic bladder is suspected or there is a history of febrile
UTI)

Magnetic resonance imaging (MRI) of the spine (if the patient has an abnormal
neurologic examination finding of the lower extremities, a visible lumbosacral spine
defect, the triad of encopresis plus gait abnormality plus and daytime symptoms, or
dysfunctional voiding that does not improve after 3 months of therapy)

Urodynamic studies and cystoscopy (if the patient has urethral obstruction or
neurogenic bladder or has dysfunctional voiding that does not improve after 3 months
of therapy

See Workup for more detail.

Jika masalah mendasar diidentifikasi dan berhasil diobati dan enuresis tetap ada,
enuresis harus dianggap sebagai masalah yang terpisah. Efek samping obat
harus dianggap sebagai penyebab yang mungkin.

Studi laboratorium yang mungkin bisa membantu meliputi:

Urinalisis (tes skrining paling penting pada anak dengan enuresis)


Pastikan urinalisis dilakukan pada spesimen urin terkonsentrasi. Spesimen
encer dengan berat jenis di bawah 1,010 mungkin tidak menunjukkan infeksi.
Jika temuan urinalisis menunjukkan adanya sistitis, kultur urin dan tes
sensitivitas
Tes darah biasanya tidak diperlukan

Studi lain yang dapat dipertimbangkan adalah sebagai berikut:

Uroflowmetry dengan pemindaian kandung kemih (membantu dalam skrining


pasien yang dicurigai memiliki disfungsi void, kandung kemih neurogenik dan
obstruksi urthrakl)
Ultrasonografi kandung kemih dan ginjal, baik sebelum dan sesudah voiding
Voiding cystourethrography (hanya jika dinding kandung kemih menebal atau
trabeculated pada ultrasonografi atau volume residu residu urin yang signifikan
<> 50 mL) dicatat atau jika ada kuman neurogenik yang dicurigai atau ada
riwayat ISK demam?
Magnetic Resonance Imaging (MRI) pada tulang belakang (jika pasien memiliki
temuan pemeriksaan neurologis yang abnormal pada ekstremitas bawah, cacat
tulang belakang lumbosakral yang terlihat, tiga serangkai encopresis plus
kelainan gaya berjalan plus dan gejala siang hari, atau ketidakstabilan
disfungsional yang tidak membaik setelah 3 bulan terapi)
Studi mikrodinamik dan sistoskopi (jika pasien mengalami obstruksi uretra
atau kandung kemih neurogenik atau mengalami ketidakfungsian disfungsional
yang tidak membaik setelah 3 bulan terapi.
Lihat Workup untuk detail lebih lanjut.

Management

Preliminary management focusing on behavioral modification and positive reinforcement is


often helpful. Bladder training exercises are not recommended. The only therapies proved to
be effective are alarm therapy and treatment with desmopressin acetate or imipramine.
Enuresis per se is not a surgically treated condition. Treatment is usually not recommended
for children younger than 6 or 7 years.

Initial management includes the following:

Caring and patient parental attitude, acknowledging that the child has no control over
the wetting

Behavioral modification with positive reinforcement

Explanation of the probable cause of the enuresis

Keen attention to establishing and maintaining a normal daytime voiding pattern,


normal bowel pattern, and normal hydration

If following this approach for up to 3 months does not result in dryness, either alarm therapy
or pharmacologic therapy should be considered.

Alarm therapy should be considered for every patient. However, if the child is still wet after a
minimum of 3 months of consecutive use, alarm therapy can be discontinued and considered
unsuccessful. Failure does not preclude future successful treatment once the child is older and
more motivated.

Pharmacologic therapies include the following agents:

Desmopressin acetate (the preferred medication for treating children with enuresis);
combination of alarm therapy with desmopressin therapy may yield dryness not
achievable with either therapy alone

Anticholinergic agents such as oxybutynin chloride and tolterodine (especially in


patients with overactive bladder, dysfunctional voiding, or neurogenic bladder); the
combination of desmopressin acetate and oxybutynin chloride may be efficacious in
children with overactive bladder or dysfunctional voiding who show daytime response
to anticholinergic therapy but continue to wet at night; long-acting preparations of
oxybutin may be more efficacious for combination therapy with desmopressin

Imipramine (because of the unfavorable adverse effect profile and the significant risk
of death with overdose, not recommended by the World Health Organization for
treatment of enuresis)
See Treatment and Medication for more detail.

Manajemen awal yang berfokus pada modifikasi perilaku dan penguatan positif
seringkali membantu. Latihan kandung kemih tidak dianjurkan. Satu-satunya
terapi yang terbukti efektif adalah terapi alarm dan pengobatan dengan
desmopressin asetat atau imipramine. Enuresis per se bukanlah kondisi yang
diobati dengan pembedahan. Pengobatan biasanya tidak dianjurkan untuk anak-
anak di bawah 6 atau 7 tahun.

Manajemen awal mencakup hal-hal berikut:

Perhatian dan sikap orang tua yang sabar, mengakui bahwa anak tidak
memiliki kontrol atas pembasahan
Modifikasi perilaku dengan penguatan positif
Penjelasan kemungkinan penyebab enuresis
Perhatian yang sungguh-sungguh untuk membangun dan mempertahankan
pola kekosongan normal siang hari, pola usus normal, dan hidrasi normal

Jika mengikuti pendekatan ini sampai 3 bulan tidak mengakibatkan kekeringan,


terapi alarm atau terapi farmakologis harus dipertimbangkan.

Terapi alarm harus dipertimbangkan untuk setiap pasien. Namun, jika anak
masih basah setelah minimal 3 bulan penggunaan berturut-turut, terapi alarm
bisa dihentikan dan dinilai tidak berhasil. Kegagalan tidak menghalangi
keberhasilan pengobatan di masa depan begitu anak tersebut lebih tua dan lebih
termotivasi.

Terapi farmakologis meliputi agen berikut:

Desmopressin asetat (obat pilihan untuk merawat anak dengan enuresis);


Kombinasi terapi alarm dengan terapi desmopressin dapat menyebabkan
kekeringan tidak dapat dicapai dengan terapi saja
Agen antikolinergik seperti oxybutynin chloride dan tolterodine (terutama
pada pasien dengan kandung kemih terlalu aktif, disfungsional voiding, atau
neurogenic bladder); Kombinasi desmopressin asetat dan oxybutynin klorida
dapat berkhasiat pada anak-anak dengan kandung kemih terlalu aktif atau
kekosongan disfungsional yang menunjukkan respons siang hari terhadap terapi
antikolinergik namun terus membasahi di malam hari; Persiapan oxybutin yang
berlangsung lama mungkin lebih manjur untuk terapi kombinasi dengan
desmopressin
Imipramine (karena profil efek samping yang tidak menguntungkan dan risiko
kematian yang signifikan dengan overdosis, tidak direkomendasikan oleh
Organisasi Kesehatan Dunia untuk pengobatan enuresis)

Lihat Pengobatan dan Pengobatan untuk detail lebih lanjut.

Background
The word enuresis is derived from a Greek word (enourein) that means to void urine. The
International Childrens Continence Society [ICCS] restricts the term to wetting that occurs at
night. Enuresis can be divided into primary enuresis (PE) and secondary enuresis (SE). A
child who has been continent for at least 6 months before the onset of the bedwetting is
considered to have SE. The pathogenesis of PE is similar to that of SE. [1, 2]
In PE, psychological problems are almost always the result of the condition and only rarely
the cause. In SE, however, psychological problems are a possible cause, albeit not a common
one. The comorbidity of behavioral problems is two to four times higher in children with
enuresis.

The emotional impact of enuresis on a child and family can be considerable. Children with
enuresis are commonly punished and are at risk for emotional and physical abuse. Numerous
studies of children with enuresis report feelings of embarrassment and anxiety, loss of self-
esteem, and effects on self-perception, interpersonal relationships, quality of life, and school
performance. [3] A substantial negative impact on self-esteem is reported even in children
whose enuretic episodes occur as infrequently as once per month.

Diagnostic criteria (DSM-5)

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), classifies
both enuresis and encopresis under the heading of elimination disorders. [4] DSM-5 criteria for
enuresis are as follows:

Repeated voiding of urine into bed or clothes, whether involuntary or


intentional

The behavior either (a) occurs at least twice a week for at least 3
consecutive months or (b) results in clinically significant distress or social,
functional, or academic impairment

The behavior occurs in a child who is at least 5 years old (or has reached
the equivalent developmental level)

The behavior cannot be attributed to the physiologic effects of a


substance or other medical condition

Enuresis can be further divided into the following three subtypes on the basis of the time of
occurrence [4] :

Nocturnal (ie, during sleep)

Diurnal (ie, during waking hours)

Nocturnal and diurnal (also known as nonmonosymptomatic enuresis)

Latar Belakang

Kata enuresis berasal dari kata Yunani (enourein) yang berarti "menghilangkan
urin." The International Children's Continence Society [ICCS] membatasi istilah
pembasahan yang terjadi pada malam hari. Enuresis dapat dibagi menjadi
enuresis primer (PE) dan enuresis sekunder (SE). Seorang anak yang telah benua
setidaknya selama 6 bulan sebelum awitan mengompol dianggap SE.
Patogenesis PE mirip dengan SE. [1, 2]

Di PE, masalah psikologis hampir selalu merupakan akibat dari kondisi dan
jarang penyebabnya. Namun, di SE, masalah psikologis adalah penyebab yang
mungkin, walaupun bukan hal yang biasa. Komorbiditas masalah perilaku dua
sampai empat kali lebih tinggi pada anak-anak dengan enuresis.

Dampak emosional enuresis pada anak dan keluarga bisa sangat besar. Anak-
anak dengan enuresis biasanya dihukum dan berisiko mengalami pelecehan
emosional dan fisik. Sejumlah penelitian tentang anak-anak dengan enuresis
melaporkan perasaan malu dan cemas, kehilangan harga diri, dan efek pada
persepsi diri, hubungan interpersonal, kualitas hidup, dan kinerja sekolah. [3]
Dampak negatif yang substansial terhadap harga diri dilaporkan terjadi bahkan
pada anak-anak yang episode epiknya jarang sekali terjadi per bulan.
Kriteria diagnostik (DSM-5)

Manual Diagnostik dan Statistik Gangguan Mental, Edisi Kelima (DSM-5),


mengklasifikasikan enuresis dan encopresis di bawah judul gangguan eliminasi.
[4] Kriteria DSM-5 untuk enuresis adalah sebagai berikut:

Bermuatan kencing berulang-ulang ke tempat tidur atau pakaian, apakah


disengaja atau disengaja
Perilaku baik (a) terjadi paling sedikit dua kali seminggu selama paling sedikit
3 bulan berturut-turut atau (b) mengakibatkan tekanan signifikan secara klinis
atau gangguan sosial, fungsional, atau akademik.
Perilaku tersebut terjadi pada anak yang berusia minimal 5 tahun (atau telah
mencapai tingkat perkembangan setara)
Perilaku tersebut tidak dapat dikaitkan dengan efek fisiologis suatu zat atau
kondisi medis lainnya

Enuresis dapat dibagi lagi menjadi tiga subtipe berikut berdasarkan waktu
terjadinya [4]:

Nokturnal (yaitu saat tidur)


Diurnal (yaitu, saat bangun tidur)
Nokturnal dan diurnal (juga dikenal sebagai enuresis nonmonosimptomatik)

Pathophysiology
Normal achievement of continence

Dryness at night usually follows achievement of continence by day (see Table 1 below).
During the second year of life, children start to develop the ability to relax the external
urethral sphincter voluntarily and to initiate voiding, even in the absence of the desire to void.
By approximately age 4 years, all children with normal bladder function should have
acquired this ability.

Table 1. Percent of Children Dry by Day and Night at Various Preschool Ages (Open Table in
a new window)

Age, y Dry by Day, % Dry by Night, %

2 25 10

2.5 85 48

3 98 78

Genetics

Numerous studies report varying but high prevalence of the condition in other family
members of patients with enuresis. According to the highest reported familial prevalence
rates, 56% of fathers, 36% of mothers, and 40% of siblings experience a problem with
enuresis. Enuresis is reported in 43% of children of enuretic fathers, 44% of children of
enuretic mothers, and 77% of children when both the mother and father had enuresis. A
family history of bedwetting is found in approximately 50% of children with SE.

Enuresis is usually transmitted in an autosomal dominant fashion. Chromosome 22 was


identified as the site of enuresis locus in a Danish family in 1995. [5] Subsequent reports link
enuresis in other families to loci chromosomes 8, 12, and 16. [6] Identified genes cannot
control for enuresis per se. Rather, an identified gene would have to control a
pathophysiologic factor such as arousal, nocturnal polyuria, or bladder capacity.

A family history of enuresis does not seem to influence the outcomes of any of the various
treatments.

Pencapaian normal kontinu

Kekeringan di malam hari biasanya mengikuti pencapaian kontinu per hari (lihat Tabel 1 di
bawah). Selama tahun kedua kehidupan, anak-anak mulai mengembangkan kemampuan
untuk melemaskan sfingter uretra eksternal secara sukarela dan untuk memulai void, bahkan
tanpa adanya keinginan untuk membatalkannya. Dengan usia sekitar 4 tahun, semua anak
dengan fungsi kandung kemih normal seharusnya memperoleh kemampuan ini.

Tabel 1. Persen Anak Kering dengan Siang dan Malam di Berbagai Usia Prasekolah (Tabel
Terbuka di jendela baru)
Umur, y Kering setiap hari,% Kering pada Malam hari,%
2 25 10
2,5 85 48
3 98 78

Genetika
Sejumlah penelitian melaporkan berbagai kejadian namun prevalensi yang tinggi pada pasien
keluarga lain dengan enuresis. Menurut tingkat prevalensi keluarga tertinggi dilaporkan, 56%
ayah, 36% ibu, dan 40% saudara kandung mengalami masalah dengan enuresis. Enuresis
dilaporkan pada 43% anak-anak dari ayah yang enuretik, 44% anak-anak dari ibu yang
enuretik, dan 77% anak-anak ketika ibu dan ayah memiliki enuresis. Riwayat keluarga
mengompol ditemukan pada sekitar 50% anak-anak dengan SE.

Enuresis biasanya ditularkan secara dominan autosom. Kromosom 22 diidentifikasi sebagai


lokasi lokus enuresis dalam keluarga Denmark pada tahun 1995. [5] Laporan selanjutnya
menghubungkan enuresis pada keluarga lain dengan kromosom lokus 8, 12, dan 16. Gen
yang teridentifikasi tidak dapat mengendalikan enuresis per se. Sebaliknya, gen yang
teridentifikasi harus mengendalikan faktor patofisiologis seperti gairah, poliuria nokturnal,
atau kapasitas kandung kemih.

Riwayat keluarga enuresis tampaknya tidak mempengaruhi hasil dari berbagai perawatan.

Etiology
Possible causes of PE and SE are summarized in Table 2 below.

Table 2. Possible Causes of Primary and Secondary Enuresis (Open Table in a new window)

Causes of Primary Enuresis Causes of Secondary Enuresis

Idiopathic Idiopathic

Disorder of sleep arousal Disorder of sleep arousal

Nocturnal polyuria Nocturnal polyuria

Small nocturnal bladder capacity Small nocturnal bladder capacity

Overactive bladder or dysfunctional Overactive bladder or dysfunctional


voiding voiding

Cystitis Cystitis

Constipation Constipation
Neurogenic bladder Psychological

Urethral obstruction Acquired neurogenic bladder

Psychological Seizure disorder

Ectopic ureter Obstructive sleep apnea

Diabetes insipidus Diabetes mellitus

Acquired diabetes insipidus

Acquired urethral obstruction

Idiopathic

If no cause can be identified, the important pathophysiologic factors include a disorder of


sleep arousal, nocturnal polyuria, and a low nocturnal bladder capacity.

Etiologi

Kemungkinan penyebab PE dan SE dirangkum dalam Tabel 2 di bawah ini.

Tabel 2. Kemungkinan Penyebab Enuresis Primer dan Sekunder (Tabel Terbuka di jendela
baru)
Penyebab Enuresis Primer Penyebab Enuresis Sekunder
Idiopatik

Gangguan tidur gairah

Poliuria nokturnal

Kapasitas kandung kemih nokturnal kecil

Idiopatik

Gangguan tidur gairah

Poliuria nokturnal
Kapasitas kandung kemih nokturnal kecil

Kandung kemih terlalu aktif atau disfungsional voiding Overactive bladder atau disfungsional
voiding
Sistitis Sistitis
Konstipasi Sembelit
Neurogenic kandung kemih Psikologis
Obstruksi Uretral Mengakuisisi kandung kemih neurogenik
Gangguan kejang psikologis
Uctopic ureter Obstructive sleep apnea
Diabetes insipidus Diabetes melitus
Mengidap diabetes insipidus
Mendapatkan obstruksi uretra
Idiopatik

Jika tidak ada penyebab yang dapat diidentifikasi, faktor patofisiologis yang penting
termasuk gangguan gairah tidur, poliuria nokturnal, dan kapasitas kandung kemih nokturnal
yang rendah.

Disorder of sleep arousal

Sleep studies reveal that children with enuresis do not wake up normally in response to an
auditory signal; this finding confirms a problem in arousal.

Arousal to the sensation of a full or contracting bladder involves interconnected anatomic


areas, including the cerebral cortex, the reticular activating system (RAS), the locus ceruleus
(LC), the hypothalamus, the pontine micturition center (PMC), the spinal cord, and the
bladder. The RAS controls depth of sleep, the LC controls arousal, and the PMC initiates the
command for a detrusor contraction. Various neurotransmitters are involved, including
norepinephrine, serotonin, and antidiuretic hormone (ADH).

Gangguan tidur gairah

Studi tidur menunjukkan bahwa anak-anak dengan enuresis tidak terbangun


secara normal sebagai respons terhadap sinyal pendengaran; Temuan ini
menegaskan adanya masalah dalam gairah.

Gairah pada sensasi kandung kemih penuh atau berkontraksi melibatkan area
anatomi yang saling berhubungan, termasuk korteks serebral, sistem
pengaktifan retikuler (reticular activating system / RAS), lokus ceruleus (LC),
hipotalamus, pusat karsinoma pontine (PMC), sumsum tulang belakang, Dan
kandung kemih. RAS mengontrol kedalaman tidur, LC mengendalikan gairah, dan
PMC memulai perintah untuk kontraksi detrusor. Berbagai neurotransmiter
terlibat, termasuk norepinephrine, serotonin, dan hormon antidiuretik (ADH).
Nocturnal polyuria

Studies reveal nocturnal polyuria in some but not all children with enuresis. Although
nocturnal polyuria is important in the pathophysiology of enuresis, overproduction of urine
per se cannot be the sole causal factor. Nocturnal polyuria does not explain why children with
enuresis do not wake up to the sensation of a full or contracting bladder or enuresis that
occurs during daytime naps.

Nocturnal polyuria in children with enuresis likely has multiple causes, including the
following:

Increased fluid ingestion from the time a child arrives home from school through the
afternoon and evening to bedtime

Reduced fluid ingestion from the time a child wakes through the school day

Food consumption from the time a child arrives home from school through the
afternoon and evening to bedtime

Low nocturnal secretion of ADH

Increased nocturnal solute excretion

Ingestion of fluids from the time a child arrives home from school through to bedtime is a
common cause. Solid food ingestion is also a cause because excretion of solute by the kidney
is accompanied by an obligate amount of water.

Many children with bedwetting drink very modest amounts of fluids at breakfast and
throughout the school day. Accordingly, they arrive home from school hungry and thirsty, and
most of their fluid intake often occurs in the few hours between arriving home and bedtime.
This pattern favors nocturnal polyuria.

Production of urine is controlled by several factors, including ADH, which directly controls
water absorption, and atrial natriuretic peptide (ANP) and aldosterone, which control solute
and thus indirectly affect water excretion.

Norgaard et al first reported the absence of the expected nocturnal increase in ADH secretion
in adults with enuresis. [7] Subsequent reports suggested that low nocturnal secretions of ADH
are present in some but not all children with enuresis. [8] Urine sodium and potassium
excretion are increased in some children with enuresis, but the reasons for these increases are
not clear. Rittig et al report that secretion of ANP in children with enuresis shows a normal
circadian rhythm and that the renin-angiotensin-aldosterone system is intact. [9]

Bladder distention may influence nocturnal secretion of ADH. Some studies report that ADH
secretion is increased in response to bladder distention and reduced with bladder emptying. If
ADH secretion falls with bladder emptying, the observed low nocturnal blood levels of ADH
may be a consequence of enuresis rather than a cause.
Poliuria nokturnal

Studi menunjukkan poliuria nokturnal pada beberapa tapi tidak semua anak
dengan enuresis. Meskipun poliuria nokturnal penting dalam patofisiologi
enuresis, kelebihan produksi urin per se tidak dapat menjadi faktor penyebab
tunggal. Poliuria nokturnal tidak menjelaskan mengapa anak-anak dengan
enuresis tidak terbangun dengan sensasi kandung kemih atau kantung kemih
penuh atau kontraksi yang terjadi pada siang hari siang.

Poliuria nokturnal pada anak-anak dengan enuresis kemungkinan memiliki


banyak penyebab, termasuk yang berikut ini:

Meningkatnya konsumsi cairan sejak anak tiba di rumah dari sekolah sampai
siang dan malam sampai menjelang tidur
Mengurangi konsumsi cairan sejak anak terbangun melalui hari sekolah
Konsumsi makanan sejak anak tiba di rumah dari sekolah sampai siang dan
malam sampai menjelang tidur
Sekresi neksibilitas ADH yang rendah
Meningkatkan ekskresi solute nokturnal

Tertelan cairan dari saat seorang anak pulang dari sekolah sampai menjelang
tidur adalah penyebab yang umum. Konsumsi makanan padat juga menjadi
penyebabnya karena ekskresi zat terlarut oleh ginjal disertai dengan jumlah air
yang wajib.

Banyak anak yang mengompol meminum cairan dalam jumlah sangat sederhana
saat sarapan dan sepanjang hari sekolah. Dengan demikian, mereka tiba di
rumah dari sekolah lapar dan haus, dan sebagian besar asupan cairan mereka
sering terjadi dalam beberapa jam antara tiba di rumah dan waktu tidur. Pola ini
menguntungkan poliuria nokturnal.

Produksi urin dikendalikan oleh beberapa faktor, termasuk ADH, yang secara
langsung mengendalikan penyerapan air, dan atrial natriuretic peptide (ANP) dan
aldosteron, yang mengendalikan zat terlarut dan secara tidak langsung
mempengaruhi ekskresi air.

Norgaard dkk pertama kali melaporkan tidak adanya peningkatan nokturnal yang
diharapkan pada sekresi ADH pada orang dewasa dengan enuresis. [7] Laporan
selanjutnya menunjukkan bahwa sekresi nokturnal ADH yang rendah hadir pada
beberapa tapi tidak semua anak dengan enuresis. [8] Konsentrasi natrium urin
dan potassium meningkat pada beberapa anak dengan enuresis, namun alasan
kenaikan ini tidak jelas. Rittig dkk melaporkan bahwa sekresi ANP pada anak-
anak dengan enuresis menunjukkan ritme sirkadian normal dan sistem renin-
angiotensin-aldosteron utuh. [9]

Distensi kandung kemih dapat mempengaruhi sekresi ADC di malam hari.


Beberapa penelitian melaporkan bahwa sekresi ADH meningkat sebagai respons
terhadap distensi kandung kemih dan dikurangi dengan pengosongan kandung
kemih. Jika sekresi ADH jatuh dengan pengosongan kandung kemih, kadar ADC
yang diamati pada hari nokturnal rendah dapat menjadi konsekuensi enuresis
dan bukan penyebabnya.

Small nocturnal bladder capacity

Small functional bladder capacity (FBC) is now known to play a role in the pathogenesis of
enuresis. For some time, it was considered a less likely explanation for enuresis in children
without daytime symptoms, but studies confirmed that children without daytime symptoms
may have a low nocturnal bladder capacity and that this is a very common factor in enuresis.

In a study by Mattsson and Lindstrom, FBC was positively correlated with nighttime urine
output. [10] It has been theorized that children with enuresis may maintain a smaller nocturnal
bladder volume and that this situation may condition the detrusor muscle to contract at a
lower volume. According to this theory, the low nocturnal bladder capacity is a consequence
of enuresis rather than a cause.

Bloom et al suggested a problem with the external urethral sphincter as a possible cause of
low nocturnal bladder capacity, [11] noting that the control of voiding rests at the external
urethral sphincter, where constant activity is present as a guarding reflex to preserve
continence. They speculated that the activity of the external urethral sphincter might fall
below a critical level during sleep and thereby trigger a detrusor contraction.

Kapasitas kandung kemih nokturnal kecil

Kapasitas kandung kemih fungsional kecil (FBC) sekarang diketahui berperan dalam
patogenesis enuresis. Untuk beberapa waktu, ini dianggap sebagai penjelasan enuresis yang
kurang mungkin pada anak-anak tanpa gejala di siang hari, namun penelitian mengkonfirmasi
bahwa anak-anak tanpa gejala siang hari mungkin memiliki kapasitas kandung kemih
nokturnal yang rendah dan ini adalah faktor yang sangat umum dalam enuresis.

Dalam sebuah studi oleh Mattsson dan Lindstrom, FBC berkorelasi positif dengan hasil urin
malam hari. [10] Telah berteori bahwa anak-anak dengan enuresis dapat mempertahankan
volume kandung kemih nokturnal yang lebih kecil dan bahwa situasi ini dapat menyebabkan
otot detrusor berkontraksi pada volume yang lebih rendah. Menurut teori ini, kapasitas
kandung kemih nokturnal rendah adalah konsekuensi enuresis dan bukan penyebabnya.

Bloom dkk mengemukakan suatu masalah pada sfingter uretra eksternal sebagai
kemungkinan penyebab kapasitas kandung kemih nokturnal yang rendah, [11] mencatat
bahwa pengendalian kekosongan terletak pada sfingter uretra eksternal, di mana aktivitas
konstan hadir sebagai refleks pengaman untuk mempertahankan kontinuitas. Mereka
berspekulasi bahwa aktivitas sfingter uretra eksternal mungkin berada di bawah tingkat kritis
selama tidur dan dengan demikian memicu kontraksi detrusor.

Overactive bladder or dysfunctional voiding

Overactive bladder or dysfunctional voiding is more common among girls in preschool or


elementary school, usually presenting with urinary frequency, urgency, squatting behavior,
daytime wetting, and enuresis.

Squatting behavior, a common and distinct symptom of overactive bladder or dysfunctional


voiding, is a learned response and an attempt to suppress an unexpected and unwelcome
detrusor contraction. The squatting posture elicits a bulbar detrusor inhibitory reflex. In some
children, a period of normal voiding occurs, and the onset of the bedwetting is compatible
with SE. If enuresis is present, the cause is presumed to be a low nocturnal bladder capacity,
but a disorder of arousal must also be present. Squatting is commonly associated with a
history of cystitis.

Symptoms tend to improve or resolve with time and are less common after puberty.
Vesicoureteral reflux is more common in these children, and cystitis and constipation are
frequent complicating problems. Urodynamic studies reveal unstable detrusor contractions
early in the filling phase.

ystitis

Cystitis is a common cause of enuresis and an aggravating factor associated with other
causes; cystitis associated with enuresis may present at any age. Cystitis causes uninhibited
detrusor contractions that can lead to episodes of day and nighttime wetting.

If cystitis is the only cause of enuresis, other symptoms of infection are usually present, and
the wetting resolves with an appropriate antibiotic. Cystitis is more common in children with
overactive bladder or dysfunctional voiding, neurogenic bladder, urethral obstruction, ectopic
ureter, or diabetes mellitus. In these conditions, daytime symptoms do not resolve completely
with antibiotic treatment.

Psychological causes

Various common situations predispose to a psychological cause of enuresis, including birth of


a new sibling, parental divorce or separation, death in the family, child abuse, or any other
cause of social dysfunction at home or school.

A study by von Gontard et al found that children with SE have a significantly higher rate of
behavioral disorders, life events, and continuous psychosocial stress than those with PE. [12]
Stressful life events and psychiatric diagnoses are reported to precede the diagnosis of SE.
The later the onset of SE, the greater the likelihood of preceding psychological stress.
Constipation

Constipation can cause both PE and SE and is a common aggravating factor that should be
considered when other causes are present.

Although the mechanism is not clear, the pressure effect of stool in the descending or sigmoid
colon likely restricts bladder capacity, and colonic movements at night might trigger an
uninhibited detrusor contraction. Constipation is usually present in children with neurogenic
bladder and is more common in those with overactive bladder or dysfunctional voiding.

Sleep-disordered breathing

Sleep-disordered breathing (SDB) is a disorder associated with both an abnormality in


arousal and enuresis. The most common cause of SDB in childhood is adenotonsillar
hypertrophy, which has a peak incidence in children aged 2-5 years. Nocturnal polyuria is
reported in individuals with obstructive sleep apnea (OSA). A decrease in nocturnal secretion
of ADH and an increase in ANP secretion are possible explanations for nocturnal polyuria.

Neurogenic bladder

A neurogenic bladder can result from a lesion at any level in the nervous system, including
the cerebral cortex, the spinal cord, and the peripheral nerves. As many as 37% of children
with cerebral palsy have enuresis. Patients with myelomeningocele almost always have
enuresis. Other spinal cord abnormalities, such as caudal regression syndrome, tethered cord,
tumors, anterior spinal artery syndrome, and spinal cord trauma, can cause enuresis.

Specific dysfunction in the external urethral sphincter can develop after pelvic extirpative
surgery, radiation therapy for pelvic malignancy, pelvic fracture, or incontinence surgery.
Sacral agenesis can be associated with a neurogenic bladder. As many as 5% of patients with
an imperforate anus have a neurogenic bladder, and most patients also have a lumbosacral
anomaly.

Urethral obstruction

Urethral obstruction can be congenital (as with posterior urethral valves, congenital stricture,
or urethral diverticula) or acquired (as with a traumatic or infectious stricture or with meatal
stenosis after circumcision). Traumatic strictures may develop after a traumatic urethral
catheterization, a foreign body in the urethra, or pelvic trauma. Infectious strictures are a
complication of purulent urethritis due to bacteria such as Neisseria gonorrhoeae.

Meatal stenosis is a common cause of distal urethral obstruction in circumcised males, but it
is not considered a cause of enuresis.

Seizure disorder
SE may be a symptom of an unobserved overnight major motor convulsion in a child with a
known seizure disorder. New-onset seizures rarely occur only at night; consequently,
bedwetting is a rare manifestation.

Ectopic ureter

Ectopic ureter is due to the insertion of the ureter in a location other than the lateral angle of
the bladder trigone. The most common site of the ectopic orifice is adjacent to the external
urethral meatus and is below the external sphincter in females. Children with ectopic ureter
tend to wet constantly. Enuresis results when the insertion is distal to the external urethral
sphincter. Ectopic ureter is three to four times more common in girls than in boys and causes
incontinence only in females.

Diabetes mellitus

Enuresis usually is not the presenting complaint in a child with new-onset diabetes mellitus.
Conventional symptoms of insulin deficiency usually overshadow the presence of
bedwetting.

SE in a child with established diabetes mellitus may be a symptom of suboptimal control,


with nocturnal polyuria due to hyperglycemia. Although nocturnal polyuria is presumed to be
the cause of the bedwetting, a disorder of arousal is also likely to be present because most
school-aged patients develop nocturia but maintain a dry bed. Diabetes mellitus is also
associated with abnormalities in the afferent sensory pathways to the bladder, which may
contribute to enuresis.

Diabetes insipidus

Diabetes insipidus is a very rare cause of enuresis. Although nocturnal polyuria is often
presumed to be the cause of bedwetting, a disorder of arousal may also be present. Diabetes
insipidus may be either central or nephrogenic. Central diabetes insipidus may result from an
intracranial tumor, head trauma, encephalitis, or meningitis; nephrogenic diabetes insipidus
may result from any cause of renal failure, diffuse renal cortical or medullary damage,
hypokalemia, hypercalcemia, or nephrotoxic drugs.

Epidemiology
United States and international statistics

In the United States, the prevalence of PE varies by age. At age 4 years, 25% of children
frequently wet the bed, but by age 7 years, only 5-10% still wet the bed, and by age 10 years,
fewer than 5% of children do so.

The resolution rate of PE is approximately 15% per year; by the late teenaged years, very few
patients have the condition. This high resolution rate is often used as a justification for
waiting and not treating PE. However, it probably is not applicable to children who wet every
night and likely applies only to those children who have already started to have dry nights.
Worldwide, the prevalence of PE seems to be approximately the same, though no
standardized evaluation of the prevalence of bedwetting has been made on a global basis.

Age-, sex-, and race-related demographics

The prevalence of enuresis gradually declines during childhood. Of children aged 5 years,
23% have enuresis. During elementary school years, 10% of 7-year-old children and 4% of
10-year-old children still experience enuresis. In adults, however, the reported prevalence of
enuresis is 0.5-2%. A Korean epidemiologic study found that the overall prevalence of
nocturnal enuresis in subjects aged 16-40 years was 2.6%. [13]

When PE and SE are reported, a secondary onset accounts for about 25% of cases. The
prevalence of SE as a percentage of all cases increases with age. In a cohort of New Zealand
children, 7.9% developed SE by the age of 10 years. [14]

Enuresis is more common in males. The reported prevalences of enuresis at the ages of 7 and
10 years are 9% and 7%, respectively, in boys and 6% and 3%, respectively, in girls. No
racial predisposition has been documented.

Prognosis
Mortality attributable directly to enuresis has not been reported, but children with enuresis
have been fatally abused by parents and other caregivers, and bedwetting was considered a
trigger for the abuse in some situations. The morbidity, in terms of psychosocial stress, has
been recognized in the psychology literature. [15] Enuresis can also be associated with
significant family stress. Punishment should be considered a potential morbid consequence of
enuresis.

Severe perineal, genital, and lower abdominal rash may also occur in patients with enuresis,
potentially leading to skin breakdown and, rarely, cutaneous infections.

Relapse of the enuresis is the most common complication and requires restarting the
treatment that resulted in an improvement or cure of the condition.

The most important reason to treat enuresis is to improve the loss of self-esteem and other
secondary psychological or behavioral problems resulting from this behavior. Improvement
in self-esteem is noted with all therapies, reaching levels comparable to those in children
without enuresis after only 6 months of treatment.

Even without treatment, the reported spontaneous cure rate is reportedly about 15% per year.
However, children who wet every night are unlikely to become dry in the short term and
many of these children continue to wet until adolescence.

When enuresis is the sole symptom, behavioral therapy or a bedwetting alarm can be
curative. The only therapies that have been shown to be effective in randomized trials include
alarm therapy and treatment with desmopressin and imipramine.
A Cochrane review of alarm therapy concluded that alarm therapy is beneficial; about two
thirds of children on alarm therapy were dry. [16] A Cochrane review of desmopressin therapy
concluded that it reduces bedwetting; treated children had an average of 1.3 fewer wet nights
per week than those receiving a placebo. [17] A Cochrane review of imipramine therapy
concluded that imipramine reduces bedwetting; treated children had an average of 1 fewer
wet nights per week those receiving a placebo. [18]

When daytime symptoms are also present, the prognosis depends on the underlying cause.
The prognosis is excellent when enuresis is due to cystitis, ectopic ureter, OSA, diabetes
mellitus, diabetes insipidus, or seizure disorder. Enuresis due to cystitis should resolve with
appropriate antibiotic therapy; ectopic ureter and OSA respond to specific surgical
interventions; and diabetes mellitus and diabetes insipidus respond to specific medical
interventions.

Enuresis due to overactive bladder or dysfunctional voiding usually resolves, but daytime
symptoms continue after puberty and into adulthood in as many as 20% of patients. The
prognosis for enuresis due to neurogenic bladder depends on the neurologic cause and on
whether a surgical solution is available.

Patient Education
Punishment has no role in the treatment of enuresis. The impact of enuresis on the childs
self-esteem and emotional health of the child is already sizable enough without the added
insult of punishment for a problem beyond the childs control.

Punishment is not always overt and intentional; it can be subtle and unrecognized by an
otherwise well-meaning parent. A child easily interprets fluid restriction and requests to wear
diaper training pants or to launder sheets and clothes as punishment. Accordingly, parents
benefit from education regarding how to present such requests sensitively so as to minimize
any sense of being punished on the part of the child.

For patient education resources, see the Childrens Health Center and the Kidneys and
Urinary System Center, as well as Bedwetting, Bladder Control Problems, and Understanding
Bladder Control Medications.

http://emedicine.medscape.com/article/1014762-overview#showall