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Am Fam Physician. 2022;106(5):549-556

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Nocturnal enuresis is defined as nighttime urinary incontinence occurring at least twice weekly in children five years and older. Approximately 14% of children have spontaneous resolution each year without treatment. Subtypes of nocturnal enuresis include nonmonosymptomatic enuresis and primary and secondary monosymptomatic nocturnal enuresis. Monosymptomatic enuresis is characterized by nighttime bedwetting without daytime urinary incontinence. Pathophysiology of primary monosymptomatic nocturnal enuresis may be due to sleep arousal disorder, overproduction of urine, small bladder storage capacity, or detrusor overactivity. Children with nonmonosymptomatic enuresis have daytime and nighttime symptoms resulting from a variety of underlying etiologies. An in-depth history is an integral component of the initial evaluation. For all types of enuresis, a comprehensive physical examination and urinalysis should be performed to help identify the cause. It is important to reiterate to the family that bedwetting is not the child’s fault. Treatment should begin with behavioral modification, which then progresses to enuresis alarm therapy and oral desmopressin. Enuresis alarm therapy is more likely to produce long-term success; desmopressin yields earlier symptom improvement. Treatment of secondary monosymptomatic nocturnal enuresis and nonmonosymptomatic enuresis should primarily focus on the underlying etiology. Pediatric urology referral should be made for refractory cases in which underlying genitourinary anomalies or neurologic disorders are more likely.

Nocturnal enuresis, defined as involuntary bedwetting at least twice weekly in children five years and older,1 affects 15% to 20% of children by five years of age.2 Children with enuresis have lower self-esteem, lower self-confidence, and decreased quality of life compared with children who do not have enuresis.3,4 Each year, 14% of children will experience spontaneous resolution, with sharp decreases in incidence among older children (1% to 2% by 17 years of age) and adults (0.5% to 1%), according to cross-sectional data.2 Severe enuresis (nightly, heavy wetting or daytime symptoms) is less likely to resolve spontaneously; early intervention is key to resolution.5 Treatment improves patients’ health-related quality of life scores, including self-esteem, emotional well-being, and relationships with friends and family.6 Familial disposition is the biggest risk factor for enuresis; children from families without a history of enuresis have an incidence of 15%, whereas children from families with a history of enuresis have a 44% and 77% likelihood of developing enuresis if one or both parents were enuretic, respectively.2 Enuresis tends to resolve in first-degree relatives at similar ages.1,7,8 Additional risk factors for nocturnal enuresis are listed in Table 1.9,10 This article addresses common questions about nocturnal enuresis.

Adenotonsillar hypertrophy
Attention-deficit/hyperactivity disorder
Being male (affected twice as often as females)
Bladder dysfunction
Daytime enuresis (diurnal enuresis)
Developmental delay
Emotional stress
Family history of nocturnal enuresis
Sleep deprivation


What Is the Difference Between Monosymptomatic and Nonmonosymptomatic Nocturnal Enuresis?


Nocturnal enuresis can be divided into two subtypes: monosymptomatic, in which nighttime bedwetting is the only symptom, and nonmonosymptomatic enuresis, which includes the presence of daytime lower urinary tract symptoms with bedwetting1 (Table 21,11). Monosymptomatic nocturnal enuresis can be subdivided into primary monosymptomatic nocturnal enuresis, where there has never been six months of continuous dry nights, and secondary monosymptomatic nocturnal enuresis, where a period of six months of continuous nighttime dryness existed and then bedwetting recurred.1

Low or high daytime voiding volumes (voiding fewer than four or more than seven times per day)
Straining to void
Weak stream


Primary monosymptomatic nocturnal enuresis may be attributed to sleep arousal disorder, nocturnal polyuria, low bladder storage capacity, or detrusor overactivity. Children with sleep arousal disorders have a harder time waking in response to normal bladder cues. These children have more fragmented and nonrestorative sleep.1214 Nocturnal polyuria and large volume voids are present when the kidneys do not concentrate urine appropriately. The formal evaluation of polyuria includes weighing sheets or diapers and measuring the first-morning void volume. Factors contributing to polyuria include drinking large volumes before bedtime; ingestion of large amounts of solute, such as salt or sugar; and decreased vasopressin release from the pituitary at night.1 Underlying bladder issues, including low bladder storage capacity and detrusor overactivity, may also cause enuresis.1 Secondary monosymptomatic nocturnal enuresis is more likely to have an underlying pathologic cause and may be the first sign of a new medical issue. Common causes of secondary monosymptomatic nocturnal enuresis2 are listed in Table 3.1,15,16

Acute renal failure
Diabetes insipidus
New-onset diabetes mellitus
Stress (e.g., addition of a new sibling, bullying, parental deployment, parental discord)
Urinary tract infection

Nonmonosymptomatic nocturnal enuresis occurs in 15% to 30% of children with enuresis.17 It is usually attributed to an underlying pathologic cause; common causes are listed in Table 4.1,17 Diagnosis and treatment of the underlying pathology causing the daytime symptoms should occur before nocturnal enuresis therapy.17 Children with nonmonosymptomatic nocturnal enuresis have a higher incidence of comorbid psychological disorders, including attention-deficit/hyperactivity disorder, conduct disorder, developmental delay, oppositional defiant disorder, and separation anxiety.1720

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