Genetic and physiological. Enuresis has been associated with delays in the develop- ment of normal circadian rhythms of urine production, with resulting nocturnal polyuria or abnormalities of central vasopressin receptor sensitivity, and reduced functional blad- der capacities with bladder hyperreactivity (unstable bladder syndrome). Nocturnal en- uresis is a genetically heterogeneous disorder. Heritability has been shown in family, twin, and segregation analyses. Risk for childhood nocturnal enuresis is approximately 3.6 times higher in offspring of enuretic mothers and 10.1 times higher in the presence of paternal urinary incontinence. The risk magnitudes for nocturnal enuresis and diurnal incontinence are similar.
Enuresis has beeh reported in a variety of European, African, and Asian countries as well as in the United States. At a national level, prevalence rates are remarkably similar, and there is great similarity in the developmental trajectories found in different countries.
There are very high rates of enuresis in orphanages and other residential institutions, likely related to the mode and environment in which toilet training occurs.
Noctumal enuresis is more common in males. Diurnal incontinence is more common in fe- males. The relative risk of having a child who develops enuresis is greater for previously enuretic fathers than for previously enuretic mothers.
Functional Consequences of Enuresis
The amount of impairment associated with enuresis is a function of the limitation on the child’s social activities (e.g., ineligibility for sleep-away camp) or its effect on the child’s self—esteem, the degree of social ostracism by peers, and the anger, punishment, and rejec- tion on the part of caregivers.
Neurogenic bladder or another medical condition. The diagnosis of enuresis is not made in the presence of a neurogenic bladder or another medical condition that causes polyuria or urgency (e.g., untreated diabetes mellitus or diabetes insipidus) or during an acute urinary tract infection. However, a diagnosis is compatible with such conditions if urinary inconti- nence was regularly present prior to the development of another medical condition or if it per- sists after the institution of appropriate treatment of the medical condition.
Medication side effects. Enuresis may occur during treatment with antipsychotic med- ications, diuretics, or other medications that may induce incontinence. In this case, the di- agnosis should not be made in isolation but may be noted as a medication side effect.
However, a diagnosis of enuresis may be made if urinary incontinence was regularly pres- ent prior to treatment with the medication.
Although most children with enuresis do not have a comorbid mental disorder, the prevalence of comorbid behavioral symptoms is higher in children with enuresis than in children without enuresis. Developmental delays, including speech, language, learning, and motor skills delays, are also present in a portion of children with enuresis. Encopresis, sleepwalking, and sleep terror disorder may be present. Urinary tract infections are more common in children with enuresis, especially the diurnal subtype, than in those who are continent.
Diagnostic Criteria 307.7 (F98.1)
A. Repeated passage of feces into inappropriate places (e.g., clothing, floor), whether in- voluntary or intentional.
B. At least one such event occurs each month for at least 3 months.
0. Chronological age is at least 4 years (or equivalent developmental level).
D. The behavior is not attributable to the physiological effects of a substance (e.g., laxa- tives) or another medical condition except through a mechanism involving constipation.
Specify whether:
With constipation and overflow incontinence: There is evidence of constipation on physical examination or by history.
Without constipation and overflow incontinence: There is no evidence of constipa- tion on physical examination or by history.