Epidemiology & Risk Factors

Age threshold: Urinary incontinence in children $\geq$ 5 years of age.
Gender: More common in boys.
Family History: Strong genetic predisposition (high concordance in monozygotic twins).
Risk factors:
- Chronic constipation (compresses bladder, reduces capacity). c
- Psychological stressors (e.g., parental divorce, new sibling, school issues).
- Obstructive sleep apnea (OSA) (hypoxia/hypercapnia leads to ↑ ANP secretion).
- Developmental or neurological delays.

Clinical Features

Primary Enuresis: Bedwetting in a child who has never achieved $\geq$ 6 consecutive months of nighttime dryness.
Secondary Enuresis: Recurrence of bedwetting after $\geq$ 6 months of nighttime dryness (frequently triggered by stress, UTI, or new-onset DM1).
Monosymptomatic: Urinary incontinence during sleep only, with no daytime lower urinary tract symptoms.
Non-monosymptomatic: Nighttime wetting + daytime symptoms (e.g., urgency, frequency, daytime incontinence, weak stream).
Associated findings: Encopresis or severe constipation (critical to assess on physical exam).

Initial Evaluation:
- Comprehensive history (sleep hygiene, fluid intake, bowel habits, stressors).
- Complete physical exam (abdominal palpation for stool, sacral/spine exam for dysraphism, neurological reflexes of lower extremities).
Key Labs: Urinalysis (UA) mandatory for all pts.
- Rule out UTI (leukocyte esterase, nitrites, WBCs).
- Rule out DM (glucosuria, ketonuria).
- Rule out DI or renal concentrating defect (dilute urine/low specific gravity).
Imaging: Not routinely indicated. Renal ultrasound and/or VCUG indicated only if daytime symptoms, recurrent UTIs, or abnormal neurological/spinal findings are present.

Urinary Tract Infection (UTI): Diff by dysuria, frequency, urgency, fever, and abnormal UA (pyuria, bacteriuria).
Diabetes Mellitus Type 1 (DM1): Diff by systemic symptoms (polydipsia, polyphagia, weight loss) and hyperglycemia/glucosuria.
Diabetes Insipidus (DI): Diff by profound polyuria, polydipsia, and low urine specific gravity ( $< 1.005$ ) despite water restriction.
Obstructive Sleep Apnea (OSA): Diff by snoring, mouth breathing, adenotonsillar hypertrophy, and daytime somnolence.
Spinal Dysraphism (Spina Bifida Occulta): Diff by sacral dimple, tuft of hair, gait abnormalities, or lower extremity neurological deficits.

First-line: Lifestyle & behavioral modifications.
- Restrict fluid intake in the evening (avoid caffeine/sugary drinks).
- Void immediately before going to bed.
- Treat concurrent constipation (e.g., polyethylene glycol).
- Maintain a stool/voiding diary.
- Positive reinforcement (reward charts for dry nights); strictly avoid punishment.
Second-line (Most effective long-term): Enuresis alarm therapy.
- Indicated if behavioral modifications fail and family is motivated.
- Requires 3–4 months to see full benefit; has the lowest relapse rate.
Pharmacotherapy (Short-term/Refractory): Desmopressin (DDAVP).
- Oral formulation used for rapid, short-term relief (e.g., sleepovers, camp).
- High relapse rate once discontinued.
- Crucial counseling: Restrict evening fluids to prevent hyponatremia and water intoxication.
Refractory/Tertiary: Imipramine (TCA).
- Rarely used due to cardiotoxicity (QT prolongation, arrhythmia) in overdose.

Low self-esteem and peer isolation (social withdrawal, avoidance of sleepovers).
Family distress and conflict (increased risk of child abuse).
Hyponatremic seizures (due to desmopressin use without fluid restriction).

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