A 7-year-old boy comes to the office with his father due to nighttime bed wetting. The patient was daytime toilet trained by age 2 but has continued to wet his bed about 3 nights a week, leading to several canceled camping trips. The patient urinates 5 or 6 times during the day and has no urgency or dribbling. He has a soft bowel movement every day. His father achieved nighttime dryness at age 9. Medical history includes attention deficit hyperactivity disorder that is treated with lisdexamfetamine. The patient is seeing a speech therapist for stuttering and has struggled with low self-esteem. He was born at 34 weeks due to non-reassuring fetal heart tones. Growth and development have been on track. Vital signs, examination, urinalysis, and urine culture are normal. Which of the following is the greatest risk factor for this patient's nighttime bed wetting?
Primary nocturnal enuresis | |
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ADH = antidiuretic hormone. | |
This patient's bed wetting is consistent with primary nocturnal enuresis, which is defined as nighttime urinary incontinence in a child age ≥5 who has never achieved a prolonged period (≥6 months) of dryness overnight. Boys are twice as likely to have primary nocturnal enuresis compared to girls and typically have no other urinary tract symptoms (eg, daytime incontinence, urgency, dribbling).
Genetic factors play a large role in the pathogenesis of primary nocturnal enuresis, and family history of bed wetting is the greatest risk factor. Most patients have at least one parent who experienced enuresis as a child, and children with two parents who were affected are highly likely to develop the condition. The history and severity of enuresis also often follow the course experienced by the affected family member, with resolution expected around a similar age.
(Choice A) The prevalence of enuresis is increased in children with attention deficit hyperactivity disorder (ADHD) compared to those without the disorder, which may be due to a delay in brain maturation seen in both conditions as well as exacerbation of inattentive and hyperactive behaviors due to sleep disturbance. However, the greatest predictor for primary nocturnal enuresis is family history, not ADHD.
(Choice C) Emotional stressors (eg, parental conflict, bullying) are often associated with secondary enuresis (ie, bed wetting after establishing nighttime continence). Although an acute stressor may temporarily worsen primary nocturnal enuresis, long-standing and consistent nighttime incontinence, as seen in this patient, is not typically related to external stressors.
(Choice D) Although delayed development of bladder control contributes to the pathogenesis of primary enuresis, premature infants are not at higher risk for developing primary nocturnal enuresis because most experience catch-up in brain development in the first 2 years of life. In addition, developmental delays are typically minimal in late preterm infants (gestational age 34-37 weeks), like this patient.
(Choice E) Stimulants (eg, lisdexamfetamine) can cause difficulty falling asleep but are not associated with nocturnal enuresis.
Educational objective:
Primary nocturnal enuresis is defined as nighttime urinary incontinence in a child age ≥5 who has not achieved a prolonged period of nighttime dryness. A family history of bed wetting is the greatest risk factor for developing this condition.