Adult Nocturnal Enuresis

Overview

Nocturnal enuresis (NE) is the involuntary voiding of urine during sleep. Studies show that at least 2% of adults have a lack of control of urination during the night.   Nocturnal enuresis is not to be confused with nocturia or waking two or more times per night to void. Different types of enuresis exist, which need to be differentiated. 

Persistent Primary Nocturnal Enuresis is a condition that begins during childhood, where nighttime dryness has not been achieved for longer than six months.  About 2-3% of male and female adults that are older than 18 years of age have this type of nocturnal enuresis. Adult Onset Secondary Enuresis is defined as nocturnal enuresis in which nighttime dryness is achieved at some point in life and, for some, dryness may have occurred for years, but nighttime wetting begins at an older age.

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Prevalence

Nocturnal enuresis has affected people for many years.  Evidence of this problem can be traced back as far as 1500 BC.   While extensive research has been devoted to nocturnal enuresis in children, persistent primary enuresis and adult onset secondary enuresis in particular have not been studied as thoroughly.  It must be understood that bedwetting is unintentional and is not something that can be voluntarily controlled at any age.

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Background

To begin, a discussion of the anatomy and bladder function will be helpful.  Urine is produced by the kidneys and travels through the ureters to the bladder to be stored.  The bladder is a muscular sac that holds urine until it is ready to be released into the urethra, the tube that connects the bladder to the outside of the body.  The bladder is emptied when the detrusor muscle, the muscle within the bladder wall, contracts thereby squeezing urine out of the body. At the same time the bladder contracts, the urinary sphincter relaxes. The relaxed sphincter acts like an open door, which allows the urine to pass and exit the body.  For successful urination, both the detrusor muscle contraction and sphincter relaxation must occur simultaneously.  Nerves in the muscular wall of the bladder release acetylcholine [uh-seet-l-koh-leen], a chemical that attaches to receptors on the muscle cells causing them to contract. Signals from the nerves are sent to the cortex of the brain communicating that it is time to be emptied. This process is primarily autonomic, which is not a voluntary control.  Overall, the normal communication between different nerves, muscles, and the brain is very complicated.

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Causes

The reason nocturnal enuresis occurs in adults is thought to be attributed to multiple factors. A large percentage of adults have significant symptoms associated with bedwetting and may have daytime wetting as well.  It is important to recognize these symptoms associated with nocturnal enuresis, as they may indicate a urological disorder.

Firstly, nocturnal enuresis can occur due to genetic linkage. Though this is not true with all people, evidence has shown that bedwetting is hereditary.  One study has shown that someone with two bedwetting parents has a 77% chance of becoming a bedwetter.  When one parent wet the bed as a child, his son or daughter was found to have a 40% chance of becoming a bedwetter.   These probabilities carry into adulthood as well.

ADH, or antidiuretic [an-tee-dahy-uh-ret-ik] hormone, is a signaling hormone that tells the kidneys to decrease the amount of urine produced.  Normally the body produces more ADH at night causing the kidneys to produce less urine.  Decreased urine production at night allows people to sleep through the night without having to urinate.  However, some people do not produce the appropriate amount of this hormone at night, which leads to high production of urine.  This is very similar to a symptom related with Type II Diabetes where an ineffective amount of ADH is produced. In other cases, the body produces ADH, but the kidneys do not respond and continue to produce the same amount of urine.   This abnormality is defined as nocturnal polyuria, the excessive production of urine during sleep, which can cause nocturnal enuresis in adults.  It can also be a symptom related to Type I Diabetes. Since similar symptoms can be shared by individuals with different conditions. Consulting a healthcare professional is helpful especially if you feel that you may be experiencing diabetes or nocturnal enuresis.

Another cause cited for primary nocturnal enuresis is a “smaller” bladder.  This does not mean, however, that the physical size of the bladder is actually smaller in nocturnal enuresis patients than in their peers.   Instead, it means that their functional bladder capacity (FBC), the amount of urine the bladder will hold until sending a signal to the brain indicating it is time to urinate, is a smaller volume than that of their peers.  The overactive contractions of the detrusor muscle indicate that the muscle is never fully relaxed and therefore the bladder capacity is not as large.

Along with FBC, detrusor overactivity, or instability, can also cause nocturnal enuresis.  Detrusor overactivity is spontaneous detrusor muscle contractions that may cause accidents.   Many studies have found a high incidence of detrusor instability with nocturnal enuresis. Detrusor overactivity has been found in up to 70-80% of primary nocturnal enuresis patients.  Bladder irritants, such as alcohol and caffeine, can also contribute to detrusor instability, in addition to serving as diuretics that only increase urine production.

Some medications have been documented to cause nocturnal enuresis as a side effect including hypnotics or medications taken for insomnia  and drugs taken for psychiatric purposes such as thioridazine, clozapine, and risperidone.   Obstructive sleep apnea or sleep disorders can cause nocturnal enuresis as well. Be sure to talk to your healthcare provider about any medications prescribed and their side effects. Much research supports the belief that secondary enuresis in adults is usually a serious symptom of an underlying problem that should be investigated.  Generally, this type of bedwetting occurs with other symptoms and is often associated with daytime wetting.   Adult onset nocturnal enuresis is often a result of problems with the urethra, such as prostatic or primary vesicle neck obstruction.  Such problems can be associated with the prostate in men or pelvic organ prolapse  in women.

Additional causes of secondary enuresis may also include diabetes, urinary tract infection, urinary tract stones, neurological disorders, anatomical abnormalities, urinary tract calculi, prostate cancer, prostate enlargement, bladder cancer, and obstructive sleep apnea.  In very rare cases, acute anxiety or emotional disorder may cause adult bedwetting.

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Diagnosis

One of the most useful tools for a healthcare provider is to have a great deal of information about your symptoms and general habits.  Consider keeping a symptom diary of daily habits and routines for at least two days prior to a medical appointment. These details will assist your healthcare provider when determining the cause and severity.

  • Take care to note when you void during the day and night
  • When accidents occur (time of day or night)
  • Amount of urine voided
  • Drinking patterns (do you drink a lot of fluids in the later afternoon/evening?)
  • What you drink (sugary, caffeinated, artificially sweetened, carbonated, alcoholic drinks, etc.)
  • Nature of the urinary stream (is the urinary stream strong and constant or is there difficulty initiating a void or continuous dribbling?)
  • Any existing recurrent urinary tract infections
  • The number of wet versus dry nights
  • In addition, note any other symptoms associated with nocturnal enuresis such as night sweats

Any and all of this information can help a healthcare provider determine the cause of the problem and the appropriate treatment.

At the time of the appointment, you should be prepared to supply such information and details related to personal and family medical history as well as medication usage.  In addition to helping you find options to help cure bedwetting, it is also important to see a healthcare provider to rule out any other serious problems that may cause nocturnal enuresis as a side effect.

At the appointment you can expect:

  • A physical examination
  • Neurological evaluation
  • Urinalysis and urine culture: The urinalysis and urine culture are different tests that determine the contents of the urine.

Further tests include:

  • Uroflowometry: involves urinating into a specialized funnel that measures the flow rate, amount of urine, and time required for urination
  • Post-void residual urine measurements: require an ultrasound and are non-invasive procedures that determine the volume of urine left in the bladder after voiding

If other problems are suspected, you can expect further tests for diagnosis.

What type of professional should you see?

If you suffer from persistent primary nocturnal enuresis, you may first see a primary care professional, such as a family practice physician or nurse practitioner. However, individuals with adult onset nocturnal enuresis usually need to be referred to a specialist, such as an urologist or sleep disorder specialist. While you may be embarrassed to address the issue with others, a medical professional is able to give you options to help treat bedwetting.  In many cases, bedwetting can be cured.

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Treatment

For those suffering from persistent primary nocturnal enuresis, many treatments can be used at any age.

Behavioral Therapy
  • Monitoring Fluid Intake: Limiting intake of fluids in the late afternoon and evening before bedtime causes a decreased amount of urine produced at night. This could be a helpful first step to reduce wet nights.  Also, decreasing the amount of caffeinated and alcoholic beverages may help.  However, this does not mean that you should reduce your overall fluid intake. Only change the time of fluid intake, as drinking adequate fluids is important for general health. Be sure to drink plenty of water.
  • Bladder Volume Training: This technique is an effort to increase bladder capacity in those who have a small FBC. (See Causes of Nocturnal Enuresis). The training involves drinking large amounts of fluid during the daytime and refraining from voiding as long as possible, up to 2-3 hours.  Through training, the functional bladder capacity is increased, making voids more infrequent. This method may be especially helpful to those with diagnosed detrusor overactivity, a condition in which the muscles of the bladder contract frequently and involuntarily. For men experiencing symptoms of enlarged prostate, consult a healthcare provider for behavioral therapy options, as bladder volume training can result in distending, or stretching, the bladder.
  • Bedwetting Alarm System: A bedwetting alarm is a device that awakens an individual from sleep as soon as the accident begins. Multiple variations of the alarm exist, ranging from vibrating to sounding alarms and wet-detection devices that can be attached to the underwear or a pad on which the individual sleeps. Once awoken, the individual is able to stop the flow of urine, finish voiding in the bathroom, and return to bed. Eventually the body is conditioned to wake up with the urge to urinate before wetting the bed.  This treatment option takes some weeks to work, requiring motivation and commitment. It is not as effective if the alarm goes off multiple times per night due to more than one bedwetting episode from decreased functional bladder capacity. Although, in many cases of bedwetting, this device helps the user overcome the condition.
  • Waking: While this option does not treat the problem, it may be helpful in preventing a wet bed.  It involves setting an alarm during the night at a random time in order to urinate.  It is important to set the alarm at a random time so that your bladder does not grow accustomed to emptying at a scheduled time during the night regardless of whether or not you are awake.
Pharmacological Therapy

Different medicinal options exist to treat nocturnal enuresis.  These may be used alone or combined with some of the behavioral treatments listed above, which generally has proven to be more effective.  Many studies have shown, however, that while pharmacological treatment may be initially effective in lowering the number of wet nights, the medicine is often effective only as long as it is taken. In other words, relapse rates are high once treatment has stopped, as only symptoms are addressed by the medication rather than the underlying condition or causal factors. The professional medical advice of a healthcare provider should be sought before starting any of these treatments.

  • Desmopressin: The most popular pharmacological option is desmopressin, also known as DDAVP.  This medication is an analog of the hormone already discussed, ADH or vasopressin.  By mimicking this hormone, the kidney produces less urine.  Taken at night before bedtime, many respond well and have dry nights when taking the medicine, which comes in the form of a nasal spray or pill.  This is also a good option while using other treatments (such as the bedwetting alarm) when spending the night away from home to prevent the worry of a bedwetting episode.  Studies have also shown that this treatment is more successful when the drug is slowly discontinued over a period of weeks by weaning an individual from the treatment and then restarting the medication again after some time has been spent without it. In fact, its effects are not long lasting and thus it is most often recommended for short term usage. The most common side effects included mood changes, dry mouth, and sleep disturbances. As a general rule it has been contraindicated for use in the elderly for reasons such as electrolyte imbalance. When an individual’s body does not have the proper amount of electrolytes it will cause dehydration, dizziness, and fatigue. DDAVP is not generally recommended at high doses for older people because of the possible risk of elevation of blood pressure.
  • Imipramine: This drug is a tricyclic-antidepressant whose off-label use has been shown to decrease wet nights in nocturnal enuretics, although the mechanism is not known. This option needs to be used with extreme caution and would be most appropriate as an alternative option in cases where individuals have not responded to other treatments such as desmopressin or behavioral therapy.  The reason extreme caution must be used is because of the more serious side effects, which are heart related problems including the lowering of blood pressure and an increased risk of suicide. The more commonly noted side effects include sleep disturbance, loss of appetite, gastrointestinal symptoms, and in some cases personality changes have been exhibited.
  • Anticholinergic Medications: These prescription medications are effective for treating enuresis with detrusor overactivity, demonstrating success in 5-40% of cases. The main side effects with anticholinergic medications are dry mouth, dizziness, and blurred vision.
  1. Darifenacin: This medication relieves bladder spasms and treats overactive bladder. It basically decreases bladder contractions and increases bladder capacity.
  2. Oxybutynin: This anticholinergic medicine relaxes the detrusor muscle of the bladder. It reduces wet nights in those with nocturnal enuresis and can be combined with bladder volume training. It is available in immediate and time-release tablets as well as transdermal patches.
  3. Tolterodine: This medication is an antimuscarinic [an-tee-mus-kuh-rin-ik] antagonist that is available in both short-and long-acting doses and functions much like oxybutynin.
  4. Trospium Chloride: This anticholinergic medication treats an unstable bladder by blocking cholinergic receptors that are found on muscle cells in the wall of the bladder. Once the receptors are blocked the bladder then can relax so overactivity does not occur.
  5. Solifenacin: This is a recently introduced anticholinergic that is a more selective antimuscarinic agent with fewer anticholinergic side-effects.
Surgical Methods

The involvement of surgery when attempting to treat severe detrusor overactivity is limited and should only be considered when all other less invasive treatment options have proven to be unsuccessful. All of the procedures mentioned below have associated risks that must be considered and discussed with a healthcare professional.

  • Sacral Nerve Stimulation: Sacral nerve roots are stimulated by neuromodulation, a process where neurotransmitters control various neuron groups. This increases the external sphincter tone causing the detrusor muscle neurons to stop activity. When detrusor muscle neurons have a decreased activity level the muscle will not contract constantly, which ultimately causes less frequent urination episodes. SNS is recommended for people with moderate to severe urge incontinence and for whom other treatments have not been helpful or for whom prescriptions are contraindicated.
  • Clam Cystoplasty: This is a surgical treatment where the bladder is cut open and a patch of intestine is placed in between the two halves. The goal of this procedure is to reduce bladder instability and increase bladder capacity.
  • Detrusor Myectomy: This process is also known as autoaugmentation that involves removing a portion or all of the exterior muscle surrounding the bladder. It intends to strengthen bladder contractions and reduce the number of them.
Treatments Undergoing Testing

  • Botulinum Toxin A: This form of treatment is an injectable bulking agent given through a flexible cystoscope, a thin medical instrument used to examine the interior of the bladder, in different areas of the detrusor muscle wall. This outpatient procedure lasts between six to nine months with few reported adverse side effects. This “off label” use is still undergoing testing in clinical trials.
  • Laser Acupuncture: This newer branch of acupuncture uses a laser to painlessly target specific areas of the body to treat a variety of medical problems.  One study found that laser acupuncture had a success rate equal to that of desmopressin therapy after three months.

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Management Options

Options to help manage bedwetting during treatment exist.

  • Mattress Covers: A variety of products exist to protect the bed including vinyl, waterproof, and absorbing mattress covers or even sheet protectors, which can make clean-up easier.
  • Absorbent Briefs: These products are a form of modified underwear designed to absorb liquid, therefore preventing leakage. Both reusable and disposable products are available. For those prone to skin irritation, disposable types may be a better option.
  • Skincare Products: Many products exist to protect the skin from irritation and soreness that occur when a person experiences nocturnal enuresis. A range of soaps, lotions, and cleansing cloths exist for various skin types.

Conclusion

Nocturnal Enuresis may be the symptom of an underlying condition. If this is the case, successful treatment of the condition can result in achieving nighttime dryness. Please contact NAFC by going to www.nafc.org or call 1-800-BLADDER. In addition to contacting NAFC, you should visit a healthcare provider to discuss symptoms and receive proper treatment.

References

 

  1. Baykara, M., S. Yucel, O. Kutlu, and E. Kukul. "Impact of Urodynamics in Treatment of Primary Nocturnal Enuresis Persisting Into Adulthood." Urology 64, 5 (2004): 1020-1025. Abstract.
  2. Sakamoto, Kyoko, and Jerry G. Blaivas. "Adult Onset Nocturnal Enuresis." Journal of Urology 165 (2001): 1914-1917.
  3. Monda, Jefferey M., and Douglas A. Husmann. "Primary Nocturnal Enuresis: A Comparison Among Observation, Imipramine, Desmopressin Acetate and Bed-Wetting Alarm Systems." The Journal of Urology 154 (1995): 745-748. 8 June 2006.
  4. Pan, Cynthia.  “Urinary Incontinence and Bed-Wetting.” Pediatric Rounds.  2005. Children's Hospital of Wisconsin. 28 July 2006 www.chw.org/ Yeung, C. K., J. D. Sihoe, F. K. Sit, M. Diao, and S. Y. Yew. "Urodynamic Finding in Adults with Primary Nocturnal Enuresis." Journal of Urology 171: 2595-2598. PubMed. Duke University, Charleston, SC. 28 July 2006 www.ncbi.nlm.nih.gov/.
  5. Ward-Smith, Peggy, and Dana Berry. "The Challenge of Treating Enuresis." Urologic Nursing 26 (2006): 222-224.
  6. Williams, Amanda, Keye Ajayi, and Harry Naerger. "Adult Nocturnal Enuresis: Guide to Causes and Treatment." Prescribing in Practice (2005): 23-26. 11 Aug. 2006 www.escriber.com.
  7. Williams, Amanda, Keye Ajayi, and Harry Naerger. "Adult Nocturnal Enuresis: Guide to Causes and Treatment." Prescribing in Practice (2005): 23-26. 11 Aug. 2006 www.escriber.com.
  8. Kerrebroeck, P. Van. "Standardization of Terminology in Nocturia: Commentary on the ICS Report." British Journal of Urology International 90 (2002): 16-17. 3 Aug. 2006 www.blackwell-synergy.com/.
  9. Williams, Amanda, Keye Ajayi, and Harry Naerger. "Adult Nocturnal Enuresis: Guide to Causes and Treatment." Prescribing in Practice (2005): 23-26. 11 Aug. 2006 www.escriber.com.
  10. Wadie, Bassem S. "Primary Nocturnal Enuresis Persistent to Adulthood, Functional Evaluation." Neurourology and Urodynamics 23 (2004): 54-57.
  11. Cited in Wadie, Bassem S. "Primary Nocturnal Enuresis Persistent to Adulthood, Functional Evaluation." Neurourology and Urodynamics 23 (2004): 54-57
  12. Lin, A. D., A. T. Lin, K. K. Chen, and L. S. Chang. "Nocturnal Enuresis in Older Adults." Journal of the Chinese Medical Association 67 (2004): 136-140. PubMed. Duke University, Charleston, SC. 11 Aug. 2006 www.ncbi.nlm.nih.gov/.
  13. Monji, Akira, Kazuyuki Yanagimoto, Ichiro Yoshida, and Sadayuki Hashioka. "SSRI-Induced Enuresis: A Case Report." Journal of Clinical Psychopharmacology 24 (2004): 564-565. PubMed. Duke University, Charleston, SC. 28 July 2006 www.ncbi.nlm.nih .gov/
  14. Williams, Amanda, Keye Ajayi, and Harry Naerger. "Adult Nocturnal Enuresis: Guide to Causes and Treatment." Prescribing in Practice (2005): 23-26. 11 Aug. 2006 www.escriber.com.
  15. Sakamoto, Kyoko, and Jerry G. Blaivas. "Adult Onset Nocturnal Enuresis." Journal of Urology 165 (2001): 1914-1917.
  16. Novicki, Donald E. "Adult Bed-Wetting: A Concern?" 21 Nov. 2005. The Mayo Clinic. 11 Aug. 2006 www.mayoclinic.com/.
  17. Makari, John, and H G. Rushton. "Nocturnal Enuresis." American Family Physician 73 (2006): 1611-1613. 28 July 2006 www.aafp.org/.

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