![]() An example of a bladder diary is available at. Information from the bladder diary can assist in selecting treatment options and assessing response. 2, 6, 8, 11 – 13 A bladder diary can be used to assess nighttime voiding patterns, urine output, and daytime drinking habits. Table 1 provides a list of questions and the clinical responses to the answers. A sense of the child's and parents' concerns about the bed-wetting should be determined, as well as their motivation and desire for treatment. They should also ask about daytime lower urinary tract symptoms, because these may not be volunteered by the child or parents who are focused on the bed-wetting. 6 When evaluating a child with enuresis, physicians should ask about the frequency, timing, and volume of bed-wetting. The pathophysiology of primary enuresis involves the inability to awaken from sleep in response to a voiding stimulus (i.e., a full bladder), coupled with excessive nighttime urine production or decreased functional capacity of the bladder. Referral to a pediatric urologist is indicated for children with primary enuresis refractory to standard and combination therapies, and for children with some secondary causes of enuresis, including urinary tract malformations, recurrent urinary tract infections, or neurologic disorders. The choice of therapy is based on the child's age and nighttime voiding patterns, and the desires of the child and family. First-line treatments for enuresis include bed alarm therapy and desmopressin. Treatment of primary monosymptomatic enuresis (i.e., the only symptom is nocturnal bed-wetting in a child who has never been dry) begins with counseling the child and parents on effective behavioral modifications. If identified, these conditions should be evaluated and treated. Several conditions, such as constipation, obstructive sleep apnea, diabetes mellitus, diabetes insipidus, chronic kidney disease, and psychiatric disorders, are associated with enuresis. Initial evaluation should include a history, physical examination, and urinalysis. The pathophysiology of primary nocturnal enuresis involves the inability to awaken from sleep in response to a full bladder, coupled with excessive nighttime urine production or a decreased functional capacity of the bladder. Approximately 5% to 10% of all seven-year-olds have enuresis, and an estimated 5 to 7 million children in the United States have enuresis. Enuresis is defined as intermittent urinary incontinence during sleep in a child at least five years of age.
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