The first sentence of the conclusion of this review article reads: “In the past decade the role of psychological factors in the pathogenesis of nocturnal enuresis has changed from a primary causal factor to a consequence or comorbidity.” The authors also state that, “In the medical setting of a 10-15 minute consultation, general practitioners and paediatricians are hardly touching the problem.” It is now well established that the primary physiological aetiology of nocturnal enuresis is an imbalance between nocturnal diuresis volume and functional bladder volume combined with a deficient arousal / disordered sleep process. Once the standard management (regular voiding, regular fluid input and monitoring of night-time urine output) has been carried out, the three-systems model has allowed treatment to be tailored towards a combination of desmopressin for over-production of urine, anticholinergics to improve functional bladder capacity (if there are daytime symptoms of urgency, etc.), and modification of sleep patterns – even, on occasion, tonsillectomy to improve nocturnal oxygenation. However, 20-30% of children have a disorder of psychopathology as classified in the ICD-10 diseases classification of the DSM-IV-TR Manual of Mental Disorders. This may explain why the success rate of monotherapy is disappointing at 23-60%. Older male children with a low socioeconomic status have a higher incidence of psychological disorders. The authors of this paper outline the psychological factors associated with nocturnal enuresis. They differentiate between symptoms that are sub-clinical, such as sadness, embarrassment, guilt, humiliation, and obvious clinical symptoms – either externalised, such as conduct disorders, attention deficit hyperactivity disorder (ADHD), or internalised, such as depression and anxiety. In general parents report more internalised problems than the children themselves. ADHD occurs in around 9% of children with nocturnal enuresis and is the predominant externalised disorder. A high age (9-12) of children with ongoing nocturnal enuresis is also associated with ADHD. Children with ADHD also have a higher incidence of nocturnal polyuria than low functional ladder volume. This paper is important for all practitioners seeing children with enuresis as it highlights some of the other issues involved in managing these patients.

Challenging factors for enuresis treatment: psychological problems and non adherence.
Van Herzeele C, De Bruyne P, De Bruyne E, Vande Walle J.
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Henrik Steinbrecher

Southampton University Hospital NHS Trust

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