Pathogenesis of enuresis: Towards a new understanding

Abstract

Abbreviations & Acronyms ADHD = attention deficit hyperactivity disorder CNS = central nervous system LC = locus coeruleus PAG = periaqueductal gray area PMC = pontine micturition center Abstract: Enuresis was historically viewed as a primarily psychiatric disorder, but this understanding has changed dramatically since the end of the last century, when it became clear that somatic factors, such as nocturnal polyuria as a result of vasopressin deficiency, nocturnal detrusor overactivity and high arousal thresholds, all play a crucial role in enuresis pathogenesis. It has also become clear that enuresis is inherited in the majority of cases, although the correlation between genotype and enuretic phenotype is not straightforward. The standard view of enuresis as being the result of either (i) nocturnal polyuria and high arousal thresholds; or (ii) nocturnal detrusor overactivity and high arousal thresholds has become well-established, but further research now complicates the picture. First, psychological/psychiatric problems are overrepresented in enuresis, and might in a minority of cases have a causal or aggravating role. Second, nocturnal polyuria is not always linked to vasopressin deficiency. Third, nocturnal detrusor overactivity is in itself pathogenetically heterogeneous, and could be linked to constipation. Fourth, the sleep of enuretic children might be "deep," but possibly also disturbed (by obstructed airways or a distended or contracting bladder). These children might have high arousal thresholds because of the enuresis instead of the other way around. The same might possibly be said about nocturnal polyuria. Taking these new insights into account, a new model of enuresis pathogenesis is presented, which is more complicated but hopefully also more true than the standard consensus.

The adverse effects of oral desmopressin lyophilisate (MELT): personal experience on enuretic children

“…The patient's chronological age should be at least 5 years of age (or equivalent developmental level) and the behavior should not be attributable to the physological effects of a substance (e.g., a diuretic, antipsychotic or selective serotonin reuptake inhibitor) or another medical condition (e.g., diabetes, spina bifida, a seizure disorder). [2,3] The choice of treatment depends on the frequency and severity of symptoms, the child's age and motivation. Treatment options for NE are use of desmopressin, alarm devices, and imipramine.…”

Editorial Comment to Pathogenesis of enuresis: Towards a new understanding

“…The present article is a “state‐of‐the‐art” review article regarding the pathogenesis of enuresis of children . I hope this article will help urologists to develop an understanding of enuresis.…”

Pathophysiology and treatment of enuresis: Focus on sleep

“…Currently, nocturnal polyuria as a result of desmopressin deficiency, nocturnal detrusor overactivity and high arousal threshold is considered to be central to the pathogenesis of enuresis . The sleep of enuretic children might be deep, but possibly disturbed (by obstructed airways or by a distended or contracting bladder).…”

“…The sleep of enuretic children might be deep, but possibly disturbed (by obstructed airways or by a distended or contracting bladder). Because both detrusor contractions and bladder distension are recognized as strong arousal stimuli, many investigators have speculated that there must be something amiss with the enuretic children's arousal mechanisms . A striking report came from Yeung et al ., who demonstrated, using polysomnography and continuous cystometry, that the signals from an overactive bladder cause increased arousal during sleep, and that the sleep of enuretic children might in fact be disturbed by frequent, inefficient arousal reactions (an interaction between bladder overactivity and cortical arousability: a “bladder–brain dialogue”) .…”