Objective To evaluate primary nocturnal enu-resis in adult females with regard to the possible underlying aetiology using clinical data and urodynamic assessment.
Patients and Methods Between May 1999 and July 2001, this study was carried out on 60 enuretic female patients with a mean age of 18 ± 6.93 years (range 16 – 34 years). The mean follow up was 7 months ranging from 5 to 13 months. All patients were subjected to enuresis history, a void-ing diary and the evaluation of urinary and enuresis-related symptoms, such as enco-presis, constipation and sleep disorders. A family history was also taken. A com-prehensive physical and neurological examination was done. Work-up included urinalysis, KUB film, ascending and voiding cytourethrography. Voiding cystometry was done routinely for all patients.

Results Analysis of the patients’ data revealed that repeated wetting during daytime oc-curred in 38%, polyuria in 8%, diurnal fre-quency in 28% and urgency in 8%. A po-sitive family history of one parent was detected in 8%. Signs suggestive of neurological disorders were found in 12% of the patients. Ascending cystourethrography showed a Christmas-tree appearance of the bladder in 5%. Cystometry based on the diagnosis revealed an overactive bladder in 32%.
Conclusion The underlying pathology should be considered in the adult female enuretic patient. Persistence of primary enuresis into adulthood may indicate a possible bladder dysfunction.
Key Words adult enuresis, urodynamics, overactive bladder

INTRODUCTION

Nocturnal enuresis is defined as the involuntary, nocturnal repeated bedwetting or wetting of the clothes occurring twice a week for at least three consecutive months. Primary enuresis is the term used to describe the condition of individuals who have achieved daytime bladder control, but have not been able to achieve bladder control at night for at least 6 consecutive months1.

Recent reports denoted that about 3% of the adult population are bedwetters, and the incidence is almost equal among male and female adults2. It was reported that one of every 50 teenagers and one of every 100 adults are bedwetters3. The dis-ease is transmitted in an autosomal do-minant fashion. The enuresis gene has
Table 1: Presenting Symptoms of 60 Patients with Nocturnal Enuresis

Table 2: Clinical Disorders Among 19 Patients with Urodynamic Abnormalities

data in females with primary nocturnal enuresis.

PATIENTS AND METHODS

Between May 1999 and July 2001 a total of 60 enuretic female patients with a mean age of 18 6.93 years (range 16 – 34 years) suffering from persistent enuresis completed the study which was carried out only on patients who had passed the childhood, i.e. adolescent and adult females. Inclusion criteria included also associated urological problems. Patients with underlying congenital, anato-mical or psychological diseases requiring

been identified to be located on chro-mosome 224.

Nocturnal enuresis is a genetic disorder affecting 44% of sibilings in families where one parent has enuresis, 77% in families where both parents have the disorder and 15% in families without a history of enu-resis5. Primary nocturnal enuresis (PNE) is four times more frequent in adults than secondary nocturnal enuresis (SNE)6. Some of the common disorders are urolo-gical and/or psychological problems and sleep disorders. A work–up should be done to exclude structural, neurological causes, systemic diseases and functional incontinence7.

In this study, we aim at the evaluation of the possible underlying causes and at the assessment of urodynamic and clinical

medication were not exempted. All patients were subjected to an assessment of their enuresis history over two weeks. This included a voiding diary recording fluid intake, daytime frequency and urine volume, the number and times of bedwetting episodes and nocturnal polyuria. Urinary frequency, urgency, double voiding and obstructive symptoms were also recorded. History taking also comprised enuresis-related symptoms, such as enco-presis, constipation and sleep disorders as well as a family history

(Table 1).

A comprehensive physical examination was carried out on all patients with particular emphasis on a neurological evaluation and testing of the saddle shape area’s sensations. The back spine was examined for findings suggestive of myelodysplasia such as dimple, hair tuft and skin discoloration.

Work–up also comprised a random urin-alysis for pus cells and RBCs. A significant pyuria was considered with more than 5-8 white blood cells per high-power field and confirmed by a bacterial colony count of more than 100.000, while microhaematuria was denoted with more than 6-10 red blood cells per high power field. Attention was also paid to specific gravity (diabetes mellitus, diabetes insipidius, renal disease). A routine KUB film was done to reveal spinal deformities or radio-opaque shadows. Additionally, abdomino-pelvic ultrasonography was performed on 22 patients who had other urinary symptoms to detect a thickened trabeculated wall of the bladder or significant (>60 ml) post-voiding residual urine. Ascending and voiding cysto-urethrography was done in 6 patients with suspected neurogenic disorders. Urodynamic tests included voiding cystometry for all patients and urethral pressure profilometry for 6 patients with neurogenic problems. The device used was the Dantec 9023 A0011 (Dantec, Denmark) machine. Access is gained via a transurethral catheter using saline, con-tinuous filling at an infusion rate of 20 mls/min. The parameters assessed were sensations, cystometric capacity, detrusor compliance and instability.

RESULTS

Analysis of the voiding diary revealed a frequency of bedwetting of 1 – 2 times/ week in 12 patients, 3-5 times/week in 28 patients and 6 times/week or more in the remaining 20 patients. Repeated wetting per night was

detected in 23 patients. In 5 patients (8.3%) family history revealed that one parent suffered from the same disorder.

Neurological examination showed lost sad-dle area’s sensations in 4 patients and signs of hair tuft and dimple at the sacral spine sug-gestive of neurological disorders in 3 patients.
ed bladder wall in 4 patients and significant post-voiding residual urine in 2 cases.

Ascending cystourethrography showed a reduced bladder capacity in 5 patients (8.3%) and a Christmas-tree appearance of the blad-der in 3 cases (5%).

Voiding cystometry of 60 female enuretics showed that the maximum cystometric capa-city ranged from 183 ml/s to 682 ml/s with an average of 329.76 94 ml/s.

Premature sensations were detected in 6 patients and delayed sensations in one case, whereas normally intact sensations were found in 53 patients (88.3%).

An average detrusor compliance was found in 55 patients (91.6%).

Urodynamic-based diagnosis revealed that 19 patients (31.6%) had an overactive bladder (Fig. 1) The clinical presentation of these 19 patients showed associated diurnal frequency in 17, cystitis in one and polyuria in the remaining case (Table 2).

DISCUSSION

In this study we evaluated primary enuresis in adult females found in about 1% of the population. Such patients usually suffer psy-chologically and socially. We randomly select-ed patients with different anatomical, con-genital, psychological and neurogenic disor-ders.

It has been stated that the majority of adult enuretics do not have an anatomic ab-normality8. An organic cause has been postulated in 2%-3% only9. In our patients, associated urological problems were found in 32%, while other authors reported an incidence of only 10%. Psychological disorders were found in 10% of our patients, while 80% had sleep disorders 3,10,18 .

In this series, diurnal frequency was found in 28% of the patients and all showed an over-active bladder on urodynamic testing. This is in accordance with the results reported in earlier studies where 97% of adults with diurnal enuresis were found to have urodynamic ab-normalities10,21. On the other hand, a lower incidence (15%) was reported by other au-thors11,19. When nocturnal enuresis is asso-

REFERENCES

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All correspondence to be sent to:

M.M. El Qadhi, M.D.
Urology Department
National Institute for Urology and Nephrology
Cairo
Egypt

melqadhi@hotmail.com

Urinalysis showed significant pyuria in 5 patients, microhaematuria in 2 patients and specific gravity was raised in one case.

KUB films showed radiological deformity of the spina bifida in 7 patients (11%) and sacral agenesis in one case. Abdominopelvic ultra- sonography of 22 patients revealed a thicken-

ciated with daytime frequency, urgency, urge incontinence or obstructive symptoms, other significant organic conditions should be con-sidered in the differential diagnosis12,20. Con-versely, David and Husmann13 suggested that daytime frequency could be attributed to an unstable detrusor (50%), delayed maturation, decreased sensations, urinary tract infection or carelessness.

In our series, a small bladder capacity was detected in 4% of patients. In another study with similar results the authors took into con-sideration, however, that there was no evi-dence that a small capacity or unstable bladder contributed to nighttime wetting but that it was more likely to occur when the functional capacity was reached and that this might be low 13.

In 13% of our patients presenting with enuresis, a urodynamically proven small blad-der capacity and an overactive bladder, it was detected that nocturnal enuresis was associated with myelodyplasia and a clinically diagnosed neurogenic bladder. Similar cases of neurogenic abnormalities in association with a small bladder capacity have previously been reported in the literature4,14,15.

An overactive bladder associated with poly-uria was present in only 8.3% of our patients, although von Gontard et al.16 considered poly-uria and diabetes insipidius as the main causes of adult enuresis. We cannot comment on this theory because we did not routinely investigate for serum ADH except with clinically associated polyuria.

An overall incidence of urodynamic ab-normalities (uninhibited contractions) was detected in 31.6% of our patients . This may be attributed to the underlying diseases. Con-versely, von Gontard et al.16 stated that adults with primary enuresis without infection had no urodynamic abnormalities, whereas Arcus17 agreed with our finding that patients with underlying problems always showed an over-active detrusor while idiopathic enuretics rarely showed an abnormal detrusor activity.

In conlusion, an underlying cause should be looked for in cases with primary persistent nocturnal enuresis in females. Primary noc-turnal enuresis persisting into adulthood to-gether with cystometric findings of an over-active bladder might be considered as an indicator of bladder dysfunction.
12. Bloom DA, Faeberg, Bomalaski MD. Urinary incontinence in girls: Evaluation, treatment and its place in the standard model of voiding dysfunction. Urol Clin N Amer 1995, 22:521-538.

13. Vandersteen DR, Husmann DA. Treatment of primary nocturnal enuresis persisting into adult-hood. J Urol 1999, 161:90-92.

14. Hemis H. Adult primary enuresis. Urology Forum Archives. J. of Nephrology, Surgery and Psychiatry 2001, 4:271-277.

15. Warren E, Leary. Enuresis treatment centers. New York Times Health 1996, 3:325-331.

16. Von Gontard A, Mauer-Macke K, Pluck J. Clinical behavioral problems in day and night wetting. Ped Nephrol 1999, 13:662-667.

17. Arcus D. Nocturnal enuresis. Recommended curriculum guidelines for family practicioners and residents. Care of infants and children. Journal of American Family Physicians 2001, 3:12.

18. Walling AD. Primary nocturnal enuresis: Current concepts. Journal of American Family Physicians 2001, 4:10.

19. Moffatti ME, Kato C, Pless IB. Improvement in self-concept after treatment of nocturnal enuresis. Randomized controlled trial. J of Developmental and Behavioral Pediatrics 1997, 18:49-59.

20. Klein NJ. Management of primary nocturnal enuresis. J Urol 1997, 100:228-232.

21. Shapiro. Enuresis. Treatment and overtreatment. Ped Nursing Care 1985, 3:203-214.