Purpose: We analyzed the relative contribution of detrusor instability and difficult arousal from sleep in the genesis of nocturnal enuresis (NE), and evaluate a clinical feature that may prospectively help differentiate patients with monosymptomatic NE (mono NE) from those with diurnal voiding symptoms (DVSs) of urgency and urge incontinence associated with NE (NE + DVSs).
Materials and methods: Patients referred for voiding problems and 627 controls were evaluated for NE, DVSs, nocturia and arousal from sleep on a scale of 1 to 8. Patients were categorized into 3 groups-mono NE of primary or secondary onset (200, boys 71%, girls 29%), primary or secondary NE + DVSs (329, boys 43%, girls 57%) and isolated DVSs (146, boys 21%, girls 79%).
Results: DVSs were noted in 49% of boys and 76% of girls with NE, although 40% of patients or parents did not complain of DVSs. The DVSs were elicited on detailed interrogation or on finding evidence of urinary incontinence on perineal examination. While one-third of controls and patients with isolated DVSs manifested nocturia at least twice a month, only 6% of bedwetters did so. Difficult arousal from sleep (scores 6 to 8) was more prevalent in patients with NE (59%) than controls (20%) or patients with isolated DVSs (5%), and in patients with mono NE and primary NE than in NE + DVSs or secondary NE, with reverse prevalence for nocturia. Easy sleep arousal (scores 1 to 3) was noted in 65% of patients with secondary NE + DVSs vs up to 6% of other NE subgroups. Compared to patients with mono NE, those with NE + DVSs had a higher prevalence of urinary tract infection (UTI), encopresis, psychosocial/learning problems, and family history of UTI and DVSs, ie problems associated with detrusor instability.
Conclusions: DVSs accompany NE in two-thirds of patients but can be missed during a cursory history. Difficult sleep arousal seems to have a major role in primary mono NE, and detrusor instability in secondary NE + DVSs. In patients with NE a history of frequent nocturia, easy sleep arousal, UTI, encopresis, psychosocial learning problems or family history of UTI and DVSs should raise the suspicion for associated undisclosed DVSs.