(Submitted May 15; revision accepted for publication October 31, 1969.)
This study was conducted at the University of Washington Adolescent Clinic, funded under Adoles-cent Project Grant, Department of Health, Education, and Welfare, Children’s Bureau, Washington, D.C.
ADDRESS FOR
REPRINTS: (SM.)C.D.M.R.C.
Department of Pediatrics, University of Washington,Seattle, Washington 98105.
PEnLrIucs, Vol. 45, No. 3, Part I, March 1970
426
ADOLESCENT
ENURESIS:
A
UROLOGIC
STUDY
Solbritt Murphy, M.D., and Warren Chapman, M.D.
Division of Child Health, Department of Pediatrics and Department of Urology, University of Washington, Seattle
ABSTRACT. Twenty-seven adolescent enuretics without known major organic pathology were sub-mitted to urological investigation. Seventy-five per-cent of those with completed evaluations showed some form of organic abnormality. Urethral stric-tures and stenoses were the most common type of pathology found.
Physicians seeing these patients should be aware
of the foregoing and obtain a minimum of a cys-tourethrogram and intravenous pyelogram on each patient as well as the more routine physical exami-nation. The cystourethrogram was the most produc-tive examination in terms of numbers, although some of the more major pathology was found on intravenous pyelograms. Pediatrics, 45:426, 1970,
F.NURESIS, ADOLESCENT, UROLOCIC STUDY.
T
decisions are repeatedly faced bythe physician seeing children with bed wetting problems. First, has the child’s bed
wetting become abnormal enough to be
called enuresis#{176} and, second, should an en-uretic child have a urological work-up to exclude organic pathology. At one end of the spectrum is the 2 year old whose
com-pulsive mother brings him in because she has not been able to toilet train him. At the
other end, is the 18 year old who is found to be enuretic at the time of physical exam-ination for employment or the draft and
who, on urological work-up, is found to have progressive obstructive deterioration
of the kidneys. In the first instance the mother needs help. In the second, the pa-tient obviously should have received treat-ment long ago. Between these two extremes
there lies a large grey area in which the “practitioners” are often in doubt and the “experts” often contradictory.
The adolescent patient as a rule, shows
up at the general practitioner’s or pediatri-cian’s office, and, after an often unsuccess-ful attempt at treatment, he is referred to
either a urologist or a psychiatrist,
depend-ing on the symptomatology presented by
the patient and the inclination of the
physi-cian in charge. The two specialties thus end up with a somewhat different clientele. The
urologist, who often finds identifiable
pa-thology among the group he sees, argues
that enuresis is substantially a urological problem usually associated with organic pa-thology. The psychiatrist just as frequently states that the origin of the problem is emo-tional, as the children he sees often show
definite behavioral disturbances.
This paper covers the symptomatology
presented by a group of chronic enuretic patients and the type of organic pathology
found among them. The study was based
on an adolescent clinic population and, therefore, represents a group of “hard core” enuretic subjects, older than the usual enu-retic patient seen by the pediatrician but younger than those seen at the time of
in-duction into the Armed Forces. The chil-dren were referred to the adolescent clinic by private physicians or community agen-cies. The clinic itself is multidisciplinary
The term “enuresis” is used to indicate wet-ting of the bed beyond the age of maturation of
bladder control (here defined as 5 years). Another
common usage is “nocturnal incontinence which is unaccompanied by any major organic pathology either in the nervous or urinary system” (Williams,’
Nash,’ and Campbell.’) This latter definition seems
to us to beg the important question since it
im-plies that complete evaluation has been done to
TABLE I
Pit”o:’: 01.’ ITIIOIA)(i1(AI. SYMPTOMS, IN PEIL(1:Nr
Sym p1oit Enuretics Clinic
Confr ala Level Corn-rnunity . Control, Ssgnzf-icance 7glisses/day .5 to 7 glasses/day
5 glasses/day 30 52 19 24 67 10 N.S.-not significant. 20 40 40 N.S. N.S. N.S.
indicated. These proce-done on either control
TABLE 11
TOTAL SYMPTOMATOLOGY SCORE, PERCENTAGE
Group 0 1 2>
Number of Cases Enuretic Clinic control Community control 88 76 76 15 19 20 5 5 4 27 22 25
None=0; minimal=1; marked=2>. and handles a wide range of chronic
prob-lems of adolescents, including those purely
medical, psychosomatic, and emotional.
Control groups were studied for
symptom-atology but did not have x-rays or instru-mentation.
STUDY SUBJECTS
Since this was a part of a broader
investigation4 of etiologic factors in
en-uresis, a number of exclusions were made in
the study group. The patients were
be-tween 12 and 18 years of age, the usual age range of all patients seen at this clinic.
They had regular nocturnal enuresis a mini-mum of once a month. Enuretic subjects with an I.Q. below 80, with known neuro-logical impairment of epilepsy, or with
psy-chosis or borderline psychosis were
excluded. Those with known severe
un-nary tract anomalies were not accepted, since this group could be expected to be
enuretic. The final study group consisted of 27 enuretic patients with a condition which had been classified up to that time as func-tional.
Two control groups were established.
The first consisted of 22 clinic patients, re-ferred for a variety of reasons, who had not been enuretic since age 5. They were, as closely as possible, matched to the original study group for age and sex.
The second control group included 25 jun-ior high and high school students selected
at random from school class lists. They
were also matched for age and sex. The
same exclusions were made in the control groups as in the study group.
METHODS
Number of ubject 27 22 2.5
Urgency 37 5 8 0.01
Dysuria 33 5 8 0.01
Urinary stream problem 7 0 8 N.S. 1)aytime frequency 33 19 12 N.S. history of urinary tiact
infections 12 0 0 N.S.
history of other urinary
tract pathology 19 .5 0 N.S.
Fluid Inia/ce
cystoscopy when
dunes were not
group.
All data obtained were tabulated and
statistically analyzed. Where the numbers were sufficient, the Chi square test for
sig-nificance was done.
RESULTS
Symptomatology
Table I indicates that the group of en-nuretics had more urological symptoms than did the controls; urgency and dysuria were
significantly increased in the enuretic
group. The total symptomatology score,
Table II, was obtained by scoring the
de-gree of presence of a symptom as 0 =
absent, 1 mild, and 2 = marked, then
A symptomatology picture was obtained from a questionnaire administered directly to the youngsters. Questions not pertaining
to enuresis were answered by all three
groups, those applicable to enuresis were
answered only by the study group.
A urological evaluation of the enuretic
patient was obtained whenever possible.
Laboratory procedures included urinalysis,
intravenous pyelogram,
TABLE III CI1ARACTERNTOTS 01 ENURESIS
Number
Characteristic
Frequency 5-7 nights/week l-4 iiiglits/week <1 night/week
Chronicity
I)aytime
mContinen(e
of (
Patients
10 11
6
14
6
7
(1
10
17 Never dry for a month
I)ry>1 month<1 year l)ry iisore than 1 year
No control Spotting
No problem 428
adding the total score for each subject. The
symptoms scored were the first six items from Table I. Total scores thus could range from 0 to 12. The enuretic subjects showed a significantly higher score than the
con-trols.
The characteristics of enuresis are pre-sented in Table III. Almost 80 percent of
the patients wet more than one night a
week, but the number wetting two to four
nights was about the same as that wetting
five to seven nights a week. Chronicity was high, i.e., more than half of the patients
had never been dry for over a month.
There was no true daytime incontinence, and only about one third had even occa-sional spotting. The age of the patients
within the range accepted seemed to have no effect.
Urological Evaluation
Two routine urinalysis per patient were normal in all but two of the 26 enuretics
from whom specimens were obtained. Of
the two with abnormalities, one had an
in-fection and one had orthostatic proteinuria. All 22 clinic controls had normal routine
urinalyses.
Table IV shows the type of urological
procedures performed and the urological diagnoses of the enuretic group.
Intrave-nous pyelograms were done on 25 patients. Of these, 18
(
72%)
were normal. Seven pa-tients had abnormalities, and in six of these the degree was graded as mild or moderate.The lumbosacral spine was examined on
- the regular intravenous pyelogram films
37 only, with no attempt made to confirm
ab-41 normalities by special positioning or
tech-nique. Of 25 enuretic patients, 8
(
32%)showed no abnormalities. Ten (40%) had
:
minor sacral anomalies. Two (8%) hadsco-26 liosis, and 5 (20%) had spina bifida. No films were taken on controls.
Cinecystourethrograms and retrograde
so urethrograms were the procedures which
63 most frequently demonstrated urological
- abnormality. Eighteen procedures were
done and seven
(
40%)
showed no abnor-malities. Six (36%) showed urethral stric-tures. One(
6%)
had urethrovesical refiux. This was one of the patients withduplica-tion of the ureter.
Cystoscopy was performed only when previous procedures, such as intravenous pyelogram and cystourethrograms, indi-cated possible pathology. Of the nine
cys-toscopies done, two confirmed the diagnosis of urethral stricture, one indicated a stric-hire when the cystourethrogram was
nor-mal, another revealed a urethral valve
where the cystourethrogram had indicated a stricture, and one indicated increased tra-beculation in a child with chrome urinary
tract infection. Two of the patients diag-nosed by x-ray as having minimal urethral strictures were normal by cystoscopy.
A definite urological diagnosis could not be made in the seven patients considered to have incomplete evaluations. Of the re-maining 20 patients, 5 (25%) had no pathol-ogy. Fifteen (75%) thus had pathology, al-though the degree of severity was minimal
in six, mild in seven, and moderate in only two.
lntercomparison
Cross correlations were then made
Number of PalienL, 2 4 Age (yr) 16. 16
17, 13, 14, 13
13
16, 14. 13, 13, 13
13, 12 18, 13 14 13 12 12 15 12 15 14 12 12 14 liP CUG-RUG 0 0 Normal 0 Malrotation 0 Normal Normal Normal Urethral stricture Normal Urethral stricture Normal Urethral stricture Normal Normal
Normal Ureterovesical reflux Normal Normal
Normal Normal
Chronic pyelonephritis Urethral stricture
hlydronephrosia Normal
Mild pydonephritia Normal Duplication of system 0
Horseshoe kidney 0 Duplication of system Normal
Cystoacopy 0 0 0 0 0 Normal Urethral stricture Urethral stricture Urethral stricture 0 Normal Urethral valve Normal Trabeculation 0 0 0 Uroloqical Diagno.ris No pathology Urethral stricture Urethral stricture Urethral stricture Urethral stricture Urethral stricture Meatal stricture Meatal stricture Urethral valve Urethro-pelvic junction obstruction, repaired Chronic infection Duplication ofpelvis
and ureter horseshoe kidney Duplication of pelvis
arid ureter Severity of Disease none 3 2 2 3 TABLE IV
UROLOGICAL PROCEDURES, DIAGNOSES, AND SEVERITY OF DISEASE
I =lncomplete work-up. 0=Not done. I =Minimal. 2=Mild. 3=Moderate.
analyses, only those 20 enuretic patients with complete urological evaluations could be used.
Thirteen of the 15 enuretic patients with urological pathology present had symptom-atology scores of one or more. In contrast, among the five enuretic patients with no
pa-thology, three had no symptoms. The grade of severity of disease was not related to the symptom score. This may be because of the difficulty in uniformly grading severity of
many varying conditions.
The possible correlation of frequency of enuresis with presence of urological
pathol-ogy was ascertained. Among the eight
wet-ting five to seven nights per week, six
(75%) had urological pathology, all of a type that would interfere with the urinary
stream, (i.e., four had urethral strictures and one had a urethral valve). Of the eight wetting two to four nights per week, six
(75%) showed urological pathology, but
diagnoses were very mixed, including those with horseshoe kidney, chronic urinary tract infection, and one with duplication of
sys-tem. Among the four wetting one night
per week, two (50%) had pathology.
Be-cause of the small numbers, conclusions
cannot be drawn. There is a trend for
higher frequency to be associated with a
higher incidence of pathology, but
appar-ent pathology was found in all three
groups.
A similar analysis was made correlating chronicity with urological pathology. Of the 12 enuretics with completed evaluations
who had never been dry for a month, 10
(83%) had urological pathology. Among the three dry between I month and 1 year, one
showed pathology; and, of the five dry
more than 1 year, three showed some
pa-thology. Again, apparent pathology can be found in all three chronicity groups, but the
trend is toward more pathology among
those who never had a dry period.
UROLOGICAL PROCEDURES AND ENURESIS
Among the 18 patients evaluated with a
minimum of intravenous pyelogram and
cystourethrogram-retrograde urethrogram,
some effects on the enuresis from the
proce-dures were noted. Of five patients who
430
treated
)
also ceased wetting afterdiagnos-tic procedurcs. Of the 10 patielits with
strictures or valves, three with strictures of minimal degree showed no improvement
with diagnostic procedures alone. Four
with minimal strictures in addition had
di-latation and calibration done. Two of them had temporary improvement which lasted 2 weeks to 1 month, while two others had no
change in the pattern of enuresis. Both pa-tients with mild to moderate strictures had dilatations and urethrotomy done; their
en-uresis nearly ceased for 1 month following
this, then recurred. The one patient with a urethral valve had dilatations with im-provement in urinary stream but not in
en-uresis.
Longer term follow-up showed that the
majority of the patients with strictures
stopped the enuresis and that the severity of the stricture, as measured by the usual techniques, had no relationship to the long-term outcome. Indeed, the three most persistent enuretic subjects were among those with the mildest appearing
abnormal-ities. Thus, urological procedures aimed at
curing the enuresis associated with mild urological pathology appeared relatively unsuccessful. However, paradoxically the mere performance of a diagnostic proce-dure sometimes cured the enuresis.
DISCUSSION
The frequent presence of urgency, day-time spotting, and dysuria (Tables I and III) confirm the often mentioned associa-tion of this type of symptomatology with chronic enuresis. Urinary frequency has
been mentioned by the same authors but
was not found in our series.
There was a marked increase in the num-ber of urological symptoms in the enuretic subjects as compared to the controls. By
it-self, this information is not of practical use, since a high correlation between enuresis and other symptoms would only mean that
such a symptom complex would indicate
which patient was enuretic, a fact that is easily identified at the first moment of tak-ing of a history. However, although no one
symptom can be used to indicate the pres-ence of pathology in the individual patient, the intercomparison data suggest that the
presence of additional symptomatology in enuretic subjects is more likely when
logical pathology is found.
The data showed that enuresis in this
age group tends to be chronic or primary, i.e., without long periods of dryness. This
has been demonstrated previously5 with 85% of a large enuretic school population re-ported to have primary enuresis.
A 75% incidence of urinary tract pathol-ogy is high enough to demand a urological investigation on each adolescent patient with enuresis. Since the study excluded those children with known frequent urinary
tract infections or marked urological pa-thology, these findings become even more impressive.
Documentation of the incidence of
pa-thology in the control groups would have
been preferable for comparison, but sub-jecting this asymptomatic population to
un-necessary radiation and instrumentation did not seem justified. For a few of the lesions found, the incidence in the normal popula-tion is known and is much higher in our
en-uretic group. For example, two children (8%) of the enuretic group had duplication of the renal pelvis and ureters. The usual incidence quoted is 1/150 or 0.67%.8 One (4%) of the enuretics had a horseshoe kid-ney. While this might be a chance occur-rence, the incidence is quoted as being 1/
500 to 1/1,800 (0.17 to 0.05%). The
spe-cific relationship of this type of upper tract pathology to enuresis is not clear. A high
-incidence of urethral and meatal strictures and urethral valves was anticipated from other studies. McFadden1#{176} found urethral
or bladder neck problems in 103 of 300
cases of persistent enuresis. Campbell3
found lower tract pathology in 50% and
Johnson and Marshall’1 in 54% of their cases. No significance can be attached to the
abnormalities of the lumbosacral spine
which were found. While such findings
classffication of abnormalities or in the type of films obtained. The present study suffers in this respect as well, since none of the films were taken specifically to expose the spine and films
of the controls
were
lacking.
SUMMARY
The incidence of organic urinary tract pathology found is high enough to warrant investigation in each of the adolescent
en-uretics. However, the urological lesions
were
often minimal. Also, correction of thesele-sions generally resulted in only temporary cessation or decrease in enuresis. Therefore,
organic pathology, although frequently found, would rarely be considered the sole
causative factor in enuresis. The same
group of enuretics were found to show con-siderable pathology of a social and psycho-logical nature in other aspects of this evalu-ation. Since urethral strictures, stenosis, and valves are the most common type of urinary pathology found, the cystourethrogram be-comes the most productive procedure, al-though both this and the intravenous
pyelo-gram are indicated.
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1949.
3.
Campbell, M. F. : Enuresis, its urological as-pects. J. Urol, 28:255, 1932.4. Murphy, S., Nickols, J., Umphress, A.,
Ham-mar, S., and Eddy, R. : Adolescent enuresis,
a multiple contingency hypothesis.
Sub-mitted to J. Pediat.
5. Hallgren, B.: Enuresis, a clinical and genetic study. Acta Psych. Neurol. Scand.
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58:806, 1961.
7. Campbell, M.: A clinical study of persistent
enuresis. New York J. Med., 34:190, 1934. 8. Campbell, M. F.: Anomalies of the kidney. In
Campbell, M. F., ed.: Urology, ed. 2. Phila-delphia and London: W. B. Saunders
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9. Campbell, M. F.: Anomalies of the kidney. In
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10. McFadden, C. D. F.: Anatomical abnormalities
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