Enuresis: Causes

Pathogenesis (development of disease)

Enuresis is divided by cause into:

  • Nonorganic (functional) enuresis:
    • Purely nocturnal enuresis (monosymptomatic enuresis nocturna, NEM).
    • nocturnal enuresis with additional daytime symptoms (non-monosymptomatic enuresis nocturna, non-MEN); especially in:
      • Children with overactive bladder (OAB) and small bladder capacity.
      • Habitual micturition postponement
    • Bladder dysfunction with isolated daytime symptoms:
      • Overactive bladder (OAB) and urge incontinence (imperative urge to urinate/sudden, very strong, unmanageable urge to urinate followed by involuntary urination).
      • Micturition postponement (refusal syndrome in which urine is retained and urination is delayed (habitual postponement of micturition). Thus, despite the use of holding maneuvers during the day, wetting occurs).
      • Dyscoordinated micturition (emptying the bladder) – as a result of the tension of the pelvic floor (“pinching”) (detrusor sphincter dyscoordination).
      • Underactive bladder (Engl. underactive bladder) – usually as a result of chronic micturition (more common in girls).
  • Organic enuresis (enuresis due to an anatomical or neurological disorder or disease; occurs rarely) due toe.g.:
    • Anatomic disorders/diseases:
      • Renal duplication and ectopic orifice of the ureter; symptomatology: constant dribbling out of small amounts of urine (day and night).
      • Malformations of the urethra
    • Neurological disorders/diseases:
      • Congenital (congenital), e.g.:
        • Myelomeningocele/spina bifida
        • Occult dysraphic disorders (e.g., spina bifida occulta, sacral agenesis, tethered cord syndrome)
      • Acquired tumorous or inflammatory diseases of the nervous system affecting bladder innervation.
    • Polyuric renal diseases (e.g., diabetes insipidus, tubulopathies, chronic renal failure).

Enuresis is multifactorial in origin. It is influenced by a number of comorbidities. The pathogenesis of non-organic enuresis (monosymptomatic enuresis) is not yet fully understood. It is thought to be caused by a developmental delay in bladder control combined with a regulatory disorder of urine production. The cause of MEN is probably a combination of developmental delays in central nervous bladder control and regulation of urine production.

Etiology (Causes)

Biographic causes

  • Genetic burden
    • Genetic diseases
      • Ochoa syndrome – genetic disorder with autosomal recessive inheritance characterized by the association of severe micturition dysfunction (disorders of bladder emptying) and characteristic facial expression; patients are incontinent (inability to hold the master) and have urinary tract infections and hydronephrosis (dilatation of the renal cavity system associated with destruction of renal tissue).
      • Spina bifida – cleft formation in the spine that occurs during embroynal development (sporadic, rarely familial).

Disease-related causes

Congenital malformations, deformities and chromosomal abnormalities (Q00-Q99).

  • Bladder exstrophy (displacement of the cleft bladder in the anterior bladder (and abdominal) wall region between the cleft pubic bone and recti abdominis muscles with cleft abdominal wall, combined with open urethra), epispadias (malformation of the urethra with upper urethral cleft), cloacal malformation
  • Ectopic ureteral orifice in girls (usually double kidney with dysplasia (malformation) of the upper anlage and orifice of the associated ureter (ureter) below the sphincteral plane / sphincter).
  • Malformations of the urethra
  • Infravesical obstruction (severe narrowing of the urethra) in boys.
  • Malformations of the os sacrum (sacrum) with spinal dysraphism (malformation in the closure of the neural tube).
  • Urethral valves
  • Myelomeningocele – congenital malformation of the spinal cord due to lack of closure of the neural tube with open vertebral arches and protrusion of the dural sac.
  • Ochoa syndrome (see below “Biographical causes”).
  • Spina bifida (see below “Biographical causes”).
  • Spina bifida occulta – non-visible form of spina bifida.
  • Tethered cord syndrome – neuromuscular/orthopedic dysfunction caused by a fixed filum terminale (spinal cord end).
  • Sacral agenesis – genetic absence of the sacral segments of the spinal cord.

Endocrine, nutritional and metabolic diseases (E00-E90).

  • Diabetes insipidus – congenital or acquired disease characterized by increased urine output (polyuria) and increased thirst with polydipsia (increased drinking).

Neoplasms – tumor diseases (C00-D48).

Psyche – nervous system (F00-F99; G00-G99).

  • Infections of the nervous system, unspecified (e.g., encephalitis (inflammation of the brain), poliomyelitis (polio), neuroborreliosis/complication of Lyme disease affecting the brain and neural pathways)
  • Multiple sclerosis (MS)

Symptoms and abnormal clinical and laboratory findings not elsewhere classified (R00-R99).

  • Polyuria (abnormally increased urine output)/polydipsia (abnormally increased thirst).

Genitourinary system (kidneys, urinary tract – reproductive organs) (N00-N99).

  • Chronic renal insufficiency (kidney weakness).
  • Symptomatic cystitis (inflammation of the bladder)
  • Tubulopathies – renal dysfunction caused by restriction of the tubular apparatus.
  • Vaginal Influx (ICCS: vaginal reflux) – this leads to urine dribbling during micturition (urination) up to 10 minutes after leaving the toilet; cause may be a low form of female hypospadias (congenital developmental disorder of the urethra (urethra); the mouth of the urethra (meatus urethrae externus) is thereby further ventral/proximal (ie. i.e. on the underside) located) or also be a labial synechiae (the labia minora adhere to each other).

Other causes

  • Nonneurogenic neurogenic bladder syndrome (Hinman syndrome; synonyms: “nonneurogenic neurogenic bladder” (NNNB), English also lazy bladder syndrome and infrequent voider syndrome) – rare disorder whose symptoms resemble those of neurogenic bladder; however, a neurologic cause is not demonstrable.