Enuresis and Obstructive Sleep Apnea in Children

  • Oscar Sans CapdevilaEmail author
  • Maria Eugenia Russi Delfraro
Part of the Respiratory Medicine book series (RM)


Nocturnal enuresis is a common problem, affecting an estimated 5 to 7 million children in the United States alone and occurring three times more often in boys than in girls. Nocturnal enuresis is clinically and pathogenetically a heterogeneous disorder. A significant correlation between enuresis and obstructive sleep-disordered breathing has been described in the last decade, with a high prevalence of enuresis in those patients. It seems clear that increased upper airway resistance during sleep manifesting either as habitual snoring (HS) or as polysomnographically documented obstructive sleep apnea syndrome (OSA), increases the risk of enuresis. Most importantly, after successful treatment of the respiratory disorder during sleep, bedwetting can be reduced or even eliminated. The goal of this chapter is to review the epidemiology, etiology, pathophysiology (specially the link with sleep disordered breathing), treatment and future areas of research for nocturnal enuresis.


Obstructive Sleep Apnea Obstructive Sleep Apnea Syndrome Atrial Natriuretic Peptide Detrusor Overactivity Nocturnal Enuresis 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


  1. 1.
    Barone JG, Hanson C, DaJusta DG, Gioia K, England SJ, Schneider D. Nocturnal enuresis and overweight are associated with obstructive sleep apnea. Pediatrics. 2009;124(1):e53–9.PubMedCrossRefGoogle Scholar
  2. 2.
    Brooks LJ. Enuresis and sleep apnea. Pediatrics. 2005;116:799–800.PubMedCrossRefGoogle Scholar
  3. 3.
    Butler R, Heron J. An exploration of children’s views of bed-wetting at 9 years. Child Care Health Dev. 2008;34(1):65–70.PubMedGoogle Scholar
  4. 4.
    Yeung CK, Sreedhar B, Sihoe JD, Sit FK, Lau J. Differences in characteristics of nocturnal enuresis between children and adolescents: a critical appraisal from a large epidemiological study. BJU Int. 2006;97(5):1069–73.PubMedCrossRefGoogle Scholar
  5. 5.
    Bower WF, Moore KH, Shepherd RB, Adams RD. The epidemiology of childhood enuresis in Australia. Br J Urol. 1996;78(4):602–6.PubMedCrossRefGoogle Scholar
  6. 6.
    Wille S. Nocturnal enuresis: sleep disturbance and behavioural patterns. Acta Paediatr. 1994;83: 772–4.PubMedCrossRefGoogle Scholar
  7. 7.
    Hunskaar S, Burgio K, Diokno A, Herzog AR, Hjälmås K, Lapitan MC. Epidemiology and natural history of urinary incontinence in women. Urology. 2003;62(4 Suppl 1):16–23.PubMedCrossRefGoogle Scholar
  8. 8.
    Rittig S, Knudsen UB, Nørgaard JP, Pedersen EB, Djurhuus JC. Abnormal diurnal rhythm of plasma vasopressin and urinary output in patients with enuresis. Am J Physiol. 1989;256(4 Pt 2):F664–71.PubMedGoogle Scholar
  9. 9.
    Kawauchi A, Imada N, Tanaka Y, Minami M, Watanabe H, Shirakawa S. Changes in the structure of sleep spindles and delta waves on electroencephalography in patients with nocturnal enuresis. Br J Urol. 1998;81 Suppl 3:72–5.PubMedGoogle Scholar
  10. 10.
    Yazbeck S, Schick E, O’Regan S. Relevance of constipation to enuresis, urinary tract infection and reflux. A review. Eur Urol. 1987;13(5):318–21.PubMedGoogle Scholar
  11. 11.
    Järvelin MR. Developmental history and neurological findings in enuretic children. Dev Med Child Neurol. 1989;31(6):728–36.PubMedCrossRefGoogle Scholar
  12. 12.
    Duel BP, Steinberg-Epstein R, Hill M, Lerner M. A survey of voiding dysfunction in children with attention deficit-hyperactivity disorder. J Urol. 2003;170(4 Pt 2):1521–3. discussion 1523–4.PubMedCrossRefGoogle Scholar
  13. 13.
    Weider DJ, Hauri PJ. Nocturnal enuresis in children with upper airway obstruction. Int J Pediatr Otorhinolaryngol. 1985;9(2):173–82.PubMedCrossRefGoogle Scholar
  14. 14.
    Alexopoulos EI, Kostadima E, Pagonari I, Zintzaras E, Gourgoulianis K, Kaditis AG. Association between primary nocturnal enuresis and habitual snoring in children. Urology. 2006;68(2):406–9.PubMedCrossRefGoogle Scholar
  15. 15.
    Brooks LJ, Topol HI. Enuresis in children with sleep apnea. J Pediatr. 2003;142:515–8.PubMedCrossRefGoogle Scholar
  16. 16.
    Nevéus T. Sleep enuresis. Handb Clin Neurol. 2011;98:363–9. Review.PubMedCrossRefGoogle Scholar
  17. 17.
    Nevéus T, Hetta J, Cnattingius S, et al. Depth of sleep and sleep habits among enuretic and incontinent children. Acta Paediatr. 1999;88:748–52.PubMedCrossRefGoogle Scholar
  18. 18.
    Yeung CK, Chiu HN, Sit FK. Bladder dysfunction in children with refractory monosymptomatic primary nocturnal enuresis. J Urol. 1999;162(3 Pt 2):1049–55.PubMedGoogle Scholar
  19. 19.
    Nijman RJ. Role of antimuscarinics in the treatment of nonneurogenic daytime urinary incontinence in children. J Urol. 2004;63(3 Suppl 1):45–50.Google Scholar
  20. 20.
    Nørgaard JP, Pedersen EB, Djurhuus JC. Diurnal antidiuretic hormone levels in enuretics. J Urol. 1985;134:1029–31.PubMedGoogle Scholar
  21. 21.
    Hunsballe JM, Hansen TK, Rittig S, et al. The efficacy of DDAVP is related to the circadian rhythm of urine output in patients with persisting nocturnal enuresis. Clin Endocrinol. 1998;49(6):793–801.CrossRefGoogle Scholar
  22. 22.
    Vurgun N, Yiditodlu MR, Ypcan A, et al. Hypernatriuria and kaliuresis in enuretic children and the diurnal variation. J Urol. 1998;159(4):1333–7.PubMedCrossRefGoogle Scholar
  23. 23.
    Läckgren G, Nevéus T, Stenberg A. Diurnal plasma vasopressin and urinary output in adolescents with monosymptomatic nocturnal enuresis. Acta Paediatr. 1997;86(4):385–90.PubMedCrossRefGoogle Scholar
  24. 24.
    Gozal D, O’Brien LM. Snoring and obstructive sleep apnoea in children: why should we treat? Pediatr Respir Rev. 2004;5:S371–6.CrossRefGoogle Scholar
  25. 25.
    Wang RC, Elkins TP, Keech D, Wauquier A, Hubbard D. Accuracy of clinical evaluation in pediatric obstructive sleep apnea. Otolaryngol Head Neck Surg. 1998;118:69–73.PubMedCrossRefGoogle Scholar
  26. 26.
    Kaditis AG, Alexopoulos EI, Hatzi F, et al. Overnight change in brain natriuretic peptide levels in children with sleep disordered breathing. Chest. 2006;130:1377–84.PubMedCrossRefGoogle Scholar
  27. 27.
    Sans Capdevila O, McLaughlin Crabtree V, Kheirandish-Gozal L, Gozal D. Increased morning brain natriuretic peptide levels in children with ­nocturnal enuresis and sleep-disordered breathing: a community-based study. Pediatrics. 2008;121:e1208–14.PubMedCrossRefGoogle Scholar
  28. 28.
    Cinar U, Vural C, Cakir B, Topuz E, Karaman MI, Turgut S. Nocturnal enuresis and upper airway obstruction. Int J Pediatr Otorhinolaryngol. 2001;59(2):115–8.PubMedCrossRefGoogle Scholar
  29. 29.
    Umlauf MG, Chasens ER. Sleep disordered breathing and nocturnal polyuria: nocturia and enuresis. Sleep Med Rev. 2003;7(5):373–6.CrossRefGoogle Scholar
  30. 30.
    Mikkelsen EJ, Rapoport JL. Enuresis: psychopathology, sleep stage, and drug response. Urol Clin North Am. 1980;7:361–77.PubMedGoogle Scholar
  31. 31.
    Nevéus T, Stenberg A, Läckgren G, et al. Sleep of children with enuresis: a polysomnographic study. Pediatrics. 1999;106(6 Pt 1):1193–7.CrossRefGoogle Scholar
  32. 32.
    Krieger J, Petiau C, Sforza E, Delanoë C, Hecht MT, Chamouard V. Nocturnal pollakiuria is a symptom of obstructive sleep apnea. Urol Int. 1993;50(2):93–7.PubMedCrossRefGoogle Scholar
  33. 33.
    Patwardhan AA, Larson MG, Levy D, et al. Obstructive sleep apnea and plasma natriuretic peptide levels in a community-based sample. Sleep. 2006;29(10):1301–6.PubMedGoogle Scholar
  34. 34.
    Monda JM, Husmann DA. Primary nocturnal enuresis: a comparison among observation, imipramine, desmopressin acetate and bed-wetting alarm systems. J Urol. 1995;154(2 Pt 2):745–8.PubMedGoogle Scholar
  35. 35.
    Robson WL, Leung AK. Side effects and complications of treatment with desmopressin for enuresis. J Natl Med Assoc. 1994;86(10):775–8.PubMedGoogle Scholar
  36. 36.
    Glazener CM, Evans JH. Desmopressin for nocturnal enuresis. Cochrane Database Syst Rev. 2002;(3):CD002112Google Scholar
  37. 37.
    Basha S, Bialowas C, Ende K, Szeremeta W. Effectiveness of adenotonsillectomy in the resolution of nocturnal enuresis secondary to obstructive sleep apnea. Laryngoscope. 2005;115(6):1101–3.PubMedCrossRefGoogle Scholar
  38. 38.
    Leiberman A, Stiller-Timor L, Tarasiuk A, Tal A. The effect of adenotonsillectomy on children suffering from obstructive sleep apnea syndrome (OSAS): the Negev perspective. Int J Pediatr Otorhinolaryngol. 2006 Oct;70(10):1675–82. Epub 2006 Jul 18.Google Scholar
  39. 39.
    Bonnet MH, Arand DL. Heart rate variability: sleep stage, time of night, and arousal influences. Electroencephalogr Clin Neurophysiol. 1997;102(5): 390–6.PubMedCrossRefGoogle Scholar
  40. 40.
    de Groat WC, Booth AM. Physiology of the urinary bladder and urethra. Ann Intern Med. 1980;92(Pt 2):312–5.Google Scholar
  41. 41.
    Schrier RW, Liberman R, Ufferman RC. Mechanism of antidiuretic effect of beta-adrenergic stimulation. J Clin Invest. 1972;51:97.PubMedCrossRefGoogle Scholar
  42. 42.
    Aston-Jones G, Rajkowski J, Cohen J. Locus coeruleus and regulation of behavioral flexibility and attention. Prog Brain Res. 2000;126:165–82.PubMedCrossRefGoogle Scholar
  43. 43.
    Koyama Y, Imada N, Kayama Y, et al. How does the distention of urinary bladder cause arousal? Psychiatry Clin Neurosci. 1998;52(2):142–5.PubMedCrossRefGoogle Scholar
  44. 44.
    Fujiwara J, Kimura S, Tsukayama H, et al. Evaluation of the autonomic nervous system function in children with primary monosymptomatic nocturnal enuresis power spectrum analysis of heart rate variability using 24-h Holter electrocardiograms. Scand J Urol Nephrol. 2001;35(5):350–6.PubMedCrossRefGoogle Scholar
  45. 45.
    Unalacak M, Aydin M, Ermis B, et al. Assessment of cardiac autonomic regulation in children with monosymptomatic nocturnal enuresis by analysis of heart rate variability. Tohoku J Exp Med. 2004;204:63–9.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2012

Authors and Affiliations

  • Oscar Sans Capdevila
    • 1
    Email author
  • Maria Eugenia Russi Delfraro
    • 1
  1. 1.Division of Sleep Medicine, Pediatric NeurologyHospital Sant Joan de Déu, Passeig de Sant Joan de DéuBarcelonaSpain

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