What is the diagnosis and treatment approach for an adult patient with enuresis (involuntary urination), considering potential underlying conditions such as diabetes, neurological disorders, or sleep disorders?

Adult Enuresis: Diagnosis and Treatment

Immediate Diagnostic Priority

Adult-onset nocturnal enuresis without daytime incontinence is a serious red flag symptom that typically indicates severe urethral obstruction and demands urgent urological investigation, as it is associated with hydronephrosis (63%), bladder diverticula (38%), and vesicoureteral reflux (50%). 1

Critical Distinction: Adult-Onset vs. Persistent Primary Enuresis

The evaluation and treatment approach fundamentally differs based on whether this is:

• Adult-onset enuresis (new symptom in adulthood): This is pathological until proven otherwise and requires aggressive workup 1
• Persistent primary enuresis (lifelong, continuing from childhood): This follows a more conservative treatment algorithm 2

Mandatory Initial Evaluation

Essential History Elements

• Distinguish monosymptomatic (nighttime only) from non-monosymptomatic enuresis by specifically asking about daytime urgency, holding maneuvers, interrupted micturition, weak stream, and any daytime incontinence 3, 4
• Assess for obstructive symptoms including weak stream, straining to void, or need to use abdominal pressure, which suggest urethral obstruction 4, 1
• Screen for diabetes mellitus by asking about polydipsia, polyuria, and weight changes 3, 4
• Evaluate for sleep apnea by specifically asking about snoring, witnessed apneas, and daytime sleepiness 5, 4
• Document bowel habits to identify constipation, which causes mechanical bladder pressure and treatment resistance 3, 4
• Review medications that may cause secondary enuresis including lithium, valproic acid, clozapine, and theophylline 4
• Obtain family history of enuresis, as 44% have one affected parent and 77% have both parents affected 5

Required Physical Examination

• Abdominal examination to palpate for bladder distention and fecal impaction 4
• Genital examination for meatal abnormalities, epispadias, and phimosis 4
• Back examination to inspect for sacral dimple or vertebral anomalies suggesting spinal cord pathology 4
• Complete neurologic examination to rule out subtle dysfunction 4

Obligatory Laboratory Testing

• Urinalysis with dipstick is the only mandatory test to exclude diabetes mellitus, kidney disease, and urinary tract infection 3, 4
• Urine culture if urinalysis is abnormal 4
• No routine imaging unless there is continuous wetting, abnormal voiding pattern, recurrent UTIs, weak stream, or abnormal urinalysis 3, 4

Diagnostic Algorithm for Adult-Onset Enuresis

For adult-onset nocturnal enuresis without daytime symptoms, proceed immediately to comprehensive urological evaluation including:

• Post-void residual urine measurement to assess for retention 1
• Uroflowmetry to evaluate for obstruction (average maximum flow in these patients is 8.5 mL/second) 1
• Video urodynamics to assess bladder compliance and detrusor function 1
• Cystoscopy to evaluate for bladder pathology and urethral obstruction 1
• Upper tract imaging to assess for hydronephrosis, which occurs in 63% of these patients 1

This aggressive workup is justified because adult-onset nocturnal enuresis typically heralds severe prostatic or bladder neck obstruction requiring surgical intervention. 1

Treatment Algorithm

For Adult-Onset Enuresis with Obstruction

Transurethral prostatic resection is the definitive treatment when severe prostatic or vesical neck obstruction is identified, with complete symptom resolution in all patients who underwent surgery 1

• Alpha-adrenergic antagonists can be used for patients who decline surgery, with adjunctive clean intermittent self-catheterization if needed 1

For Persistent Primary Monosymptomatic Enuresis

Step 1: Behavioral Modifications (All Patients)

• Regular daytime voiding schedule every 2-3 hours 4
• Restrict evening fluids after dinner 4
• Void immediately before sleep 4
• Treat constipation aggressively with disimpaction and healthy bowel regimen, as this often eliminates enuresis 5, 4

Step 2: First-Line Pharmacotherapy

• Desmopressin 20-40 mcg nightly for 6 months achieves continence in 66% initially, but only 7% remain dry after discontinuation 2
• Critical warning: Restrict fluid intake on desmopressin to prevent hyponatremia 4
• Desmopressin is preferred when rapid response is needed or alarm therapy is impractical 4

Step 3: Enuresis Alarm (If Desmopressin Fails or Relapse Occurs)

• Enuresis alarm for 6 months achieves continence in 33% of adults who failed desmopressin 2
• Requires frequent follow-up and parental/partner commitment for monitoring 4
• Minimum 2-3 months treatment duration before declaring failure 4

Step 4: Imipramine (If Alarm Fails)

• Imipramine 50 mg nightly achieves continence in 29% of patients refractory to both desmopressin and alarm 2

Overall success rate: 83% achieve continence with this algorithm, with 38% continent off all medications and 45% requiring ongoing pharmacotherapy. 2

For Non-Monosymptomatic Enuresis

Treat underlying bladder dysfunction first before addressing nocturnal enuresis 4

• Anticholinergics for overactive bladder symptoms 6
• Urotherapy consisting of proper voiding posture, double voiding technique, and regular voiding schedule 6
• Urgent specialty referral if weak stream, abdominal pressure to void, or continuous incontinence is present 4

Special Considerations

Sleep Apnea

Surgical correction of upper airway obstruction (enlarged tonsils/adenoids) has led to improvement or cure of enuresis 5

Secondary Enuresis (Previously Dry, Now Wet)

• Investigate psychological stressors including parental divorce, school trauma, sexual abuse, or hospitalization 5, 4
• Rule out new-onset diabetes, UTI, or neurological conditions 4

Critical Pitfalls to Avoid

• Never skip urinalysis, as it is the only mandatory test and missing it could overlook diabetes, UTI, or kidney disease 3
• Never dismiss adult-onset nocturnal enuresis as benign without comprehensive urological evaluation, as it typically indicates severe obstruction requiring surgery 1
• Never overlook constipation, which is paramount in treatment resistance and must be treated aggressively before enuresis therapy 4
• Never use punitive approaches, as enuresis is involuntary and non-volitional 3, 4
• Never declare treatment failure before 2-3 months of adequate therapy 4
• Never order routine imaging unless specific indications are present (UTI history, abnormal voiding, continuous wetting, abnormal urinalysis) 3, 4