It is generally accepted that a major cause of nocturnal enuresis or Bedwetting is directly related to Sleep Disordered Breathing.  Correction of the airway may cure the bedwetting problem but the question is what is the best way to correct the airway.  This article (PubMed Abstract below) in Urol. 2014  “Why does adenotonsillectomy not correct enuresis in all children with Sleep Disordered Breathing.” asks the question why Tonsil and Adenoid removal is only partially successful in eliminating enuresis.

The answer is that children with large tonsils and adenoids have developed smaller airways than children who have normal development. Treatment with Rapid Maxillary Expansion has also been shown to be very effective in treating enuresis (abstract below) when there is maxillary constriction, a common epigenetic error created by impaired nasal breathing, enlarged tonsils and adenoids and abnormal swallowing and tongue posture.

The impaired nasal airway causes secondary airway obstruction that is not treated during T & A procedure.  Much of this is well illustrated in orthodontic literaturee looking at abnormal development secondary impaired breathing.

A third article, “Treatment outcomes of adenotonsillectomy for children with obstructive sleep apnea: a prospective longitudinal study.” discusses exactly this quandary of only partial resolution of  airway problems with Adenoid and tonsillectomy.

A fourth article, “Sleep architecture parameters that predict postoperative resolution of nocturnal enuresis in children with obstructive sleep apnea.” showed that the most severe pediatric apnea patients who had increased stage two sleep responded best to T & A procedure.

The important conclusion to all of these articles is that any and all causes of Sleep Disorderd Breathing must be corrected to prevent nocturnal enuresis.

The good news is that the Perfect Start System can correct the developmental orthopedic and pneumopedic issues as young as two years of age. Correction begins with a habit corrector.   Utilizing the Perfect Start System early may prevent the need of tonsillectomy and adenoidectomy.  In cases requiring surgical intervention growing the airway can prevent regrowth of adenoids.

Urol. 2014 May;191(5 Suppl):1592-6. doi: 10.1016/j.juro.2013.10.032. Epub 2014 Mar 26.
Why does adenotonsillectomy not correct enuresis in all children with Sleep Disordered Breathing.
Kovacevic L1, Wolfe-Christensen C1, Lu H1, Toton M1, Mirkovic J1, Thottam PJ2, Abdulhamid I3, Madgy D2, Lakshmanan Y1.

We analyzed the outcome of nocturnal enuresis after adenotonsillectomy in children with sleep disordered breathing. We also evaluated differences in demographic, clinical, laboratory and polysomnography parameters between responders and nonresponders after adenotonsillectomy.
We prospectively evaluated children 5 to 18 years old diagnosed with sleep disordered breathing (snoring or obstructive sleep apnea syndrome) on polysomnography and monosymptomatic primary nocturnal enuresis requiring adenotonsillectomy to release upper airway obstruction. Plasma antidiuretic hormone and brain natriuretic peptide were measured preoperatively and 1 month postoperatively.
Sleep studies were done in 46 children and 32 also underwent blood testing preoperatively and postoperatively. Mean ± SD patient age was 8.79 ± 2.41 years and the mean number of wet nights weekly was 6.39 ± 1.26. Polysomnography revealed obstructive sleep apnea syndrome in 71.7% of patients and snoring in 28.3%. After adenotonsillectomy 43.5% of patients became dry. Preoperative polysomnography findings indicated that responders, who were dry, had significantly more arousals and obstructive apnea episodes but fewer awakenings than nonresponders, who were wet. Significant increases in plasma antidiuretic hormone and significant decreases in plasma brain natriuretic peptide were seen in all children with no difference between responders and nonresponders. No difference between the groups was noted in age, gender, race, body mass index, constipation, preoperative number of wet nights weekly or type of sleep disordered breathing.
Nocturnal enuresis resolved after adenotonsillectomy in almost half of the children with sleep disordered breathing. Those who became dry had more frequent arousal episodes caused by apnea events than those who remained wet.
Copyright © 2014 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.
adenoidectomy; bladder; enuresis; sleep apnea syndromes; tonsillectomy

Eur J Paediatr Dent. 2014 Mar;15(1):67-71.
The impact of rapid palatal expansion on children’s general health: a literature review.
Eichenberger M1, Baumgartner S1.
Author information

The original indication for rapid palatal expansion was to treat skeletal maxillary constriction. As positive effects were clinically proven, the number of indications for rapid palatal expansion has continuously grown. The purpose of the present article was to review the literature and to evaluate the effect of rapid palatal expansion on nose breathing, natural head position, obstructive sleep apnoea syndrome, nocturnal enuresis and conductive hearing loss.
It can be concluded that rapid palatal expansion is predominantly recommended in children with maxillary constriction. In those with normal occlusion, maxillary expansion can be considered as the really last choice of treatment when other treatment options in patients with nose breathing, obstructive sleep apnea syndrome (OSAS), nocturnal enuresis and conductive hearing loss (CHL) have failed. Therefore, collaboration between paediatricians, otolaryngologists, paediatric dentists and orthodontists will lead to the best treatment outcomes in the future.

Sleep. 2014 Jan 1;37(1):71-6. doi: 10.5665/sleep.3310.
Treatment outcomes of adenotonsillectomy for children with obstructive sleep apnea: a prospective longitudinal study.
Huang YS1, Guilleminault C2, Lee LA3, Lin CH4, Hwang FM5.
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To evaluate the efficacy of adenotonsillectomy (AT) in the treatment of children with obstructive sleep apnea (OSA) in a 3-y prospective, longitudinal study with analysis of risk factors of recurrence of OSA.
An investigation of children (6 to 12 y old) with OSA documented at entry and followed posttreatment at 6, 12, 24, and 36 mo with examination, questionnaires, and polysomnography. Multivariate generalized linear modeling and hierarchical linear models analysis were used to determine contributors to suboptimal long-term resolution of OSA, and Generalized Linear Models were used for analysis of risk factors of recurrence.
Of the 135 children, 88 terminated the study at 36 months post-AT. These 88 children (boys = 72, mean age = 8.9 ± 2.7 yersus boys 8.9 ± 2.04 y, girls: 8.8 ± 2.07 y; body mass index [BMI] = 19.5 ± 4.6 kg/m(2)) had a preoperative mean apnea-hypopnea index (AHI0) of 13.54 ± 7.23 and a mean postoperative AHI at 6 mo (AHI6) of 3.47 ± 8.41 events/h (with AHI6 > 1 = 53.4% of 88 children). A progressive increase in AHI was noted with a mean AHI36 = 6.48 ± 5.57 events/h and AHI36 > 1 = 68% of the studied group. Change in AHI was associated with changes in the OSA-18 questionnaire. The residual pediatric OSA after AT was significantly associated with BMI, AHI, enuresis, and allergic rhinitis before surgery. From 6 to 36 mo after AT, recurrence of pediatric OSA was significantly associated with enuresis, age (for the 24- to 36-mo period), postsurgery AHI6 (severity), and the rate of change in BMI and body weight.
Adenotonsillectomy leads to significant improvement in apnea-hypopnea index, though generally with incomplete resolution, but a worsening over time was observed in 68% of our cases.
adenotonsillectomy; comorbidity; obstructive sleep apnea; polysomnography; treatment outcomes

Ann Otol Rhinol Laryngol. 2013 Nov;122(11):690-4.
Sleep architecture parameters that predict postoperative resolution of nocturnal enuresis in children with obstructive sleep apnea.
Thottam PJ1, Kovacevic L2, Madgy DN1, Abdulhamid I3.
Author information

We performed a prospective cohort study in a pediatric tertiary care center to determine whether preoperative sleep architecture is associated with complete resolution of nocturnal enuresis (NE) after adenotonsillectomy.
Thirty-seven pediatric patients with primary NE who underwent adenotonsillectomy for obstructive sleep apnea (OSA) were evaluated. Preoperative polysomnograms, as well as preoperative and postoperative reports of NE, were recorded. We performed chi2 analysis, Fisher’s exact test (for p values), and t-tests to evaluate the impact of multiple demographic characteristics on sleep architecture, comparing children with resolved NE to those with unresolved NE after adenotonsillectomy.
The patients’ mean age was 8.0 years (SD, 2.32 years). All children had presurgical primary NE. No age or gender differences were identified between children with resolved NE and those with unresolved NE. After surgery, more than half of the participants had resolution of NE. A higher percentage of boys had unresolved NE (chi2 = 3.63; p = 0.06). Improvement of NE was identified in children with a higher obstructive apnea-hypopnea index and more desaturation events. Eleven of the 12 children with prolonged stage 2 sleep reported resolution of NE (p = 0.001). Children with an obstructive apnea-hypopnea index of greater than 10 had a significantly greater rate of resolution of NE (p = 0.01). Logistic regression demonstrated that an elevated body mass index and the interaction of severe OSA and prolonged stage 2 sleep predicted resolution of NE. All 10 children with severe OSA and an abnormal total time spent in stage 2 sleep had resolution of NE.
Adenotonsillectomy is a treatment option for children with OSA and NE. Postoperative resolution of NE was seen in 51.4% of patients who underwent adenotonsillectomy. The children with both severe OSA and prolonged stage 2 sleep were 3.4 times as likely to have postoperative resolution of NE. These results suggest that there are significant differences in preoperative sleep architecture between children whose NE resolves after adenotonsillectomy and those whose NE does not resolve.