Enuresis is defined as a state of a nearly complete evacuation of bladder, at a wrong place and time, at least twice a month after 5 years of age. It is, typically, more common in boys than girls. Types of Enuresis: It can be classified into 2 kinds:
1. Primary Enuresis
In Primary enuresis, the tendency of bed wetting is present since birth. There is a delay in the maturity of the neurological control mechanism of the sphincters. Such children usually have never been dry at night. It may be a mental subnormality.
2. Secondary Enuresis
In secondary enuresis the said tendency develops at least 6 months after birth. It may even extend to several years afterwards.Here, the sphincter control is developed at the normal age and child remains dry for several months. But due to certain secondary factors, the child develops bed wetting. The Reasons could be
• Faulty Behavior of Parents
• Diabetes
Causative Factors of Enuresis-
• Maturation delay
• Inadequate sleep disorder
• Hormonal imbalance
• A urinary tract infection
• Diabetes
• Chronic constipation
• Structural problem(s) in urinary tract or nervous system.
• Stress
• Worm infestation.
Normal voiding of the urine
The sacral spinal reflex arc is alone responsible to control urination in an infant. Therefore, enuresis incontinence is normal under the age of 2 years.As the nervous system matures, the cortical control over the spinal reflex results in a voluntary control over urination.
Pathophysiology
Maturational delay is most likely to cause enuresis. During night-time, the ADH hormone (with a circadian rhythm and a 24 hour cycle) has increased secretion, peaking between 4 and 8 am.Lack of circadian rhythm or impaired response of kidneys to the ADH is responsible for nocturnal enuresis.
It may also be precipitated by acute stressful condition, due to neurological disorders like lumbosacral vertebral defects, bladder irritability in urinary tract infection and a full rectum during constipation.
Evaluation
A detailed historical and physical examination of children, with enuresis, should be done, in order with the underlying cause, organic to secondary enuresis.Special attention should be paid to the manifestation of any urinary tract infection, a chronic kidney disorder and/or spinal cord disorders, if any.
Lab Investigations/Prescribed Tests
• Urine analysis and urine culture
• Bladder ultrasonography (KUB)
• Fasting blood sugar and postprandial blood sugar.
• CBC
• RFT
Precautions And Treatment
When should keep distance from the consumption of drinks with high caffeine content, especially during the evening hours.
Adequate fluid intake during day is recommended to be 40% in the morning, 40% in the afternoon and 20% in the evening.
The first line of treatment should usually be non-pharmacological, comprising of motivational therapy and an alarm therapy.
Motivational Theraphy
• It has been successful in curing 25% of patients with enuresis.
• The child should be reassured and provided emotional support.
• The child is encouraged to assume active responsibility, including dry night diary, passing urine before going to bed etc.
• Dry nights should be rewarded with praise. Punishments and other angry parental responses should be avoided.
• Behavioral modification should be encouraged to achieve good bladder and bowel habits.
Alarm Therapy
It involves the use of a device to manifest a conditioned response of awakening from the sensation of a full bladder.
Herbal Treatment
Bimbi Moola, Ashwagandha Churna, Vidanga Churna, Brahmi Ghrit, Triphala Churna, Eranda Taila may be used under medical guidance.
Conclusion
It can be concluded that though the disorder enuresis is self limiting, persistent stress upon children can worsen it. Stress has become a part of every child’s life and needs to be cured. A cure that impacts the psyche and the urinary system of the child altogether, will alone be able to truly and effectively treat enuresis.