Enuresis is a syndrome of involuntary, uncontrolled urination, urinary incontinence, mainly during sleep. It is more common in preschool and early school age children with a history of concomitant neurological pathology. Causes psychological trauma in the child, conflicts with peers in the team, punishment by parents in the family, neuroses, which further aggravates the course of enuresis. It often occurs together with other urological diseases (cystitis, pyelonephritis). The main task of diagnosis is to identify its cause. To do this, a full urological examination is carried out, as well as neurological and psychological testing of the patient.
ICD 10
F98.0 R32 N39.4
Meaning
Enuresis is involuntary urination. As a rule, this term refers to involuntary nocturnal urination in children (nocturnal enuresis). Nocturnal enuresis is considered involuntary urination in children at an age when arbitrary control over the activity of the bladder should already be established. Many researchers in the field of urology believe that nocturnal enuresis is not a disease, but represents a transitional stage between lack of control and complete control over physiological functions.
According to various data, disease is observed in 15-20% of children aged 5 years and in 7-12% of children aged 6 years. Enuresis affects 3% of children aged 12 and 1% of children under the age of 18. In boys, nocturnal enuresis develops one and a half to two times more often than in girls. In 2-3% of patients who were observed in childhood for enuresis, periodic involuntary nocturnal urination is noted throughout their lives.
The age limit separating involuntary urination normal for a child from pathological enuresis has not yet been clearly defined. It is considered that nocturnal enuresis acquires clinical significance when a child turns 5 years old. From this moment on, the problem should be regarded as a pathological condition, attract the attention of parents and doctors. Doctors of many specialties take part in the treatment of nocturnal enuresis: neurologists, psychotherapists, psychiatrists, urologists, nephrologists, etc. The participation of various specialists is due to the variety of reasons leading to the development of enuresis.
Causes
The following causes of enuresis are distinguished:
Delayed development of cerebral urination centers
In young children, urination is regulated by the spinal center and is carried out involuntarily. When a child reaches the age of 2-5 years, urination centers are formed in the brain. Normally, at this age, the interaction between the cerebral and spinal centers is gradually established, after which urination becomes completely controlled. If there are no normal relationships between the centers, the tone of the bladder is disturbed and primary enuresis develops.
Violation of ADH secretion
Normally, the secretion of vasopressin (a hormone that regulates the density and amount of urine secreted) increases at night. Urine production decreases, urine becomes more concentrated. In patients with nocturnal enuresis, a change in the rhythm of vasopressin secretion is often detected. The lack of vasopressin at night causes the secretion of a large amount of urine, overflow of the bladder, and, as a consequence, nocturnal enuresis.
Urinary tract infections and urological diseases
Some congenital (strictures and obliteration of the urethra) and infectious (worm infestations, vulvovaginitis in girls and balanoposthitis in boys) diseases can cause chronic urinary retention, against which mixed enuresis develops.
Hereditary predisposition
Hereditary predisposition to enuresis has been confirmed. If one parent suffered from enuresis, urinary incontinence in children develops in 45% of cases, if both – in 75% of cases. Boys are more susceptible to the influence of hereditary factors.
Stress and adverse psychological factors
The influence of psychological traumas on the development of secondary enuresis was noted. In this case, night incontinence develops after exposure to a certain stressful factor (parents’ divorce, relocation, transfer to another school, etc.). Sometimes a child begins to wet the bed after the birth of a brother or sister, which is associated with the need to regain the lost attention of parents.
Sleep disorders
The cause of enuresis can be a very sound sleep of the child. Some children are practically unable to wake up on their own with the urge to urinate, which leads to the development of enuresis.
Nocturnal enuresis can occur as a result of the influence of one factor or several factors in various combinations. Determining the etiology of enuresis is often associated with significant difficulties due to the secrecy of the child or the specifics of the manifestation of certain factors.
Classification
Different classifications of enuresis are based on different criteria. In accordance with them , the following forms of enuresis are distinguished:
1. Depending on the presence or absence in the past of a “dry” period without involuntary urination:
- Persistent (primary) enuresis. Primary enuresis is called nocturnal urinary incontinence in a child older than 5 years, if in the past there is at least one “dry” period lasting more than 6 months.
- Recurrent (secondary) enuresis is a condition in which a child begins to urinate in bed after a dry period lasting from several months to several years. In cases of recurrent enuresis, there is often a connection between involuntary urination and urological, endocrinological, neurological or mental diseases.
2. Depending on the time of involuntary urination:
- nocturnal – observed in 85%,
- day – at 5%
- mixed – in 10% of children suffering from involuntary urination.
Nocturnal enuresis often develops in children who sleep very soundly (profundosomnia). Daytime and mixed enuresis can signal that the child is experiencing neurological or emotional problems.
3. Depending on the presence or absence of concomitant pathology:
- uncomplicated is enuresis that develops in the absence of signs of infection or pathological changes in the organs of the genitourinary system.
- complicated enuresis is diagnosed when urinary tract infection is detected, anatomical and functional changes in the urinary tract or pathological neurological conditions are diagnosed. The accepted terminology does not reflect the causes and consequences of pathological conditions. In this case, the above conditions should be considered, rather, as a cause of urinary incontinence, and not as complications of enuresis.
The existing classification cannot reflect all the features of the development and course of enuresis. A number of researchers distinguish neurotic and neurosis-like enuresis.
Neurotic enuresis usually develops in timid, shy patients and is accompanied by severe experiences of the child.
Children suffering from neurosis-like enuresis, unlike the previous group, are indifferent to their condition until adolescence.
Some researchers suggest that monosympathetic nocturnal enuresis, which occurs in 85% of patients and includes subgroups with the presence and absence of nocturnal polyuria, with positive and negative reactions to desmopressin treatment, with bladder dysfunctions and impaired awakening, should be isolated into a separate group.
Diagnostics
The diagnosis of “nocturnal enuresis” is established if the child has involuntary nocturnal urination for three or more months. The examination includes general and specific diagnostic methods:
- Preliminary examination. At first, the patient is carefully interviewed, finding out the history of the disease, the details of incontinence and the amount of water consumed at night. Palpation of the abdomen, rectal examination, bladder ultrasound and abdominal ultrasound are performed. It is necessary to exclude congenital anomalies of the development of the genitourinary system, pelvic tumors, diabetes insipidus and diabetes mellitus.
- Urological methods. The volume and rhythm of urination are investigated. If a pathology of the urinary system organs is suspected, nephroscintigraphy, intravenous urography, cystography, urofluomentry and cystoscopy may be prescribed.
- Neurological examination. To exclude the pathology of the spinal cord, the child is examined by a neurologist. To assess the emotional state of the patient and identify possible mental pathology, a consultation of a psychiatrist or psychotherapist is required.
- Additional diagnostics. The cortical centers of urination are located near the pharyngeal tonsils. In some cases, an increase in the tonsils can lead to difficulty breathing during sleep, the spread of signals to the cortical centers and involuntary urination. To exclude inflammatory diseases and enlarged tonsils, patients with nocturnal enuresis should be examined by an otolaryngologist.
Treatment
The patient is prescribed a special drinking regime. It is recommended not to take liquid for two hours before going to bed. It should be monitored so that the child receives a sufficient amount of fluid during the day.
Pharmacotherapy
Primary enuresis is often caused by a violation of the rhythm of vasopressin release, therefore, patients with nocturnal incontinence are prescribed a synthetic analogue of this hormone – desmopressin. The dose of the drug is selected individually. Independent use of desmopressin is unacceptable, since enuresis may be caused by another pathology (for example, developmental pathology or infection of the urinary organs).
Patients with increased bladder tone are prescribed oxybutin. The drug affects the smooth muscles of the bladder, increasing its volume and reducing spasms. In some cases, driptan therapy is combined with desmopressin. Patients with reduced bladder tone are recommended to urinate every 2-3 hours, prescribe drugs that increase the tone of smooth muscles (neostigmine).
Non-drug methods
Psychological correction is indicated for patients suffering from neurotic enuresis. For neuroses and neurosis-like conditions, courses of vitamin therapy, drugs that improve metabolic processes in the brain (phytopreparations, picamilon, piracetam) are recommended. Complex treatment of enuresis includes physiotherapy procedures (thermal procedures, ultrasound, current treatment), therapeutic gymnastics to strengthen the pelvic floor muscles and restorative massage.
To develop a conditioned reflex, it is recommended to use special devices. When the first drops of urine appear, the device gives a sound signal that wakes up the patient and teaches him to wake up when the urge to urinate. The use of devices gives a good effect if parents manage to develop the right tactics of behavior and negotiate with the child. Conflict situations arising from repeated night awakening can lead to the child’s refusal to use the device.
Prognosis and prevention
It should be remembered that the treatment of enuresis of almost any etiology is a long process. Parents need to be patient and not wait for immediate results of therapy. Pressure on the child and increased expectations can lead to neuroticism of the child and complicate the treatment process.
Enuresis changes the child’s psyche, leads to an aggravation of feelings of inferiority. Patients are shy of their peers, withdraw into themselves, seek solitude. A chronic traumatic situation can cause low self-esteem, timidity, isolation, indecision. Sometimes children become aggressive. Character changes can go unnoticed by parents and only come to light in adolescence. In order to minimize the negative impact of enuresis on the psyche, the child should be supported in every possible way. Any manifestations of condemnation or disgust are unacceptable.