ENURESIS (BED WETTING) – Types, Treatment

DEFINITION :-

• The term Enuresis, is defined as complete evacuation of bladder at a wrong place and time at least twice a month at or after the age of 5 year.
• Nocturnal enuresis is mostly functional (behavioral).
• But it is also during day time then it may be organic due to brain anomalies (Meningitis, Brain injury).

Introduction :-

• It is more common in males.
• Even 1% of adolescents suffer from bed wetting.
• It is fairly common pediatric problem, occuring in about one-fourth of children, and is a potential cause of embarrassment to the child as well as the parents.
• A proportion of children suffering from this disorder may wet their garments during waking hours as well (Diurnal enuresis)

EPIDEMIOLOGY :-

• Approximately 60% of children with nocturnal enuresis are boys.
• Enuresis has a reported prevalence of:

1. 15% in 5 year old.
2. 7% in 8 year old.
3. 1% in 15 year old.

TYPES :-

Enuresis is classified as:

1. Diurnal (Day time)
2. Nocturnal (Night time)

Other useful classification of enuresis is:

1. Primary= When the child has never been dry.
2. Secondary= When bed wetting starts after a min. period of 6 months of dryness at night.

Etiology :-

# Multifactorial:-
Genetic+ Physiologic+ Psychologic factors.

1. Delayed maturation= mostly cases of nocturnal enuresis. spontaneous improvement with age.
2. Anxiety= anxiety producing episode during 2nd to 5th year, due to any reason like parentral conflict, rejection, sibling rivalry etc.
3. Loss of circadian rhythm of ADH ADH secretion is maximum during 4:00 am to 8:00 am. ADH will help more absorption of water so less urine formation. So if circadian rhythm is lost then probability of passing urine on bed increases in morning time (4:00am to 8:00am)
4. Chronic constipation= due to constipation distended colon/ rectum presses on urinary bladder. So reflex contraction of bladder may occur.
5. Organic cause= E.g Cerebral palsy, Spine trauma, Spina bifida.
6. UTI= due to irritation of bladder.

INVESTIGATION :-

• CBC= To rule out sepsis/septicemia.
• Urine analysis= pus cell, protein, glucose and specific gravity to look for evidence of chronic UTI, renal disease, and diabetes mellitus. Further testing such as urine culture, is based on the urine analysis. Children with complicated enuresis, may lead evaluation with a renal sonogram and a voiding cystourethrogram

TREATMENT :-

• Pharmacologic treatment is usually not given till 6th year of age.main cause is usually maturation delay. NON PHARMACOLOGICAL TREATMENT=
• Avoid caffeinated drinks E.g Tea, coffee, soda particularly in evening.(after 4 pm).
• Adequate fluid intake during the day as 40% in morning, 40% in afternoon, and 20% in evening.
• Motivation= 25% improvement.
• Never scold the child.
• Reward child with chocolate or gifts when dry by night.

ALARM THERAPY :-

• Involves the use of a device to elicit a conditioned response of awakening to the sensation of a full bladder.
• The alarm device consists of a small sensor attached to the child’s underwear, or a mat under the bedsheet and ring is attached to collar of baby.
• When the child starts wetting,the sensors are activated causing the alarm to ring.
• In 2/3rd patients enuresis subsides by combination of motivation.

PHARMACOLOGICAL THERAPY:-

1. Desmopressin= short-term relief from bedwetting. @0.2-0.4 mg orally.
2. IMIPRAMINE= @ 1.0mg/kg OD at bed time. may increase upto 2.5mg/kg side effect- Arrythmia (so avoided).
3. Anticholinergic therapy= Tolterodine: @2mg OD at bed time. Oxybutynin: 5mg at bed-time.
4. NASAL SPRAY :- 1 SPRAY INTRANASAL AT BED TIME

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