Enuresis-Bedwetting in children.

ENURESIS

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Enuresis is defined as normal, nearly complete evacuation of the bladder at a wrong place and time at least twice a month after 5 yr of age.

Enuresis should be differentiated from continuous or intermittent incontinence or dribbling.

The bed is usually soaking wet in enuresis, compared to incontinence in which there is loss of urine without normal
emptying of the bladder.

It is worth noting that the term "bedwetting" is often used interchangeably with "enuresis".

Strictly speaking, enuresis refers to involuntary urination during the day or night.
People often use the term enuresis when they are in fact referring to nocturnal enuresis.

Enuresis is usually functional while continuous or daytime incontinence is often organic.

More than 85% children attain complete diurnal and nocturnal control of the bladder by five years of age. The remaining 15% gain continence at approximately 15% per year, such that by adolescence only 0.5-1 % children have enuresis. Up to the eleventh year, enuresis is twice as common in boys as it is in girls; thereafter, the incidence is similar or slightly higher in girls.

Enuresis is called primary when the child has never been
dry and secondary when bed wetting starts after a minimum period of six months of dryness at night.

It is termed monosymptomatic if it is not accompanied by any lower urinary tract symptoms and nocturnal if it occurs only during sleep. Children with monosymptomatic nocturnal enuresis require no further evaluation.
Nocturnal, when it occurs onyl.during night.
Diurnal, when only during day.

Etiology(Causes)

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*Maturational delay is the most likely cause of nocturnal enuresis, suggested by high spontaneous cure rates with increasing age.
*Anxiety producing episodes during the second to fifth years, the time for development of nocturnal bladder control, are associated with increased risk of enuresis.
*Antidiuretic hormone (ADH) has a circadian rhythm,with increased secretion occurring during the night and peak secretion between 4 and 8 am. A lack of this circadian rhythm or impaired response of the kidneys to ADH may be a possible etiology for nocturnal enuresis. A lack of inadequate arousal is also believed to impair vasopressin secretion, leading to polyuria.

Secondary enuresis may be precipitated by acute stressful condition or traumatic experience. Bladder irritability due to urinary tract infection or severe constipation with the full rectum impinging on the bladder can cause enuresis. Conditions causing polyuria (diabetes mellitus or insipidus), spina bifida (neurological bladder dysfunction), ectopic ureter and giggle and stress incontinence are other causes.

Treatment

The decision about when to start treatment should be guided by the degree of concern and motivation on the part of the child rather than the parents. General advice should
be given to all enuretic children, but active treatment need not begin before the age of 6 yr.

Caffeinated drinks like tea, coffee and sodas should be avoided in the evening.

Adequate fluid intake during the day as 40% inthe morning, 40% in the afternoon and 20% in the evening is recommended.

The first line of treatment is usually non-pharmacological, comprising motivational therapy and use of alarm devices.

Motivational therapy alone is successful in curing enuresis in 25% patients. The child is reassured and provided emotional support. Every attempt is made to remove any feeling of guilt. The benign nature of the disorder is explained to the child and parents using diagrams, if required, to explain the probable basis of the disorder. The child is encouraged to assume active responsibility, including keeping a dry night diary, voiding urine before going to bed and changing wet clothes and bedding.

Dry nights should be credited with praise and encouraging words from the parents. Punishments and angry parental responses should be avoided.

Behavioral modification is encouraged to achieve good bladder and bowel habits. The child is encouraged both to void frequently enough to avoid urgency and daytime incontinence and to have a daily bowel movement. A stool softener such as polyethylene glycol helps children with constipation.

Alarm therapy
Alarm therapy involves the use of a device to elicit a conditioned response of awakening to the sensation of a full bladder. Gradually, the association with bladder distention evokes micturition.
The alarm device consists of a small sensor attached to the child's underwear, or a mat under the bed-sheet and an alarm attached to the child's collar or placed at the bedside.

When the child starts wetting the bed, the sensors are activated causing the alarm to ring. The child should awaken to the alarm, void in the toilet and reattach the alarm; a parent should attend the child each time to ensure the child does not merely wake to switch off the alarm. The alarm is best used after seven years of age and is successful in about two-thirds of children; a third of children may relapse afterwards.

Alarm systems are now available in India; however, the ordinary alarm clock may be used to wake the child up, to void in the toilet at a critical time when the bladder is full and the child is still dry. The combination of motivational and alarm therapy is successful in up to 60-70% of children.
[source](OP Ghai textbook of pediateics)