DEFINITION
Involuntary discharge of urine at night by children old enough to be expected to have bladder control
- Persists beyond the age of 5 years
- Total bladder control never achieved or relapsed
- Incidence of more than twice weekly
- Continent during the day
- Types of nocturnal enuresis (NE)
- PNE (primary) when bladder control has never been attained
- SNE (secondary) previously dried for at least six months.
Mechanism Involved for bladder control
The mechanism relevant to the acquisition of sphincter control is mainly of four types:-
- 1. Maturation.
- 2. Development.
- 3. Conditioning.
- 4. Learning.
1) Maturation
The mechanism of sphincter control is complex. We must depend on the maturation of the nervous system. There is commonly a familiar pattern, just as some children are earlier or later than the others in learning to sit, walk, talk or use their eyes or ears. Some children are earlier or later than the others in controlling the bladder or bowel.
2) Development of sphincter
The frequency of urination in babies varies from child to child. There is often a temporary phase of increased frequency at the age of about 21 months. At 2 ‘/years there is often a retention span of about 5 hours. The retention span rapidly increases with age.
3) Conditioning
Babies commonly empty the bowel and bladder immediately after a meal, esp. in the first 8 months. They can often be ‘conditioned’ to use the potty any time after 6-8 months of age. This condition frequently breaks down due to teething or some disturbance of routine particularly between 12 to 18 months. There is no voluntary control at this time; voluntary control does not begin till about 15 to 18 months of age.
4) Learning
The first indication of voluntary control is awareness at about 15 to 18 months of age. The child is pointing it out to the mother shortly after the urination. The child is able to say ‘No’ with reasonable correctness when asked if he wants to urinate. He now begins to tell his mother just before he passes urine, but he does not give time to take him to the toilet. The urgency decreases as he grows older and by 18-24 months he tells the mother in sufficient time for her to place him on the potty. By 2 to 2 4 years he is able to pull his pants down and go to the lavatory. Children at 2 to 2.5 years begin to take responsibility for not wetting their pants but they are still wet by night. By 2 years the retention span is longer and between 2 to 3 years if lifted out at 10 or 11 pm, he is dry in the morning. By 2 % years, 1/5th of the children are usually dry by day and half of them by night. Occasional accidents may occur, till he is 4 or older. Girls tend to acquire sphincter control earlier than boys.
Types of Nocturnal Enuresis
- a) Persistence, Primary or continuous type: – In which child has never attained bladder control.
- b) Regressive, Secondary or Discontinuous type:- In which previously continent child begins to wet bed again. The age of onset is 5-8 years.
- It is precipitated by stressful environment events such as the birth of a sibling or a death in the family, marital conflict. Move to a new place etc in both types. Organic pathology is present only in 5% of cases. These include worm infestations, spina bifida, neurogenic bladder, urinary tract infection, diabetes Mellitus, seizure disorders etc.
- Most of the children start having bladder control after the age of 4 yrs.
- About 15-2 0% of children wet the bed after the age of 5 years and about 5% of 10 year old children continue bedwetting.
- Occurs more commonly in boys aged 4 – 11years than girls.
ETIOLOGY
- A) Psychodynamic causes.-Most of the authors now believe that symptoms of Nocturnal Enuresis are psychologically determined. Sources of the etiological assumptions are mentioned below.
- (i) Enuresis episode occurs as a part of a dream which in its manifest reveals the unconscious conflicts.
- (ii) Freud considered enuresis to be a form of pollution or masturbatory equivalent.
- (iii) Gerald Pointed out that bed wetting occurred in a variety of emotional conflicts. She spoke of:
- a) Regressive cases are precipitated by the arrival of a new sibling.
- b) Revenge responsive cases in retaliation for a nagging, punitive attitude of the mother.
- c) Neurotic cases based on unconscious fear of harm from persons of the opposite sex.
- (iv)Sperling emphasized the importance of fantasies of genital damage and contented that the wetting may represent punishment meted out to the parents for inflicting the damage and emphasizes the importance of power struggles between the mother and child.
- (v) It is an expression of the child’s insecurity about his position in life and a defensive compensatory continuation or return to an infantile mode of behaviour.
- (vi) The coincidence of onset of the Secondary Enuresis is with emotional Disturbances of the child and the cessation with the solution of child’s conflicts. Toilet trained children may sometimes begin to wet due to
- -Separation of mother or father.
- -Arrival of a new baby in the family.
- – Stress of the examination.
- B) Toilet training and parental Attitudes.
Lack of Training: It results from maternal over protection as well as lack of knowledge regarding proper training. In mothers having the idea of training, the child’s Nocturnal Enuresis is accepted by thinking that he is too small or delicate to be trained. Behind this there is usually the mother’s desire to keep her offspring wholly dependent on her for as long as possible. So in such circumstances the child is encouraged to retain infantile mode of micturition.
- C) Heredity: It is believed that Nocturnal Enuresis is a hereditary trait determined by a single recessive gene substitution.
- Pfister spoke of Nocturnal Enuresis As a hereditary stigma on the basis of higher frequency of psychoses and psychoneurosis in the ascendancy of the enuresis. In more than half of cases one of the other members of the family found to be enuresis.
- D) Folk medicine: It refers to a ‘weak bladder’ or a ‘weak kidney’. The child having weak bladder or kidney cannot help it and therefore no help is expected, one has simply wait until the organ will become stronger
Hormonal problems- A hormone called antidiuretic hormone, or ADH, causes the body to pee less at night. But some people’s bodies don’t make enough ADH, which means their bodies may make too much urine while they’re sleeping.
Impact of Enuresis in Children
- Psycho-social impact
- Low self-esteem
- Shame, embarrassment
- Guilt
- In school, they may have lower social skills and performance than other children.
- A child suffering from bedwetting may exhibit more aggressive behavior, trouble paying attention in class, and poor self-image.
- Bedwetting children are in constant fear of being found out and teased.
- Children can go into depression and social isolation.
- Parents become intolerant of bedwetting.
- Interferes with age appropriate peer activities
Management of Nocturnal Enuresis
Treatment of children with Nocturnal Enuresis depends on understanding of possible causative factors suggested by an adequate psychological inventory and physical examination.
Some General Measures Recommended for Enuresis are:
- a) Restriction of fluid intake after 8 pm.
- b) The child should avoid it before retiring.
- c) Waking the child repeatedly to take him to the toilet is useful only in a few children; it may further aggravate anger in child or parent.
- d) Bladder expansion retention control training (RCT), small functional capacity has been indicated as important considering gradual increases in amounts of liquid and asking them to retain from voiding urine for gradually extended periods of times.
- e) Urine alarm devices which send an alarm when a child voids urine and wakes him up to the toilet.
Advice to Parents
These are based on the works of Alfred Adler, one of the fathers of Psychiatry.
1. be consistent with what you decide to say and do, do not give up on your child. Show your faith and allow time. Understand your child’s need to belong.
2. Foster mutual respect, it means establishing a sense of order, setting limits appropriate for a child’s age, teaching and modelling expected behaviour, being consistent and dealing with them with kindness, firmness and understanding.
3. Love and accept unconditionally, in order for your child to become a responsible person with healthy self-esteem, he must know that your love for him is not based on what he does but your love is unconditional. Accept your child’s feelings and show empathy and let them develop emotional control. Give them the courage to share the good as well as bad with you.
4. Take care of yourself. Many parents are guilty of having unreasonably high expectations and feel discouraged by their achievements.
Prevention
Bladder training
- The bladder training is best started at 12-16 months of age, after bowel control had been to some extent established. In the process of bowel training, the child learns to void in the receptacle, since micturition ordinarily accompanies defecation.
- In training for bladder control, the child is placed on the toilet at a definite time during the day, preferably in relation to some event in the daily routine, so that an association may be established for example, at waking in the morning, after every sleep (nap time), before meals, after coming in from outdoors and at bedtime. The toilet seat should be comfortable with adequate back support
- No longer than two or three minutes on the toilet should be permitted with a little training, infants with full bladder will urinate almost immediately after being seated.
- Dry night chart is to be maintained to check whether child is improving or not.
Conditioning devices– The alarm causes inhibition of further micturition and the child awakens. If properly used, it is an effective method of therapy.
MATERIA MEDICA
- Belladonna: This remedy is indicated for children who have frequent and profuse urination after midnight approaching the morning hours. A good remedy choice if the bedwetting is due to a bladder infection.
- Kreosotum: Indicated when the child urinates while dreaming of urination.
- Argentum nitricum: When the child urinates due to restlessness, nervousness or anticipation of an event.
- Equisetum: Indicated when the individual wets the bed during nightmares and dreams, experiences incontinence such as passing water without any cause, with involuntary stools, without feeling any relief. It can be used on the child that has the constant urge to urinate.
- Sulfur: indicated for the child that loves sweets and who wets the bed in the early half of the night (before midnight). It can also be used on the child that sleeps with his/her feet sticking out of the covers and experiences vivid dreams.
- Borax: When the child urinates frequently at night due to fear.
- Rhus Tox: When there is a constant dribbling of urine due to a weak bladder. The child may wake up with only a small amount of urine on his/her clothing.
- Causticum: When the bedwetting is significantly more during the winter compared to summer.
- Sepia: This remedy can be used to treat bedwetting and kidney problems. It is often recommended in female children, if they wet the bed during the first half of the night and love to be active and dance.
- Benzoic Acid– For Bedwetting when Urine Smells Foul. The urine also tends to leave brown stains on the bed sheet.
- Cina -is a medicine used to treat bedwetting related to worms. Grinding of teeth during sleep, shrieking, crying or being scared during sleep, an irritable or obstinate behavior.
- Muriaticum acid –Urine passes slowly; bladder weak, must wait a long time; has to press so that anus protrudes. Cannot bear least touch, not even a sheet on genitals.
- Nitricum acid- scanty, dark-brown, strong-smelling, “like horse’s urine”; cold when it passes; turbid, looks like remains of a cider barrel. Irritable, headstrong; hateful and vindictive; inveterate, ill-willed, unmoved by apologies.
- Phosphoricum acid- looks like milk mixed with jelly-like, bloody pieces; decomposes rapidly; profuse urination at night of clear, watery urine. Muttering, unintelligible; lies in a stupor, or a stupid sleep, unconscious of all that is going on around him.
Pulsatilla-This is for a mild, frequently tearful, often very clingy child, who wants to cuddle. The Pulsatilla child will often feel the urge to pee if she lies on her back.
CONCLUSION
Nocturnal Enuresis from the above study has concluded that Nocturnal Enuresis a major health issue in today’s world and under the Homoeopathic mode of treatment children can be relieved from both Psychological and Pathological symptom of disease.
