Enuresis: Symptoms and Treatment
Enuresis is a pathological disorder in which patients experience involuntary nighttime (mostly) urination. Enuresis, the symptoms of which are mostly observed in children, however, can be diagnosed in adolescents and a certain percentage of the adult population, in addition, this disorder can occur in patients during the day.
It should be noted, however, that although enuresis is manifested in the overwhelming majority of cases at night, this does not exclude the possibility of its manifestation outside sleep, which, however, occurs at times less often. This disease is not a consequence of any one specific cause, which, in fact, excludes the concretization of the unified nature of its occurrence.
In the prevalence of the manifestation of enuresis, as stated in a number of different sources, occurs in children with a frequency within the range of 2.2-38%, which is determined depending on the specific age of the patients. Given the fact that the exact statistics in medicine on this subject are kept from a relatively recent time, the issue concerning specific figures can be considered somewhat controversial.
There is another interesting feature of this disease, which, in particular, is its attitude towards it. As we have already noted, in the overwhelming majority of cases, enuresis is manifested in children (on how this happens, we will stop somewhat below), and its occurrence causes the development of conflict situations in this family in the family. Thus, in about 61% of cases, parents consider night incontinence as a very serious problem. Moreover, one-third of families from this number are guided and inadmissible measure in the «influence» on the disease for the sake of its exclusion, punishing the child. Meanwhile, the punishment of the course of the disease only exacerbates, which leads the situation to a vicious circle, if no appropriate adjustments are made to the approach to it.
A particular problem of the disease, especially with this approach, is that children with enuresis are most prone to the subsequent development of complexes and psychopathic disorders on this background.
In childhood, enuresis in 12% of cases is diagnosed in boys, 7% in girls. 4.5% of children remain with this pathology before school age.
Enuresis in children: symptoms
As is clear from the definition we proposed for consideration above, enuresis is a disorder in which urinary incontinence occurs. In children, in most cases, this is due to the lack of ability to master this skill, which is due to their small age. With enuresis, urination is unconscious and involuntary, it can manifest as at night (which is more often), and in the daytime. Accordingly, the features of the manifestation determine the specific manifestation of the disease as variants of the symptom: daily urinary incontinence or bedwetting.
There is for this disease and a certain classification, enuresis according to it can be primary or secondary.
Primary enuresis is the most common, it is diagnosed if the child urinates in bed, being already old enough. In particular, under such «adulthood» is meant from 4-5 years, when, ideally, the control skill to this age should already be mastered sufficiently. The diagnosis of enuresis in this form is established if the patient has no neurological, urological and other anomalies, against which urination (including nighttime) is considered as a symptom of the overall clinical picture. In some cases, the indication of «adulthood» within the framework of a later age period (6-7 years) is allowed.
As for the next option, and this is secondary enuresis, then this diagnosis is established on the basis of incontinence in a situation where the child previously successfully coped with the task of controlling the retention of urine. In this variant, a picture of the course of the disorder is also considered, in which it develops about 6 months after mastering this skill («dry months»).
Again, on the basis of the prevailing period, the manifestations of the main symptom of enuresis are distinguished by the above variants, that is, enuresis of the day or night enuresis. With daytime incontinence is noted only in the daytime, at night, respectively, only at night. Allowed and mixed enuresis, in which the child can not cope with the retention of urine, either within the daytime, or within the time of night.
Highlight the main forms in which enuresis can occur in children:
- a simple form of enuresis;
- Neuropathic form
- the form is neurotic;
- epileptic form
- dysplastic form
- endocrinopathic form of enuresis.
Neurotic form of enuresis, if as a basis to consider the cause provoking this disorder, is its development against the background of the previous transfer of the child to a traumatic situation. This may be the first visit to a kindergarten or school, a doctor’s visit, divorce of parents and other changes in the family, including the birth of a second child.
It should especially be noted separately the last situation associated with the birth of a second (or regular) baby in the family. Often the older child in such a situation is subjected to «infantilization» (the state of «childishness», «underdevelopment», relating to behavior), in part of the disease we are considering, this manifests itself in the loss of control over urination. The basis for this is a conscious or unconscious form of protest against attention deficit and affection from parents (far-fetched or real), which, it seems, completely switch to a «new» child in the family. It is not excluded, of course, that this form of enuresis also develops as a result of the previously considered factors (visiting a doctor, a kindergarten, a school, etc.).
Again, divorce, as well as quarrels arising between parents in the family, can lead to the development of a similar type of situation. Undoubtedly, there can be a whole range of reasons that could cause the development of enuresis in a child when a corresponding psychotrauma is transferred in one or another of its scales. In practice, it is quite difficult to determine a clear line of relationship with the alleged psychotrauma and the occurrence of enuresis in a child. Simultaneously, the diagnosis of the neurotic form of nocturnal enuresis is allowed not by taking into account such probable origin, but by taking into account the clinical picture. In other words, it is possible to compare the situation (conflict in the family, poor grade in school) within the framework of one day’s consideration with the appearance of enuresis, and vice versa, comparison of the normal situation (at home, at school) with «calm» in terms of incontinence.
The neuropathic form of enuresis develops against a background of general nervousness that is relevant to the child. Such nervousness is congenital, its further formation occurs with concomitant changes concerning the nervous system. A significant role is played here also by frequent colds, which are carried at an early age. Psychotrauma, which could serve as a cause of enuresis, is absent in such cases, and if present, there is no clear relationship between them and the symptoms of the disorder. The development of this form of enuresis is relevant in connection with the following factors:
- transfer of infectious or somatic diseases (diseases of blood vessels, heart, respiratory system, etc.)
- delay in psychomotor development due to residual organic forms of CNS disorders (in particular, for example, one can consider the situation with a delay in the physical and mental development of the child during the first year of his life due to birth trauma, adverse pregnancy course and other factors ).
The neurosis-like form of enuresis can also be diagnosed by an appropriate disorder clinic. Thus, there is a somewhat monotonous flow, there is no direct dependence on the actual psychological situation, while dependence on somatic disorders becomes quite obvious. For example, if a child is just beginning to develop a common SARS (or has already transferred the disease, or has relatively recently transferred it), then the following is relevant. Regardless of external conditions (spring / autumn, the presence of heating in the house, determining heat, etc.), the manifestation of enuresis is noted almost every night. And, on the contrary, in a healthy state and in warm conditions this disorder does not manifest itself. Similarly, enuresis resulting from asthenia (neuropsychiatric weakness against a background of general overstrain in combination with rapid fatigue, sleep disturbances and other accompanying symptoms) that occurs in the child during examinations at school can be similarly applied to this picture.
It should be noted that much more often, not only in the context of treating neurotic-like forms, children are diagnosed with a simple form of enuresis. This form, in its essence, acts as a consequence of the delay in maturing children’s sleep mechanisms or as violations in this mechanism. This form of enuresis can be defined as an innate, primary or simple form of the disorder, which in any of these options does not change its essence. A simple form of enuresis is characterized by a relatively rare occurrence, but, nevertheless, regularly. Urination involuntary, can occur about 2-5 times during the week. Basically, they occur during the first half of the night (the phase of deep sleep). It should be noted that the sleep itself in children becomes sufficiently deep (as determined in frequent cases at a doctor’s appointment), it becomes rather difficult to wake them up, even in the morning. Often, the cause of this form of disorder is a hereditary factor. Psychic experiences against the background of this disorder, as a rule, the child does not arise.
Organopathic enuresis, as the next form of the disorder in our examination, is the presence of a clearly traceable relationship with significant forms of renal function changes. This may be preceded by the transfer of previously inflammatory diseases (for example, cystitis), the presence of defects in the urinary system in one form or another, as well as conditions that develop against the background of prolonged catheterization, urological surgery, etc. On the other hand, this form may be more likely Is applicable to a different type of disorder associated with urination, than under the actual enuresis. This type of disorder can also be defined as dysplastic enuresis . Actual in this case, the symptom is manifested in incontinence during daytime sleep, as well as in incontinence of feces (which is defined as encopresis).
The following form is endocrinopathic enuresis . This form of the disorder is characterized by involuntary nocturnal urination in combination with concomitant endocrinopathic disorders (which corresponds, in fact, to the definition of this form) against the background of hormonal regulation that is inherent in the body: diabetes, temperature rises, obesity, etc.
And finally, epileptic form of enuresis . It, as can be assumed from the name, develops against a background of epilepsy that is relevant to the child. The features of incontinence consist in the similarity of its manifestation to the «explosion» at which urine is released. It is accompanied by vegetative disorders, respiratory arrest and characteristic jerking of the limbs.
In general terms and on the basis of the above features of each of the forms of the disorder in question, it is possible, therefore, to determine the causes of enuresis in children:
- the delay in the maturation of the nervous system (and the corresponding disease)
- organic pathologies (diseases) of the kidneys, bladder, urethra
- heredity (determined by the presence of such a disorder in the immediate family)
- psychological trauma (considered as the main cause of enuresis in children)
- the flow of urine into the vagina (which, accordingly, is relevant for girls, this option is more correctly considered not as an enuresis, but as a violation of urination).
How to determine the enuresis in a child?
In particular, when considering this issue, I would like to complement it somewhat, adding a contiguous situation in which the child is not sick, but simply did not learn yet to hold urine.
By itself, mastering the skills associated with urination, is quite complex, because there must be coordinated work of a number of systems in the child’s body. Thus, the bladder will need to acquire the habit of absorbing a larger volume of urine while learning the ability to retain it if necessary.
Of course, the brain will be involved in these processes, in particular, it should learn to identify those signals that indicate the filling of the bladder, determine the option for expressing the request for the subsequent removal of the child to the toilet, as well as to help inhibit the emptying of the bladder In those conditions in which it is undesirable. Based on these moments, the reader can understand that urination is directly related to the nervous system and a certain degree of its maturity in particular. The nervous system matures gradually, as the child grows up and his body grows.
It should be noted that the bladder, as well as those parts of the brain that are directly responsible for his work, are formed to the full only to reach the age of four years old. Considering this, treating enuresis as a disease should not be earlier than at this age with the urgency of involuntary urination in the daytime or nighttime.
The following two features indicate the maturity of the bladder:
- A child can arbitrarily hold urine, and may «suffer» within a certain time interval
- the child is capable of recognizing the urge to urinate, and can report their appearance to parents in the circumstances of the need for this action; Again, it is also capable of suppressing the act of urination under conditions that exclude the possibility of urination or under conditions in which it is undesirable.
Enuresis in adults: symptoms
Enuresis, as the reader has already been able to understand from the treatment of this disease in children, is characterized by the fact that patients lose the ability to retain urine. Enuresis can erupt at any age, although, as also noted, it is more often diagnosed in children, to a somewhat lesser extent, it affects older people.
When considering the case with the child’s course of the disease, we did not dwell on the features of the bladder and its work, so we will start examining the disorder from this moment.
Urine, when it is secreted by the kidneys, is directed to the bladder through the ureters. The capacious capacity of the adult bladder is approximately 1-1.5 liters (this figure may be greater). The bladder itself looks like a hollow sac-shaped organ. The walls of the bladder have a sufficient degree of muscular elasticity, due to which they are easily enough to be stretched. Given this feature, with gradual accumulation of urine, the pressure in it practically does not change.
The overlap of the exit from the bladder to the urethra is due to the ring muscles — these are internal and external sphincters of the bladder. When it is filled with urine, the muscles are shortened, thereby closing the exit from the bladder, respectively, the work of these muscles can be compared with the valves, due to which the pipe is closed. The location of one of these sphincters, namely the external sphincter, is concentrated at the level of the pelvic floor, the muscles of this sphincter are formed from several muscle layers, through which the perineum is formed. At the heart of urinary incontinence is a disruption in the work of sphincters, or diseases that affect the bladder and urethra.
One of the most common causes of enuresis in women is the relaxation of the pelvic floor muscles. It provokes the stretching / relaxation of these muscles in the mostly difficult and prolonged course of childbirth.
Returning to enuresis in children, it should be noted that they have a course of this disease differs from its course in adults, because in any case, to equalize the specificity of the clinical picture in both cases does not make sense.
Enuresis in men and enuresis in women can be manifested in several ways, being stressful, urgent or mixed (combined enuresis).
Stress urinary incontinence is relevant in considering situations in which urination occurs as a result of physical exertion on the peritoneum, against which, in its Turn, the bladder undergoes a certain degree of pressure. Such situations include weight lifting, running and other loads, moreover, even laughter and cough are considered as contributing factors to such an impact.
Urgent enuresis (urge incontinence) identifies the disorder in a form in which an intense urge to urinate arises. Such a urge can be sudden and extremely strong, as a result of which not always the patients have time to reach the toilet in time. This type of incontinence in frequent cases is accompanied by the occurrence of frequent nocturnal awakenings, which also arise because of the need for emptying the bladder. In addition, such urges are frequent in the daytime.
Alternatively, mixed enuresis (mixed incontinence), , which combines the symptoms of enuresis in both of these forms. Similar to the manifestation of enuresis in children, enuresis in adults can also manifest itself day or night.
It is not superfluous to consider the causes of enuresis in men and women, but before that we note that the disease in both cases can manifest itself in a temporary form (temporary or transient enuresis) and, accordingly, in a permanent form (permanent enuresis), based on Which will be discussed below, the causes of this disease.
- Chronic constipation . The manifestation of enuresis on this soil is explained by the fact that with the accumulation of fecal matter in the rectum because of their density leads to pressure on the bladder, this, in turn, causes the violation of its muscles, providing an outlet from the bladder.
- Inflammatory processes in the urethra or in the bladder (urethritis or cystitis, respectively) . The inflammatory process provokes an increase in the irritability of the muscles in the base of the bladder, and also causes weakness of the muscles, due to which the exit from it is closed. Enuresis with urethritis or cystitis, in addition, is also accompanied by fever and painful urination, which, as can be understood, determines additional symptoms to the general picture of its course.
- Stones in the bladder . Due to this factor, enuresis develops due to concomitant irritation, which is actual for the muscle walls of the bladder.
- Diseases of the respiratory system, manifested in combination with a pronounced cough . When coughing, the pressure in the bladder area increases several times, due to which, in turn, the stressful form of enuresis develops.
- Endocrine diseases (diabetes, sugar or non-sugar) . Such diseases occur with the intensive allocation of large volumes of fluid. Diabetes mellitus, for example, provokes a disruption of the nerve functions, through which the coordination of those muscles is ensured, they are also involved in the functioning of the bladder.
- Coffee, alcohol . Due to the influence of such factors, as it is not difficult to guess, the production and, consequently, the excretion of urine must be increased.
- Certain types of medications (antihistamines, antidepressants, oral contraceptives, diuretics, etc.). The volume of excreted urine at their expense increases, which affects the overall work of the muscles at the base of the bladder.
- The formation of fistulas, due to which women connect the urethra or bladder with the vagina. This type of fistula causes an absolute loss of the ability to retain urine. As a factor accompanying their appearance, the difficult course of labor is considered.
- Relaxation of the pelvic floor muscles. This reason is the most common variant that causes enuresis in women. Among the main reasons, again, here are deliveries, as well as the onset of menopause and previous gynecological manipulations (surgical intervention). The urgency of this cause is also not excluded for men, its nature here is somewhat different — there is a direct link to the surgical intervention produced with prostate adenoma.
- Diseases of the spinal cord and brain. This includes a variety of pathologies, ranging from stroke and multiple sclerosis and ending with tumors, Alzheimer’s and other types of neurological disorders.
- Diseases of the genitals and the actual bladder. This includes prostate cancer or prostate adenoma in men, chronic form of cystitis, uterine fibroids, uterine cancer, trauma of various degrees (pelvic region and genital area).
Diagnosis of enuresis is based on taking into account the episodes of this disease, manifested in children after 4 years, lasting not less than three months. With regard to the diagnosis of this disease in adults, here as a confirmation of the fact of its presence, any manifestation of incontinence that occurs within the framework of day or night time is considered. To clarify the diagnosis, the doctor performs a palpation of the patient’s stomach, interrogates him, performs an examination of the genital area to identify possible defects (congenital or acquired form). Also, ultrasound is done — the abdominal cavity is studied, as well as the pelvic area before and after emptying.
In the future, the patient is shown the following research methods: study of rhythm and volume of urination during day and night; cystography; cystoscopy; Intravenous urography; Uroflowmetry; Additional consultation with other specialists.
Treatment of enuresis determines some problematic nature of this process, therefore the approach to it must be complex, focused on the development and subsequent recovery of an adequate lost reflex, which consists in awakening in patients urge to urinate. Also, a reference point in this matter is taken to stimulate the metabolic processes in the nervous tissue while accelerating the regulatory processes associated with urination.
Particular attention is paid to correction methods for topical neurotic disorders accompanying the disease. Different methods can be applied, including methods of physical impact on the relevant area. In some cases, certain techniques are recommended. So, it can be the development of the habit of urinating at a certain set time (for example, every two hours). Certain adjustments can affect food and beverages (a diet is being developed with the exception of the appropriate type of food, which provides a diuretic effect, in this case, extra, as well as caffeine and drinks with a similar effect). An important point is learning to relax the muscles and patience regarding urination.
With regard to children’s enuresis, by the end of 2000, and at all, facts were put forward on the basis of which treatment of this disorder in children is not mandatory. As an alternative, the method of «paradoxical intention» is proposed, in which enuresis is not blamed by parents, but, on the contrary, is encouraged. The attitude of parents in this matter, by the way, plays a decisive role in the overwhelming majority of cases. Inadmissible is humor in relation to such a problem over the child, direct or indirect ridicule, pressure and other negative means of influence — all this, as we have already noted, contributes only to aggravation of the situation. Methods of treatment of incontinence (enuresis) in children (as, indeed, in adults), in each case should be determined in the appropriate consultation with a specialist.
If you have an incontinence problem (enuresis), you need to visit a urologist, in addition, you may need to consult a neurologist, a pediatrician / therapist, an endocrinologist and a psychologist.