BEDWETTING IN CHILD

ENURESIS (BEDWETTING) IN CHILD

The term, enuresis, denotes normal urinary bladder emptying at a wrong place and time at least twice a month after the age of 5 years. Nocturnal enuresis refers to bedwetting. It is a fairly common pediatric problem, occurring in about one fourth of children, and is a potential cause of embarrassment to the child as well as the parents. A proportion of the children suffering from this disorder may wet their garments during waking hours as well. Boys suffer more often than girls. Remarkable familial pattern is observed.

Clinical features

Two clinical types are recognized: Primary (persistent) and secondary.

In the primary (persistent) enuresis, the child has never been dry at night. It is usually the result of erratic bladder training either by parents who are overanxious for prompt control, or those who are not reasonably close to the child’s needs, or chronic psychological stress not related to bladder training.

Secondary (regressive) enuresis is characterized by initial control of bladder that later gets disrupted by stressful environmental events like marital conflict, death, arrival of sibling, or shifting to a new house. It is usually intermittent and transitory.

Four types are recognized based on daytime symptoms:

1. Type 1: Monosymptomatic nocturnal enuresis
2. Type 2: Diurnal enuresis without daytime frequency
3. Type 3: Nocturnal enuresis with daytime frequency
4. Type 4: Nocturnal diuresis with daytime frequency and voiding dysfunction

Etiology

The causes are:

1. Psychologic enuresis may be manifestation of family conflict and maladjustment, e.g. too strict parents, rejection, sibling rivalry, etc. An erratic handling of the problem by the parents causes further anxiety to the child. His condition, therefore, gets more aggravated.
2. Too late, too early or improper training by the parents regarding the bladder control is also an important factor in the causation of bedwetting.
3. Physical factors like threadworm infestation, genitourinary infection, anatomic defects, etc may be responsible for enuresis in some cases.

In both types(primary and secondary), an organic pathology is present in less than 5% cases. Dysuria, frequency, straining, dribbling, gait disturbances and poor bowel control suggest an underlying organic cause.

Diagnosis

This should include a detailed interview with the parents as well as the child to find the etiologic or at least, associated emotional factors, together with a complete physical examination. Intestinal parasitosis, especially threadworm, genitourinary infection and anatomic defect should be excluded.

Urine analysis and urine culture should be performed at the initial visit to exclude UTI. An x-ray of lumbosacral spine, ultrasonography, voiding cystourethrogram and urodynamic studies are often required.

Treatment

A prompt treatment is essential or the child may continue to have enuresis plus added emotional problems in adolescence. Treatment is, as a rule, not required before 6 years of age.

If the underlying disease is detected it should be treated

In others, treatment consists of:

1. Psychotherapy and training (behavior modification) in the form of:

a.       Reassurance to the parents and the child. Parents should be told to encourage the child in having dry nights. In facts, they should offer special pat and even reward on occasions when the child does not wet the bed.

b.      Restriction of too much of water and drinks at bed time and insisting on his voiding before retiring.

c.       Walking him up once or twice to void during night.

d.      Rewarding the child for the dry nights(which should be charted on a calendar) assist in enlisting the cooperation of the child.

e.       Discouragement of punishment or humiliation of the child by parents.

f.       Ridicule by sibling and friends should not be allowed. Parents need to spent at least half an hour of quality time with the child.

2. Bladder-strengthening exercises. This include emptying the bladder before sleeping, drinking large quantity of water during daytime and holding urine as long as possible and practice repeatedly starting and stopping the stream in the flush.
3. Using an electric alarm(buzzer) device which is designed in such  a way that the child wakes up as soon as he is about to wet the bed. The device is based on the condition reflex response. It consists of a sensor fixed to child’s underwear and an alarm placed at bedside.
4. Drugs

Imipramine hydrochloride, 0.9 – 1.5 mg/kg/day (O) at bedtime for 3-6 months, gives good results. It acts by altering the arousal-sleep mechanism. The success rate considerably improves if it is supplemented with a small dose of diazepam.

Anticholinergic agent, oxybutinin, 10-20 mg/day (O), for 3-6 months, is useful for daytime enuresis with urgency and urge incontinence. It acts by reducing the uninhibited bladder contractions.

Desmopressin (DDVPj, which is a synthetic antidiuretic agent, is a relatively expensive modality for enuresis. The basis for use of this drug is that immediate triggering factor for enuresis is the overdistended bladder resulting from reduced secretion of the ADH rather than the abnormal bladder capacity or function. It is given in full dose (10-40 meg/days) as spray until child is dry for 28 successive nights. Thereafter, dose is tapered over 3 weeks period.

At times, a combination of modalities (say electric alarm device plus drug therapy) works best.

The pediatrician must also develop a positive relationship with the child to allay feeling of guilt, resentment or shame. He should motivate the child for “independent control”.