Enuresis in children is primarily a disease that affects both the life of the child himself and the way of the whole family. At first, inexperienced glance, everything is simple - a wet bed, too deep sleep, but this is only the visible part of the whole problem, which goes back to the very depths of maturation and birth, germinating even in chromosomes.
Enuresis in children is a very delicate problem. And although enuresis is a disease that can be cured in some cases without medical help, parents still should not lightly dismiss them, hoping for "it will pass by itself."
The sooner attention is paid to enuresis, the more unpleasant consequences can be avoided, namely:
- the inevitable development of mental disorders in the child;
- inflammatory diseases of the kidneys and bladder;
- problems with potency and male health in the future in boys.
What is enuresis and why does it occur in children?
The concept of enuresis. Statistics
Nocturnal enuresis in childrenIs a pathological condition in which a child from 5 years of age and older periodically cannot control his urination at night during sleep.
It should be noted that a single, for example, less than 1 time per month, involuntary nocturnal urination for a preschooler is not a pathology.
The terms nocturnal enuresis and enuresis are considered synonymous today. If a child involuntarily urinates during the day, then this condition is called daytime urinary incontinence and is already an additional diagnosis.
The lower age limit for diagnosis is 5 years.
If a child under 5 years of age with enuresis has daytime urinary incontinence and / or other urinary disorders, then you cannot wait up to 5 years, but you should consult a doctor immediately.
Statistics:
- 10-15% of cases of enuresis are cured on their own every year;
- boys suffer from enuresis 2 times more often;
- with age, the incidence of enuresis decreases: for example, at the age of 5 years, the frequency is 20 and 17% (boys and girls, respectively), and at 13 years - already 4% and 2.5%. By the time the draft age is reached, enuresis persists according to various sources from 0.5% to 2% of young men;
- running ahead - enuresis in children from 5 years old is primary in 90% of cases, and after 12 years in 50% it is secondary, that is, after physical / mental trauma.
Causes of bedwetting in children
Before listing the reasons, it is useful to mention what is necessary for the normal process of urination:
- A mature and healthy brain, thanks to which a person consciously controls this process and which is the site of vasopressin formation.
- The spinal cord, which provides the reflex act of urination.
- The kidneys are sensitive to the hormone vasopressin, the ureters and the bladder itself have elastic muscular walls.
- Muscles of the diaphragm, perineum.
- Endocrine glands (thyroid and parathyroid glands, adrenal glands), which are involved in the work of the nervous system.
If any of these organs malfunction, the process of urination itself suffers.
Enuresis in children has many reasons, which affects the scope of the examination and the nature of treatment.
The main groups of reasons are as follows.
Delayed maturation of the nervous system as a whole
Of particular importance in childhood is the course of pregnancy, childbirth and the first three years of life. During this period of life, the central nervous system is born, formed and actively developed.
She is especially sensitive at this time to a lack of oxygen, to all types of injuries, to an unbalanced diet, to infectious agents, and toxic effects. The result of the negative impact is the low quality of regulation of the work of internal organs, including the bladder and kidneys. In the future, the nervous system is able to "mature", which explains the cases of spontaneous recovery.
Normally, from 6 months, the child has a feeling of fullness of the bladder, from 1 year the formation of a "mature type of urination" begins. By the age of 3, voluntary control of the act of urination is formed. By the age of 5, a child should understand the social significance of managing their life processes.
Violation of the regulation of urine production by vasopressin
In patients with enuresis, the circadian rhythm of vasopressin release is disturbed, and the kidney's susceptibility to its action is disturbed.
Normally, the highest vasopressin concentration is reached at night. It promotes the return of fluid from the kidneys to the blood, thereby reducing the amount of urine.
Genetic predisposition
The region of the chromosome responsible for the occurrence of enuresis is located on chromosome 12.
The risk of bedwetting is 45% to 75% if one or both parents, respectively, also suffered from bedwetting during childhood.
Sleep disturbance
Normally, when the bladder fills, deep sleep is replaced by superficial. In case of violation of the sensitivity of the brain to impulses from the bladder, involuntary urination occurs.
Diseases of the urinary system (infectious-inflammatory and malformations)
With cystitis, urethritis, pyelonephritis, enuresis is associated with the fact that inflammation affects receptors and the nervous regulation of the urination process is disrupted. In this case, involuntary urination also occurs during the daytime and is clinically combined with fever, frequent and painful urination.
Photo: https://pixabay.com/photos/baby-girl-sleep-child-toddler-1151348/
Developmental defects
Often found in enuresis is renal pyelectasis, rarely - a small anatomical size of the bladder.
The abnormal position of the kidneys - nephroptosis - also matters.
Diseases of the central nervous system
Malformations such as "spina bifida" of the lumbosacral spine are important. You also need to remember about epilepsy.
Stress factors
The incidence of bedwetting is increased in families with a low social level, after psychological trauma.
Thus, enuresis is a problem of childhood mainly due to the peculiarities of the development of the nervous system, increased sensitivity to external social and physical factors, and early implementation of genetic information. In adults, this disease is not so common, but those who are “lucky” to carry it from childhood or experience it for the first time as a result of any illness or injury have to overcome many difficulties.
Which specialist deals with the treatment of enuresis
Based on the above reasons, it follows that enuresis is a disease in the process of treatment of which many specialists have to take part. Among them are pediatricians, neurologists, nephrologists, urologists, endocrinologists, neurosurgeons, psychologists, psychiatrists, physiotherapists, osteopaths, etc.
What should parents do and how not to get lost in such a variety of necessary doctors?
The first person to contact is your local pediatrician. He will be able to assess the urgency of the situation, conduct an external examination, collect the necessary information, give directions for analyzes and instrumental examination, and then refer to the necessary specialists. His competence includes prescribing treatment for uncomplicated primary enuresis.
Classification of bedwetting in children
By origin
Enuresis is subdivided into:
- primary;
- secondary.
Primary enuresis is considered when “dry” night periods lasting 6 months or more have not been observed since birth.
Criteria for the diagnosis of primary enuresis:
- Physical and mental age not less than 5 years.
- Episodes of urinary incontinence during sleep at least 2 times a month in children under 7 years of age and at least 1 time in older children.
- Absence of other somatic, neurological and mental disorders.
Secondary enuresis is called the disease in cases when it appeared after remission for more than 6 months or after a provoking factor (illness, injury).
By the presence of concomitant diseases
Primary enuresis is divided into:
- monosymptomatic;
- non-monosymptomatic.
Monosymptomatican option when enuresis is the only sign of trouble in the body. It, in turn, highlights the options:
- with / without nocturnal polyuria;
- presence / absence of response to vasopressin therapy;
- presence / absence of violations of the awakening process;
- presence / absence of dysfunction of the bladder.
Non-monosymptomatic - in addition to enuresis, there are also:
- symptoms of a disease of the nervous system;
- incontinence during the day;
- inflammatory diseases of the genitourinary system or its abnormalities;
- pathology of the digestive system, including constipation;
- symptoms of other diseases.
By severity
| Number of episodes | Mild degree | Average degree | Severe degree |
| Per night | 0-1 | 0-1 | 1-2 |
| During the week | 1-2 | 3-5 | More than 5 |
What kind of examination will you have to undergo? Condition differential diagnosis
Survey stages
Collection of complaints and medical history
Attention is paid:
- obstetric history (during pregnancy, childbirth, first month of life);
- the peculiarities of the life and development of the child in the first 3 years (bruises, concussion, neuroinfection);
- genetic predisposition;
- the presence of constipation;
- the nature of night sleep;
- the presence of sleepwalking, teeth creak, dreaming;
- parenting style.
Visual inspection
Includes status assessment:
- physical development;
- lumbosacral region;
- perineum and genitals.
Clinical analysis of urination
Includes assessment:
- frequency of spontaneous urination for 2-3 days;
- "Maturity" of urination;
- painful urination;
- the presence of uncontrollable urging and urination.
Signs of a mature type of urination: age-appropriate bladder volume, the number of urinations 7-9 per day, complete retention of urine day and night, the ability to hold and perform the process on request, emptying as needed without the urge, the desire to retire if you want to go to the toilet.
Collecting analyzes
Including:
- clinical analysis of urine;
- urine analysis according to Nechiporenko;
- if necessary - bacteriological culture of urine;
- urine analysis according to Zimnitsky to assess kidney function;
- clinical blood test;
- blood for sugar;
- biochemical blood test (assessment of kidney function, micronutrient deficiency, the presence of antibodies to ascaris, lamblia, thyroid hormone levels);
- feces per coprogram (assessment of the effectiveness of digestion, eggs of worms);
- if necessary (complaints of poor digestion, constipation, abdominal pain, pathological changes in the coprogram) - analysis of feces for dysbiosis.
Instrumental examinations
- Ultrasound of the kidneys and bladder with the measurement of the residual volume of urine, organs of the gastrointestinal tract.
- X-ray of the lumbosacral spine for developmental anomalies.
This is a basic list of examinations that a child can undergo already at the stage of admission to a pediatrician.
Specialist consultations
Including:
- neurologist (prescribes an electroencephalogram for differentiation with epilepsy, conducts a study of the neurological status);
- a psychologist (assesses the psychological level of development, the presence of deviations, treats in parallel with specialized specialists);
- an endocrinologist if there is a suspicion of a disease of the endocrine glands;
- urologist and / or nephrologist in the presence of diseases of the genitourinary system. They prescribe a more in-depth examination of her;
- a psychiatrist, if there is a suspicion of a mental illness;
- ENT doctor (to identify pathology of the nasopharynx).
Differential diagnosis
In the absence of obvious causes of enuresis, the following conditions are excluded:
- epilepsy (during sleep, a focus of pathological excitement can occur in the brain stem, affecting the center of urination. As a result, loss of control of the central nervous system over the bladder and involuntary urination). This can be done using an EEG;
- obstructive sleep apnea syndrome (cessation of breathing during sleep, due to overlapping of the upper airways due to the pathology of the ENT organs, excessive decrease in muscle tone). In childhood, the peak of the appearance of this syndrome occurs in the period 2-8 years. Night snoring, daytime sleepiness helps to suspect. In this case, enuresis occurs due to oxygen starvation of the brain, disturbances in the deep sleep phase, and increased secretion of natriuretic peptide by the cells of the right atrium. As a result, a lot of urine is produced, and the brain's sensitivity to signals that the bladder is full is dulled. Specialists help to identify: ENT doctor, neurologist, somnologist; and examinations: polysomnography and pneumogram;
- diabetes mellitus should be ruled out among the first (dangerous by the rapid development of the clinic and sudden coma). It is characterized by thirst and polyuria. Enuresis occurs due to a discrepancy between the volume of the bladder and the amount of urine. It is detected by examining urine and blood for sugar;
- enuresis leads to diabetes insipidus (a pathology in which the amount of vasopressin decreases. It is characterized by a large amount of daily urine and intense thirst).
Treatment of bedwetting in children. A complex approach
Treatment of bedwetting depends on the reasons that caused this pathology, on age, concomitant diseases, so it is selected individually and includes a set of therapeutic measures.
Drug treatment
The main groups of drugs:
- analogs of vasopressin (Minirin). Used for vasopressin deficiency at night, once a day before bedtime;
- antagonists of M-cholinergic receptors (Diptran). Has a relaxing effect on the contraction muscle of the bladder. It is used for urinary urination syndrome in children over 5 years old;
- antidepressants (imipramine). Relieve excess excitability of the nervous system and improve sleep;
- non-steroidal anti-inflammatory drugs (Diclofenac). Contributes to a decrease in the release of prostaglandins, due to which the sensitivity of the kidneys to vasopressin increases;
- nootropics (Pantocalcin, Picamilon). They improve blood circulation in the brain, increase its resistance to hypoxia. Used for various damages of the nervous system;
- vitamins of group B, A, E. Improve cell nutrition, activate cell metabolism;
- antibiotics - if you have a urinary tract infection.
These groups of drugs can be used both in monotherapy and in combination with each other.
Psychotherapy
The purpose of psychotherapy- find the cause of enuresis in the consciousness / subconsciousness of the child and get rid of it through individual or, preferably, family psychotherapy.
Attention is paid to the personality of the parents, the style of communication and conflicts between family members, the style of upbringing. In an individual lesson with an older child, hypnosis and auto-training are used. At a young age, art therapy has proven itself well, when a child paints his fears with paints.
Ethnoscience
The most commonly used and less difficult to prepare:
- decoction of dill seeds: a tablespoon of seeds is poured with 200.0 boiling water, insisted and drunk 1 time in the morning;
- collection from St. John's wort, leaves and berries of lingonberry: 30.0 collection +300 ml of boiling water and drink in small portions up to 6 times a day;
- decoction of bay leaves: 5 leaves in a glass of water, boil for 10 minutes. Reception - 3 times a day for half a glass for 7 days.
Non-drug methods
These include:
- use of "urinary alarms";
- acupuncture;
- manual therapy;
- ultrasound therapy;
- laser therapy.
As you can see above, there are a lot of treatments for bedwetting and drugs. I would like to summarize from the point of view of evidence-based medicine.
Only desmopressin (Minirin) and the method of using "urinary alarms" (due to the low availability of the latter, they rely on Minirin therapy) have fully proven efficacy in the treatment of primary monosymptomatic enuresis. These methods are suitable for both short-term and long-term treatment.
In second place in terms of effectiveness with the same type of enuresis is the drug Indomethacin and the method of laser acupuncture.
These treatments have been studied and are effective and safe for monosymptomatic primary enuresis.
The use of other groups of drugs and non-drug methods has a number of nuances:
- antidepressants are effective in treating bedwetting, but have many side effects even at the lowest effective dosage;
- Diptran, antibiotics, nootropics are effective for non-monosymptomatic enuresis;
- some non-drug methods are under study (ultrasound therapy, for example).
Disease prognosis
The prognosis of the disease is the more favorable, the earlier the treatment is started. This reduces the consequences for the child's psyche, the risks of infectious complications. Spontaneous recoveries are possible, and with treatment, 9 out of 10 patients can be cured.
Prevention
- Providing a favorable family environment for the life and development of the child.
- Instilling neatness skills and timely potty training.
The use of disposable diapers interferes with the child's perception of the consequences of urinating. Therefore, it is important to abandon them by the age of 2 years.
- Compliance with the regime of the day, work and rest.
Memo to parents - how to help the baby
Parents need:
- maintain peace in the family and a friendly attitude towards the child. Do not scold, but involve him in cleaning after an episode of incontinence;
- positively motivate the child. Celebrate successes and dry nights, ignore failures. Keep a diary of urination;
- observe the daily routine. The goal is to allow the nervous system to "mature". A full sleep is required (the norm of sleep duration from 4 years to 15 from 11.5 hours to 9 hours, respectively), the elimination of excessive physical and mental stress (revision of the number and necessity of sections, circles), limiting the time of using the TV and computer;
- observe the diet: the last meal and drink 2-3 hours before bedtime;
- follow a diet: limit / exclude foods that stimulate the nervous system (coffee, cocoa, chocolate, spices, carbonated drinks, food containing dyes and preservatives, allergenic foods);
- not to let the course of the disease "take its course", to carry out all the appointments of doctors and necessary examinations.
Conclusion
Enuresis- a complex disease that has multiple causes, requiring extensive examination and complex treatment. But the first condition for the prevention and treatment of bedwetting is a healthy, welcoming atmosphere within the family. There is a reason to think ...
Literature
- Union of Pediatricians of Russia, International Fund for Maternal and Child Health. Evidence-based treatment of primary nocturnal enuresis in children. Moscow 2002
- I. V. Kazanskaya, T. Otpuschennikova, ENURESIS: CLASSIFICATION, CAUSES, DIAGNOSTICS AND TREATMENT, MOSCOW 2005.
- Otpuschennikova T.V. Modern methods of treatment of enuresis in children with urination disorders, Saratov State Medical University named after I. Razumovsky, Ministry of Health of Russia, 2015
- D. m. N. prof. M. Studenikin et al. Scientific Center of Children's Health, Russian Academy of Medical Sciences, Nocturnal enuresis in neuropediatrics. Modern approaches to treatment.
- T. N. Garmanova, V. A. Shaderkina, Federal State Budgetary Institution "Research Institute of Urology" of the Ministry of Health of Russia, Experimental and Clinical Urology, 2014 No. 2 .: Enuresis - theoretical foundations and practical recommendations.
- Chernorutskaya E. Enurez. Causes and treatment. Doctor Plus.
