Bedwetting in children

Urinary disorders of the enuresis type have been known since ancient times. The first mention of this condition can be found in ancient Egyptian papyri and dates back to 1550 B.C. The term “enuresis” (from the Greek “enureo” – to urinate) refers to urinary incontinence. Nocturnal enuresis is defined as urinary incontinence after reaching the age at which bladder function control is expected to be achieved. Currently, the age of 6 years is defined as such a criterion.

Boys have nocturnal enuresis twice as often as girls, according to other data the ratio is 3 : 2.

In general, nocturnal enuresis is not considered to be a disease, but rather a stage in the development of physiological control. Various aspects of bedwetting treatment are dealt with by doctors of different specialties: pediatric neurologists, pediatricians, psychiatrists, endocrinologists, nephrologists, urologists, homeopaths, physiotherapists, etc. Such an abundance of specialists involved in solving the problem of nocturnal enuresis reflects the variety of causes leading to urinary incontinence in children.

Prevalence

Bedwetting is an extremely frequent phenomenon in the pediatric population and is an age-related condition. It is believed that 10% of children suffer from this condition at the age of 5 and 5% by the age of 10.

Subsequently, the prevalence of nocturnal urinary incontinence decreases significantly with increasing age; about 2% of 14-year-olds have bedwetting, and by age 18, only 1 in 100 individuals have it [4]. Although these figures indicate a high rate of spontaneous remissions, even among adults about 0.5% of the general population have nocturnal enuresis. The frequency of bedwetting depends not only on age, but also on the gender of the child.

Classification

A distinction is made between primary (persistent) bedwetting (if the patient has never had bladder control) and secondary (acquired, if nocturnal enuresis occurs after a stable control of urination) as well as complicated and uncomplicated (uncomplicated refers to cases of bedwetting without somatic and neurological defects as well as changes in urine tests). Thus, in patients with primary nocturnal enuresis the physiological reflex of inhibition of urination (“watchdog”) is not formed initially and the episodes of “missing” urine persist as the child is growing up, while in secondary enuresis nocturnal urination occurs after a long “dry” period (over 6 months). At the same time, it is noted that primary nocturnal enuresis occurs 3-4 times more often than secondary enuresis. In addition, previously, the so-called “functional” and “organic” forms of enuresis were often distinguished. In the latter case, it was implied that there were pathological changes in the spinal cord with developmental defects. Functional forms of enuresis included nocturnal (less often – diurnal) urinary incontinence due to psychogenic factors, education defects, traumas (including mental) and infectious diseases (including infections of the urinary tract).

This classification appears to be somewhat tentative. H.Watanabe (1995) after examination of a representative group of patients using EEG and cystometrography (1033 children) suggests distinguishing 3 types of nocturnal enuresis:

1. type I (characterized by an EEG response to bladder distension and stable cystometrography)
2. type IIa (characterized by absence of EEG response during bladder overflow, stable cystometrogram)
3. type IIb (characterized by no EEG response to bladder distension and an unstable cystometrogram only during sleep)

If a child has urinary incontinence not only at night, but also during the day, it may mean that he or she is experiencing some kind of emotional or neurological problem. As for nocturnal enuresis, it is often found in children who sleep extremely soundly (so-called “profundosomnia”).

Neurotic bedwetting is more common among shy, fearful, “battered” children with superficial unstable sleep (such patients are usually very worried about the defect). Neurosis-like bedwetting (primary and secondary) is characterized by a relatively indifferent attitude to episodes of bedwetting over a long period of time (until adolescence), and later by increased worries about it.

The available classification of bedwetting does not fully correspond to the current understanding of this pathological condition. Therefore, J. Noorgard et al. propose to distinguish the concept of “monosymptomatic nocturnal enuresis”, which occurs in 85% of patients. Among patients with monosymptomatic nocturnal enuresis, there are groups with or without nocturnal polyuria, responding or not responding to desmopressin therapy, and finally, subgroups with waking disorders or bladder dysfunction.

Etiology and pathogenesis

In nocturnal enuresis, the etiology is extremely multifactorial. It cannot be excluded that this pathological condition includes several subtypes distinguished by the following features:

1. time of onset (from birth or at least after a 6-month period of stable bladder control)
2. symptomatology (nocturnal enuresis only, monosymptomatic or combined nocturnal and daytime urinary incontinence)
3. response to desmopressin (good or poor response)
4. nocturnal polyuria (presence or absence)

The appearance of the second (or the next) child in the family can quite expectedly lead to “wet nights” in his older brother (or sister). In this case the older child becomes “infantilized” and learns to control urination as a conscious or unconscious protest against the seeming lack of attention, love and affection from parents, who are entirely concerned primarily with the “new” child. Such a situation is sometimes encountered in such typical situations as transfer to another school, transfer to another kindergarten or even moving to a new apartment.

Quarrels between parents or divorce can also lead to a similar situation, as can excessive strictness in parenting and physical punishment of children.
Monitoring bladder function. There is considerable individual variation in the timing of establishing stable independent control of urination. Numerous studies of domestic and foreign authors show that the control of the act of urination during night sleep is formed later than a similar function during waking during the day: about 70% of children – by 3 years, 75% of children – by 4 years, over 80% of children – by 5 years, 90% of children – by the age of 8.5 years .

There is no question that bladder function control (and nocturnal enuresis) depends on a number of factors:

1. genetic
2. circadian rhythm of the secretion of some hormones (vasopressin, etc.)
3. the presence of urological disorders
4. delayed maturation of the nervous system
5. psychosocial stress and some kinds of psychopathology

Genetic factors. Among genetic factors, family history, type of inheritance, and localization of the pathological (defective) gene deserve attention.

Scandinavian researchers have found that if both parents have a medical history of bedwetting, the risk of nocturnal enuresis in their children is 77% and if only one parent has bedwetting – 43%.

A genealogical study of twins showed that concordance levels for enuresis for monozygotic twins were almost twice as high as for dizygotic twins: 68% and 36%, respectively. Comparatively recently, appropriate genotyping has been done and genetic heterogeneity in bedwetting has been established with probable genetic disorder loci on chromosome 13 (13q13 and 13q14.2) – this region is now known as “ENUR1” – as well as on chromosome 12q. H.Eiberg (1995) indicates that a single autosomal dominant gene with reduced penetrance, i.e. influenced by environmental factors and/or other genes, is involved in the formation of nocturnal enuresis.

Among boys, 70% of monozygotic twins were concordant for nocturnal enuresis versus 31% in male dizygotic twins. Among girls, this ratio was 65% and 44%, respectively (no statistically significant differences were found). Apparently, among girls the genetic influence is not as significant as for boys.

Circadian rhythm of secretion of some hormones (regulating water and salt excretion). In normal individuals there are marked circadian (circadian) variations in urine production and osmolality, with less (concentrated) urine being produced at night. In childhood, this circadian pattern is partly regulated by vasopressin and partly by atrial natriuretic hormone and the renin-angiotensin-aldosterone system.

Vasopressin

Volunteer studies have demonstrated that reduced nocturnal urine output (about half of that during the day) is due to increased vasopressin secretion (16). More recently, it has been found that some patients with nocturnal enuresis and polyuria respond well to desmopressin therapy (17). But among these children there is a small group of patients with a normal circadian rhythm of vasopressin secretion (they do not respond to named therapy, as do children without nocturnal polyuria). It is possible that these children have impaired renal sensitivity to vasopressin and desmopressin, as do patients without nocturnal polyuria (with normal circadian fluctuations in urine output, urine osmolality, and vasopressin secretion).

Other osmoregulatory hormones. Increased secretion of atrial natriuretic hormone and decreased secretion of renin and aldosterone in obstructive sleep apnea explain the increased urinary excretion and sodium excretion at night. It has been suggested that a similar mechanism may occur in nocturnal enuresis in children.

However, the available data indicate that in children with nocturnal enuresis, the secretion of atrial natriuretic hormone is characterized by a normal circadian rhythm, and the renin-angiotensin-aldosterone system also does not undergo changes.

Urological disorders

There is no doubt that urinary incontinence (including nocturnal) often accompanies diseases and abnormalities of the urinary system, acting as the main or accompanying symptoms. The nature of these urological disorders can be inflammatory, congenital, traumatic and combined.

A trivial urinary tract infection (e.g., cystitis) can contribute to bedwetting (particularly common in girls).

Delayed maturation of the nervous system

Numerous epidemiological studies show that bedwetting is more common in children with delayed maturation of the nervous system. Nocturnal enuresis often develops in children against the background of organic lesions of the brain and the so called “minimal cerebral dysfunction” under the influence of unfavorable factors and pathology of pregnancy and delivery (antenatal and intrapartum pathological influence). It is noteworthy that in addition to the delayed rate of maturation of the nervous system, children with bedwetting often have reduced physical development indicators (body weight, height, etc.), as well as delayed puberty and discrepancy between bone age and calendar age (“delayed” ossification nuclei).

For patients whose bedwetting is observed against a background of mental retardation (they are generally characterized by a significant delay or lack of formation of adequate neatness skills), more importance should be given to the psychological age of the child (rather than the calendar age) when prescribing therapy.

Psychopathology and psychosocial stress in patients with nocturnal enuresis. Previously, the presence of nocturnal enuresis was directly associated with psychological disorders. Although nocturnal enuresis may be combined with psychiatric pathology in some patients, it occurs more often in secondary enuresis with episodes of daytime urinary incontinence. The prevalence of nocturnal enuresis is higher among children with mental retardation, autism, attention deficit hyperactivity disorder, and motor and perception disorders. It is believed that the risk of developing psychiatric disorders is significantly higher for girls with bedwetting than for boys.

There is no doubt that psychosocial factors (belonging to low socioeconomic groups, large families with poor housing conditions, children staying in institutions, etc.) can influence bedwetting. Although the exact mechanisms of this influence remain unclear, bedwetting undoubtedly occurs more often under conditions of psychosocial deprivation.

Of interest is the observation that growth hormone production is impaired under such conditions, and it is also suggested that vasopressin production may be similarly inhibited (leading to excessive urine production at night). The fact that bedwetting is often combined with stunting may support this hypothesis of a combined depression of growth hormone and vasopressin production.

Diagnosis

Bedwetting is diagnosed primarily on the basis of complaints, as well as individual and family history. It is important to remember that in 75% of cases, relatives of patients with nocturnal enuresis (first degree of consanguinity) have also had this disorder in the past. Previously, it was found that the presence of episodes of bedwetting in the father or mother increases the risk of the child developing this condition by at least 3 times.

Anamnesis

When collecting the anamnesis, first of all, it is necessary to find out the nature of the child’s upbringing and the formation of his/her neatness skills. The frequency of episodes of urinary incontinence, the type of bedwetting, the nature of urination (weak flow in the process of micturation, frequent or rare urges, painfulness when urinating), the history of urinary tract infections, as well as encopresis or constipation. The hereditary burden of enuresis is always specified. Attention is given to the presence of airway obstruction, as well as nocturnal apnea and epileptic seizures (or non-epileptic paroxysms). Food and drug allergies, urticaria, atopic dermatitis, allergic rhinitis and bronchial asthma in children may in some cases contribute to bladder hyperexcitability. When interviewing parents, it is necessary to find out if endocrine diseases such as diabetes mellitus or non-sugar diabetes, thyroid gland (and other endocrine glands) dysfunction are present among relatives. Since the autonomic status is closely related to the functions of the endocrine glands, any disorders of these glands may be the cause of enuresis.

In some cases, urinary incontinence may be induced by the side effects of tranquilizers and anticonvulsants (sonopax, valproic acid drugs, phenytoin, etc.).

Therefore, it is necessary to find out which of these drugs and in what dosage the patient is receiving (or has received before).

Physical examination

When examining the patient (evaluation of somatic status) in addition to identifying the above violations of various organs and systems, attention is paid to the condition of endocrine glands, abdominal organs and the urogenital system. Assessment of physical development indicators is mandatory.

Neuropsychiatric status

When assessing the child’s neuropsychological status, congenital abnormalities of the spine and spinal cord, and motor and sensory disorders are excluded. Sensitivity in the perineal area and tonus of the anal sphincter are studied without fail. Finding out the state of the psycho-emotional sphere is of no small importance: characteristic features (pathological), the presence of bad habits (onychophagia, bruxism, etc.), sleep disorders, various paroxysmal and neurosis-like conditions. There is a thorough defectology examination by the Wechsler method or with the use of computer test systems (“Ritmotest”, “Mnemotest”, “Binatest”) to determine the child’s state of intellectual development and status of basic cognitive functions.
Laboratory and paraclinical examinations. Since urological disorders (congenital or acquired abnormalities of the urinary tract: detrusor and sphincter dyssynergy, hyper- and hyporeflexive bladder syndromes, small bladder capacity, obstructive changes in the lower parts of the urinary tract: strictures, contractures, valves; urinary tract infections, domestic trauma, etc.) play a significant role in the occurrence of enuresis. etc.), first of all, it is necessary to exclude the pathology of the urinary system. Of the laboratory tests, urinalysis is important (including general analysis, bacteriological, determination of bladder functionality, etc.). An ultrasound examination of the kidneys and bladder is mandatory. If necessary, additional studies of the urinary tract are performed (cystoscopy, cystourethrography, excretory urography, etc.).

If abnormalities of the spine or spinal cord are suspected, X-rays (2 views), CT or MRI scans, and neuroelectromyography (NEMG) should be performed.

Differential diagnosis

Nocturnal urinary incontinence should be differentiated from the following pathological conditions:

1. nocturnal epileptic seizures
2. some allergic diseases (skin, food and drug allergies, urticaria, etc.)
3. some endocrine diseases (diabetes mellitus and non-sugar diabetes, hypothyroidism, hyperthyroidism, etc.)
4. nocturnal apnea and partial airway obstruction
5. side effects due to medications (in particular thioridazine and valproic acid preparations, etc.).

Treatment for nocturnal enuresis

Although some children’s nocturnal enuresis passes with age without any treatment, there are no guarantees in this regard. Therefore, if episodes persist or persistent nocturnal urinary incontinence persists, therapy is necessary. Effective therapy of nocturnal enuresis is determined by the etiology of this condition. In this regard, approaches to the treatment of this pathological condition are extremely variable, so for many years, physicians have used a variety of therapeutic methods. In the past, bedwetting was often attributed to late potty training of the child, while today it is often the disposable diapers which are “guilty”, although both of these ideas are wrong.

Although today it is unfortunately not 100% guaranteed that bedwetting will be cured by any known treatment method, some therapeutic methods are considered highly effective. They can be roughly divided into:

1. medical (using various pharmacological drugs)
2. non-pharmacological (psychotherapeutic, physiotherapeutic, etc.)
3. regime

The methods and volume of therapy depend on the specific situational circumstances. In any case, successful treatment of bedwetting is possible only with the active, interested participation of the children and their parents.

Medicinal methods of treatment

When nocturnal enuresis is due to a urinary tract infection, a full course of treatment with antibacterial drugs under the control of urinalysis (taking into account the sensitivity of the isolated microflora to antibiotics and uroseptics) is necessary.

The “psychiatric” approach to the therapy of nocturnal enuresis includes the prescription of tranquilizers with a sleeping effect to normalize sleep depth (Radedorm, Eunoctin), if they are resistant, it is recommended (usually in neurosis-like forms of enuresis) to take stimulants (Sydnocarb) or thymoleptic drugs (amitriptyline, mylepramine, etc.) before bedtime. Amitriptyline (Amisol, Triptizol, Elivel) is usually prescribed in doses of 12.5 to 25 mg, 1-3 times daily (available in 10 mg, 25 mg, 50 mg tablets and pills). When there is evidence that urinary incontinence is not associated with inflammatory diseases of the urogenital system, imipramine (milepramine), available in 10 mg and 25 mg tablet form, is preferred. It is not recommended to prescribe the above drug for the treatment of bedwetting in children under 6 years of age. If prescribed, it is dosed as follows: up to 7 years of age, from 0.01 g gradually increased to 0.02 g per day, at the age of 8-14 years: 0.03-0.05 g per day. There are treatment regimens in which a child gets 25 mg of the drug for 1 hour before going to bed, with no visible effect after 1 month the dose is doubled. After achieving “dry” nights the dose of milepramine is gradually reduced until complete withdrawal.

When treating neurotic enuresis tranquilizers are used:

1. Hydroxyzine (Atarax) – 0.01 and 0.025 g tablets and syrup (5 ml contains 0.01 g): children over 30 months of age at 1 mg/kg body weight/day in 2-3 doses
2. Medazepam (Rudotel) – 0.01 g tablets and 0.005 and 0.001 g capsules: daily dose 2 mg/kg of body weight (2 times)
3. Trimethosin (Trioxazine) – 0.3 g tablets: daily dose – 0.6 g in 2 doses (for 6-year-old children), for 7-12-year-old children – about 1.2 g in 2 doses
4. Meprobamate (0.2 g tablets) 0.1-0.2 g in 2 doses: 1/3 dose in the morning, 2/3 dose in the evening (course of about 4 weeks)

Taking into account the fact that in the pathogenesis of enuresis an important role is played by immaturity of the child’s nervous system, delayed development, as well as expressed neurotic symptoms, nootropic medications (calcium gopantenate, glycine, pyracetam, phenibut, picamilon, semax, instenon, gliatilin, etc.) are widely used nowadays. Nootropic drugs are prescribed in courses of 4-8 weeks in combination with other types of therapy in an age-appropriate dosage.

Driptan (oxybutynin hydrochloride) in 0.005 g (5 mg) tablets may be used in children over 5 years of age in the treatment of nocturnal enuresis resulting from:

1. instability of bladder function
2. urinary disorders due to disorders of neurogenic genesis (detrusor hyperreflexia)
3. idiopathic detrusor function disorders (motor urinary incontinence)

In nocturnal enuresis, the drug is usually prescribed 5 mg 2-3 times a day, starting with a half dose to avoid the development of undesirable side effects (with the last dose taken just before bedtime).

Among the most effective medications is desmopressin (which is an artificial analog of the hormone vasopressin, which regulates the release and absorption of free water in the body).

Today, its most common and popular form is called Adiuretin-SD in drops.

One bottle of the drug contains 5 ml of the solution (1 drop applied from the dropper contains 5 mcg of desmopressin – 1-desamino-8-D-arginine-vasopressin). The drug is administered into the nose (or rather, applied to the nasal septum) according to the following scheme: The initial dose (children under 8 years – 2 drops per day, children over 8 years – 3 drops per day) – for 7 days, then, if the onset of “dry” nights, the course of treatment continues for 3 months (with subsequent cancellation of the drug), but if “wet” nights persist, Then the dose of Adiuretin-SD is gradually increased by 1 drop per week until a stable effect is obtained (the maximum dose for children under 8 years of age is 3 drops per day, and for children older than 8 years – up to 12 drops per day). Treatment course is 3 months in an adjusted dose, then the drug is cancelled. If episodes of bedwetting return, a repeat 3-month course of treatment in an individually adjusted dose is practiced.

Experience has shown that with Adiuretin-SD, the desired antidiuretic effect occurs within 15-30 minutes after drug intake, and intranasal administration of 10-20 mcg desmopressin provides 8-12 hours of antidiuretic effect in most patients. Along with a higher therapeutic efficacy of Adiuretin compared to melipramine, less recurrence of nocturnal enuresis after completion of therapy with this drug has been reported in the literature.

Non-medicinal therapies

Urinary alarms (another name is “urine alarms”) are designed to interrupt sleep when the first drops of urine appear so that the child can finish urinating in the potty or the toilet (in this case the normal physiological stereotype is formed). Often it turns out that these devices awaken not the child himself (if his sleep is too deep), but all the other members of the family.

The technique of nightly awakening according to a schedule serves as an alternative to “urinary alarms. According to it, the child is awakened every hour after midnight for a week. After 7 days, he or she is awakened more than once during the night (strictly at certain hours after falling asleep), selecting them so that for the rest of the night time the patient does not wet himself or herself. Gradually, this time interval is gradually reduced from three hours to two and a half, two and a half, and finally to one hour after falling asleep.

If there are repeated episodes of nocturnal enuresis twice a week, the whole cycle is repeated again.

Physiotherapy

If you list just a few other, less common methods of treatment of bedwetting, they include acupuncture (acupuncture), magnetic therapy, laser therapy and even music therapy, as well as a number of other techniques. Their effectiveness depends on the specific situation, age and individual characteristics of the patient. These methods of physical therapy are usually used in combination with medications.

Psychotherapy

Special psychotherapy is performed by qualified psychotherapists (psychiatrist or medical psychologist) and is aimed at correcting obscheurotic disorders. Hypnosuggestive and behavioural techniques are used. For children who have reached the age of 10, the use of suggestion and self-hypnosis (before going to bed) of the so-called “formulas” of self-awakening at urge to urinate is applicable. Every evening before going to bed, the child tries for a few minutes to mentally imagine the feeling of fullness of the bladder and a sequence of his or her own further actions. Immediately before falling asleep, the patient should for the purpose of self-injection repeat several times the “formula” of approximately the following content: “I want to always wake up in a dry bed. While I sleep, urine is firmly and firmly locked up in my body. When I want to urinate, I quickly get up myself.

So-called “family” psychotherapy is also important. Parents can successfully use a system to encourage the child for “dry” nights. For this purpose, the child should systematically keep a special (“pee”) diary which is filled out daily (for example, “dry” nights are labeled “sunny,” and “wet” nights are labeled “clouds”). At the same time, it is necessary to explain to the child that if for 5-10 days in a row, the nights will be “dry,” a prize awaits him or her.

After episodes of urinary incontinence, it is necessary to change the bedding and underwear (it will be better if the child does it independently).
It is necessary to emphasize that it is possible to expect a positive effect from the listed psychotherapeutic measures only in children with preserved intelligence.

Diet therapy

In general, liquids are greatly restricted in the diet (see “Regimen measures” below). Of the special diets for nocturnal enuresis the most popular is the diet of N.I. Krasnogorsky, which increases the osmotic blood pressure and promotes water retention in tissues, which reduces urination.

When treating bedwetting, parents and other family members of children suffering from this condition are advised to adhere to some general rules (be tolerant, balanced, avoid rudeness and punishment of children, etc.). It is important to establish daily routines. It is important to constantly instill in children suffering from bedwetting the belief in their own strength and the effectiveness of the treatment carried out.

Regimen measures

1. It is necessary to limit as much as possible the child’s consumption of any liquid after dinner. It seems impractical not to give children any drink at all, but the total amount of liquid after the last meal should be reduced by at least half (against what is used). Limit not only drinking, but also dishes with high fluid content (soups, porridges, juicy fruits and vegetables). At the same time, nutrition must remain complete.
2. The bed of a child suffering from bedwetting should be sufficiently hard, and if the child sleeps deeply, it is necessary to turn the child several times during the night while sleeping.
3. Avoid stress reactions, psycho-emotional disturbances (both positive and negative), as well as overexertion.
4. Avoid hypothermia throughout the day and night.
5. It is desirable to avoid giving the child food and drinks containing caffeine or having diuretic effect throughout the day (these include chocolate, coffee, cocoa, all varieties of Coke, Fanta, Seven-Up, watermelon, etc.). If it is not possible to avoid them completely, you should be advised to refrain from consuming these types of food and beverages for at least three to four hours before going to bed.
6. It is necessary to insist that the child visit the toilet or “go potty” before going to bed.
7. It is often effective to artificially interrupt sleep 2-3 hours after falling asleep so that the child can empty the bladder. However, if the child urinates while asleep (not fully awake), such actions can only further worsen the situation.
8. It is better to leave a low-bright source of light in the baby’s room at night. Then the child will not be afraid of the dark and leaving the bed, if he suddenly decides to use the potty.
9. In cases where there is increased pressure of urine on the sphincter, an elevated position of the pelvis or an elevated position under the knees (placing an appropriately sized cushion) can help.

Prevention

Measures to prevent bedwetting in children are reduced to the following basic actions:

• Timely abandonment of the use of any diapers (standard reusable and disposable). Usually diapers are completely stopped when the child reaches two years of age, accustoming children to the elementary skills of tidiness.
• Monitor the amount of fluids consumed during the day (taking into account the air temperature and time of year).
• Sanitary and hygienic education of children (including teaching the rules of hygienic care of the external genitalia).
• Treatment of urinary tract infections.

When a child with bedwetting reaches 6 years of age, further “wait-and-see” tactics (with refusal of any therapeutic measures) cannot be considered justified. Six-year-old children with nocturnal enuresis should receive adequate treatment.

The most important factor determining the development of bedwetting is the ratio between the functional capacity of the bladder and the nocturnal production of urine. If the latter exceeds the bladder capacity, nocturnal enuresis occurs. It is possible that some of the symptoms considered abnormal in children with nocturnal enuresis are not, since episodes of urinary incontinence are occasionally observed in healthy children.