Enuresis

Enuresis is a nonspecific term for any kind of involuntary urinary incontinence. Despite the fact that there are two types of enuresis, namely day and night, throughout the world the term "enuresis" is taken to mean involuntary urinary incontinence only during sleep. In the case of enuresis, bedwetting is the only symptom.

[1], [2], [3], [4]

Epidemiology

Enuresis is one of the most common conditions in children and occurs in 5-10% at the age of 7 years.

Many authors believe that enuresis has a favorable course and within a year itself disappears in 15% of children. Nevertheless, in 7 out of 100 children with enuresis at the age of 7 years this condition is observed during the later life. In boys, enuresis is more common than in girls, approximately in a ratio of 1.5-2: 1.

[5], [6], [7], [8],

Causes of the enuresis

It is important to understand that enuresis is a symptom, not a disease. Unfortunately, until now the cause of enuresis is not exactly established, and the pathogenesis is not fully understood. It is believed that enuresis can be caused by various causes. In particular, there are the following reasons: a violation of the formation of CNS control over the function of the lower urinary tract, sleep disorders, the disturbance of the secretion of the antidiuretic hormone during sleep. Genetic factors.

Enuresis is often observed in children with developmental lag. Such children late start talking and walking. There is a strict correlation between the overall development of the child and the timing of the formation of CNS control over the function of the lower urinary tract.

Sleep disturbance  is one of the causes of enuresis. In children with urinary incontinence, deep sleep is noted, so signals from the subcortical centers that suppress the urinary reflex reflex do not perceive the cortical centers of the brain.

Involuntary urination can occur at any time of the night and in any phase of sleep.

It has been established that in children with enuresis, the night secretion of antidiuretic hormone is reduced. Therefore, such children at night form a significant amount of urine and this can lead to enuresis.

Genetic factors are another cause of enuresis. Statistical studies show that enuresis is more common if the parents had bed-wetting as a child. So. If both parents had nocturnal incontinence, then in 77% of cases it is also in children. At night incontinence in one of parents in 43% of children observe similar infringements. The changes in chromosome 13 are established. They are often found in patients with enuresis.

In the pathogenesis of enuresis, three factors play an important role, namely: increased urine production during the night; decreased bladder capacity and increased detrusor activity; disturbance of awakening. Thus, there is a discrepancy between increased urine production and reduced accumulation capacity of the bladder overnight. This leads to the appearance of urge to urinate. In the case of a decrease in the ability to awaken, bedwetting occurs.

[9], [10], [11]

Symptoms of the enuresis

As a rule, the conditioned reflex, responsible for the function of the lower urinary tract, is formed to 3-4 years of the child's life, therefore it is considered that the diagnosis of enuresis is competent in the case of bed-wetting at the age of the child of at least 5 years.

[12], [13]

Forms

Isolate primary and secondary enuresis. By primary enuresis means bedwetting from the moment of birth and in the absence of a "dry" period for 6 months. Secondary enuresis is a condition that occurred after a period (more than 6 months) of free from urinary incontinence.

[14], [15], [16], [17], [18],

Diagnostics of the enuresis

Diagnosis of enuresis involves two stages. At the first stage, the complaints and the history of the disease are examined in detail, a physical examination is carried out, the urine sediment is examined and the functional capacity of the bladder is evaluated on the basis of the diary of urination. When interviewing, pay attention to obstetric anamnesis (birth trauma, hypoxia during childbirth, etc.), clarify the presence of enuresis in parents and relatives, and also find out the conditions in the family. It is important to determine the presence of a "dry" period and its duration, the number of cases of enuresis (per week, month), pay attention to the nature of sleep (deep, anxious, etc.). A physical examination should include a thorough examination of the sacral region and genitals. In the anomalies of the development of the nervous system (meningocele) in the sacral region, subcutaneous lipomas, areas of increased hairiness, skin retention and pigment spots are often found. Neurological examination includes the definition of skin sensitivity, examination of reflexes of the lower extremities and bulbocavernous reflex, as well as evaluation of the tone of the anal sphincter.

On the basis of the diary of urination determine the number of urination and incontinence episodes during the day and night, evaluate the capacity of the bladder. In those cases where bedwetting is the only symptom, the treatment is prescribed.

In case of unsatisfactory results of treatment, as well as detection of other disorders of the functioning of the lower urinary tract (urinary incontinence during the day, frequent urination, etc.), neurological disorders, urinary tract infection and in cases of suspected urological diseases, a detailed examination is shown. The purpose of such a survey is to identify diseases, one of the symptoms of which is bed-wetting. Perform  ultrasound of the kidney  and bladder with the determination of residual urine, descending cystourethrography, complex UDI and CT or MRI of the spine. The consultation of the neurologist is shown.

[19], [20], [21], [22], [23]

Treatment of the enuresis

Preservation of enuresis after 7 years has a negative impact on the child and members of his family, which can cause mental disorders, so treatment of enuresis is necessary. It is necessary to start it from the behavioral moments pressed on the development of the conditioned reflex of urination. It is important to have a detailed conversation with the parents of the child to explain the causes of enuresis and treatment tactics. It is necessary to create a calm environment, recommend a warm, hard bed and reduce fluid intake 1 hour before bedtime. Useful physical exercise and exercise.

Signal therapy is considered the best type of treatment for patients with impaired wake-up and a slight increase in nocturnal urine output. Assign regular awakenings or use special signaling devices. The latter are arranged in such a way that urine, which is released by involuntary urination, closes the electrical circuit and a signal sounds. This leads to awakening and the patient ends urination in the toilet. Such treatment forms a urinary reflex. Successful results are noted in 80% of patients with enuresis.

Patients with enuresis who excrete large amounts of urine at night show treatment with enuresis with desmopressin. Desmopressin has a pronounced antidiuretic effect. The drug is released as a nasal spray and in tablets. It is recommended to start treatment with a minimum dose of 10 mcg per day with a subsequent increase to 40 mcg per day. Positive results mark in 70% of patients. The side effects of desmopressin are rarely observed and usually they disappear quickly after the drug is discontinued. In case of an overdose, hyponatremia occurs, so it is recommended to periodically monitor the sodium content in the blood serum.

With a decrease in the capacity of the bladder, treatment of enuresis with cholinergic blockers is indicated. Previously, the most commonly used tricyclic antideprisant - imipramine, which has a cholinolytic effect. In recent years, appoint oxybutynin (driptan) 5 mg 2 times a day. It is possible to increase the dose depending on the age.

Forecast

In most cases, if properly treated, enuresis disappears. If successful, it is recommended to continue treatment of enuresis for at least 3 months. Since a relapse is possible.

[24]