Enuresis

What is Enuresis?

Enuresis consists in the involuntary passing of urine; this phenomenon becomes anomalous after the age in which bladder control is normally achieved.

Acquiring the ability to hold urine is part of the normal development process. On average, complete voluntary control of urination is achieved by around 5-6 years of age and, as they grow older, it is common for children to accidentally wet their bed overnight (nocturnal enuresis) or clothes during the day (daytime enuresis). Bedwetting therefore represents a delay in the development of urination skills. The disorder can be frustrating, but should not be a cause for concern. Although enuresis persists into adulthood in about 1% of cases, this condition generally resolves spontaneously before reaching adolescence.

Treatment options include behavioral and pharmacological measures.

Clinical definition

Bedwetting is defined on the basis of the following diagnostic criteria:

• Involuntary emptying of the bladder (in bed or in clothes) occurs repeatedly;
• Behavior must be clinically significant:
  • it must occur with a frequency of at least 2 times a week, for at least 3 consecutive months
  • or it must cause psychological distress or compromise the social, school or work area;
• The biological age of the patient is at least 5 years;
• The condition is not solely caused by the direct physiological effects of a substance (such as a diuretic) or a general medical condition (anatomical abnormalities, endocrine disorders and urinary tract infections).

Premise: urination

Urination is the physiological process that determines the expulsion of urine. This, produced by the kidneys, is collected in the bladder, where it accumulates until the moment of its elimination through the urethra. The process of urination is regulated by the autonomic nervous system and coordinated by a reflex mechanism; it also involves voluntary relaxation of the sphincter. external urethral, ​​an event that causes, with a mechanism mediated by the autonomic nervous system, the subsequent relaxation of the internal urethral sphincter The urination stimulus is triggered by the stretching of the bladder walls.

Newborns do not have bladder control because the necessary cortico-spinal connections have not yet been established. There is some difference in the age at which children become physiologically aware of the need to urinate, so they are ready to go to a bathroom during the day or wake up from sleep when the bladder is full. Parents should accustom the child, before the age of two years, to anticipate the reflex with the voluntary contraction of the sphincter and thus to exercise control over urination.

Types of enuresis

• Nocturnal enuresis: the inability to control urination occurs during the night rest (the so-called "bedwetting");
• Diurnal enuresis - involuntary release of urine occurs during wakefulness;
• Mixed enuresis: it is the combination of nocturnal and diurnal enuresis.

Sometimes, bedwetting is classified into two types, depending on when the problem develops.

• Primary enuresis: the child has never acquired control of urination;
• Secondary enuresis: represents a regression, that is, the child becomes enuretic after a long period (of months or years) of perfect control of the bladder function. Bedwetting, in this case, is predominantly nocturnal and often occurs in response to a stressful emotional situation.

Bedwetting must be distinguished from:

• Incontinence: The loss of urine is continuous and uncontrollable. This condition can reflect damage to the central nervous system, the spinal cord or the nerves that innervate the bladder or the external sphincter.
• Pollakiuria: urinations are very frequent and can be induced by metabolic, renal, neuromuscular diseases or psychological disturbances.

Nocturnal enuresis

Nighttime urine loss is more common than daytime enuresis.
Most cases result from a combination of factors, including:

• Genetic Factors and Family History of Bedwetting: A genetic component is likely in many affected children; the incidence of the disorder was 40% if one of the parents was enuretic and 70% if both were.
• Delay in physical development:
• Reduced bladder capacity;
• Underdevelopment of body alarms that signal the need to urinate;
• Excessive urine production at night: In most people, the secretion of vasopressin (or ADH) reduces the amount of urine produced during the night. Some babies actually release less hormone and produce more urine than their peers. Because of this, they are more prone to bed wetting, especially when other factors are present.
• Difficulty waking up during the night: Often, enuretic children have a deep sleep, meaning that they cannot awaken easily during a night's rest and are unable to recognize bladder filling when they need to urinate;
• Obstructive sleep apnea: The interruption of breathing during sleep is associated with enuresis, as it decreases oxygen levels and can make the baby less sensitive to the sensation of a full bladder;
• Emotional problems, stressful events and anxiety: the child may be upset or worried due to conflicts in the parental couple, the birth of a sibling or the beginning of school life;
• Chronic constipation: Irregular bowel movements can irritate the bladder, as they limit its expansion. The problem can result in a decrease in bladder sensitivity and an increase in the frequency of urination.

Diurnal enuresis

Diurnal enuresis, not associated with urinary tract infection or anatomical abnormalities, is less common and tends to disappear sooner than nocturnal enuresis.
Possible causes of daytime incontinence include:

• Pathologies, such as overactive bladder;
• Wrong urination habits (example: incomplete or infrequent bladder emptying).

Some factors that contribute to bedwetting can contribute to the onset of symptoms even during wakefulness. These include: poor bladder capacity, excessive urine production, constipation, stress and consumption of foods containing caffeine, chocolate or artificial colors.

Polysymptomatic enuresis

When enuresis occurs in the absence of other symptoms attributable to the urogenital or gastrointestinal tract, we speak of monosymptomatic (or simple) enuresis. Conversely, polysymptomatic enuresis is accompanied by other nocturnal and diurnal symptoms, such as:

• Frequent and urgent need to urinate
• Painful urination
• Blood in the urine
• Chronic constipation;
• Encopresis (uncontrolled defecation in clothes);
• Unusual thirst
• Fever (38 ° C or higher);
• Neurological symptoms: weakness, changes in bowel control or changes in gait.

Polysymptomatic enuresis may suggest the presence of an underlying pathology and requires a uro-functional investigation.

When to see a doctor

• Episodes of bedwetting are often traumatic for the child: apart from the physical effects, such as skin irritation or the appearance of rashes in the genital area, bedwetting can have a negative impact on self-esteem. For this, the doctor should carefully evaluate the emotional and behavioral symptoms, as well as the psychological or family condition of the child, which often conceals the origin and causes of enuresis.
• If the enuresis is polysymptomatic or if the disorder develops suddenly, an organic or malformative cause may be present, for example diabetes, urinary disorders (infections or anatomical-functional alterations of the urinary tract) and damage to the nerves that control the bladder (spine bifida or spinal cord injury). If your doctor suspects an underlying condition is responsible for bed wetting, he may recommend some investigations. For example, a chemical and bacteriological examination of the urine can be used to rule out a urinary infection. The doctor can proceed by prescribing a specific therapeutic program.

Bedwetting in adolescents and adults

Bedwetting can continue into adulthood and only occurs in old age in some people for a variety of reasons.

If the subject has always suffered from enuresis, the following hypotheses can be advanced:

• Lack of necessary muscle and nerve control;
• Production of too much urine.

If, on the other hand, the patient has recently lost control of urination, the enuresis could be caused by:

• Urinary infection;
• Taking alcohol, coffee, or diuretic drugs;
• Sleeping pills;
• Diabetes;
• Emotional stress and anxiety;
• Other conditions, such as prostate gland hypertrophy, neurological problems and sleep apnea.

If enuresis persists or occurs in adulthood, evaluation by a specialist, such as a urologist, is usually required.

Diagnosis

Assessment of bedwetting may require medical history, complete physical examination, and urinalysis and blood tests. Depending on the circumstances, a laboratory evaluation can check for signs of infection or diagnose diabetes.
The physical exam may include:

• Examination of the genitals;
• Neurological examination;
• Abdominal examination;
• Inspection of the back and spine.

If the doctor suspects a structural urinary tract problem or other health problem, he or she may have the patient undergo a kidney and bladder ultrasound or other imaging tests.

Treatment

Many children overcome enuresis naturally, without treatment. For this reason, in most cases, the first approach to the problem involves the implementation of some simple behavioral interventions. These measures include control of fluid intake, timed emptying of the bladder, correction of constipation and, in some cases, rehabilitation of the pelvic floor. Avoid drinks that contain caffeine (cola, tea, coffee or hot chocolate), and encouraging the child to go to the bathroom regularly during the day and before going to bed can help overcome the problem.

Before initiating behavioral therapy, it is necessary to ensure that the child is cooperative and punishment and expressions of anger or frustration on the part of the parents must be absolutely discouraged. Bedwetting takes time to resolve and there may be periods of progress followed by relapses, so patience and understanding is key.

Method of the bell and pad: as soon as the enuretic begins to leak urine, the event is detected by a special sensor (inserted in the sheets or in the underwear) which triggers an audible warning. The alarm is intended to wake up the subject who can then go to the bathroom to empty his bladder. A conditioning process leads the subject to learn how to stay dry. It is a system that has proved effective in about 80% of the cases treated .

Read also: All Remedies for Nocturnal Enuresis

Pharmacological therapy

In cases where medical treatment is indicated, three types of drugs can be prescribed:

• Desmopressin. Some medical studies show that one of the causes of enuresis is a deficiency in the secretion of antidiuretic hormone during sleep (vasopressin or ADH causes the body to produce less urine). On prescription, the use of desmopressin, a synthetic version of the drug. "ADH hormone, is approved for the treatment of enuresis." The drug increases ADH levels and helps reduce the amount of urine produced by the kidneys. Desmopressin, formulated in tablets or nasal spray, should be taken by the child shortly before bedtime. Except for occasional headaches or irritation of the nasal passages, patients do not seem to suffer from any particular side effects.
• Imipramine. In special cases, under the supervision of a neurologist, the administration of imipramine can give good results. This drug is a tricyclic antidepressant that acts on both the brain and the urinary bladder. Imipramine can relax the muscles of the bladder, increasing its capacity (if taken one hour before bedtime) and reduces the need to urinate. Side effects include nervousness, dizziness, dry mouth, headache, increased appetite, gastrointestinal upset, tiredness and sensitivity to sunlight. It is important not to suddenly stop taking imipramine, as it can lead to withdrawal symptoms such as malaise. , anxiety and sleep disturbances (insomnia). Also, parents need to be very careful to keep the drug out of the reach of children, as, when taken in high doses, it can be toxic.
• Oxybutynin. If a young patient experiences daytime enuresis due to an overactive bladder, the doctor may prescribe an anticholinergic drug. Oxybutynin helps relax the bladder muscle, reducing the frequency of bladder contractions and delaying the urge to urinate. Side effects can include nausea, sleepiness, dry mouth, constipation or diarrhea and headache.

Pharmacological treatment of enuresis is not curative and, after discontinuation, relapse is possible. However, this therapeutic option may be useful in limiting the symptoms of the disorder during voiding re-education.