Enuresis at children – the violation of controlled depletion of a bladder which is followed by an involuntary urination in a dream. Enuresis at children is shown by urine dribble during sleep which can periodically arise or repeat to several times in a night. Diagnosis of enuresis demands establishment of causes of infringement from children and includes maintaining the diary of urinations, laboratory blood tests and urine, ultrasonography of a bladder, urodinamichesky researches, neurologic inspection and so forth. In complex therapy of enuresis at children the psychotherapy, physiotherapeutic treatment, medicamentous therapy is applied.
Enuresis at children
Enuresis at children – the kind of an incontience of urine at children which is followed by repeated episodes of an involuntary urination which usually occur in a dream. The enuresis problem demands integrative approach from children; its decision has to be passed with participation of experts in the field of pediatrics, children's urology and nephrology, children's neurology, children's psychology, etc. Prevalence of enuresis among children fluctuates from 4 to 20%: the involuntary urination is observed at 18-20% of 5-year-old children; 12-14% - 7-year and about 4% - teenagers of 12-14 years. (Approximately twice) enuresis meets at boys statistically more often.
Classification of enuresis at children
From the point of view of a current allocation of primary and secondary enuresis at children is represented to the most important. Primary enuresis is characterized by continuous clinical manifestations and lack of the long "dry" periods. Secondary enuresis at children is meant as a state at which the incontience of urine was absent not less than 6 months, and then appeared again. In 75-80% of cases primary enuresis is diagnosed for children.
Besides, distinguish monosimptomny (uncomplicated) and polisimptomny (complicated) enuresis options at children. In the first case it is about urine dribble as the only display of enuresis; in the second case – the incontience of urine is combined with imperative desires, the speeded-up urination and so forth the Polisimptomny option occurs at 15% of children with enuresis.
Enuresis at children is divided by the mode of violation of an urination on day, night and mixed. At 80-85% of children the involuntary urination occurs during a night dream therefore the term "enuresis" usually designates bed wetting. Depending on an etiology allocate a simple, neurotic, endokrinopatichesky, epileptic, nevrozopodobny form of enuresis at children.
The enuresis reasons at children
Simple enuresis at children is most often connected with a hereditary otyagoshchennost. If at children whose parents did not suffer from an urine incontience, the risk of enuresis makes 15%, then at the child whose parents (one or both) had in the childhood enuresis, this probability makes 44% and 77% respectively. Such form of an incontience develops without the accompanying neurologic or urological diseases.
Enuresis at children can accompany clinic of various diseases of a nervous, endocrine and urinary system, violations of mentality, etc. So, the neurotic form of enuresis at children develops as reaction to the sharp or difficult psychoinjuring circumstances. Endokrinopatichesky enuresis arises against the background of the accompanying endocrine diseases – diabetes, obesity, etc.; the epileptic form is noted at epilepsy at children. Development of nevrozopodobny enuresis in children is connected with organic defeat of TsNS owing to toxicoses of pregnancy, a hemolytic disease of a fruit, a pre-natal hypoxia, patrimonial injuries, infections (meningitis, encephalitis, flu, etc.), intoxications, ChMT.
Besides, enuresis often occurs at the children having in the anamnesis of an infection of urinary tract (cystitis), congenital defects of urogenital area (an epispadiya, a gipospadiya, an ektopiya of a bladder or mouths of mochetochnik), obstruction of urinary tract (a striktura of an urethra or a mochetochnik, ), a neurogenetic bladder, helminthoses, anomalies of development of a backbone and a spinal cord. In clinic of psychiatric diseases enuresis can accompany a current mental retardation and schizophrenia.
By consideration of pathogenesis of monosimptomny enuresis at children most of authors inclines to opinion that the delay of timely formation of reflex control of an urination is the cornerstone of violation. It is considered that normal this control is formed by 3-4 years when at the child bladder volume increases, the number of urinations is reduced to 7-9 in days, children can begin or constrain consciously an urination, feel need for observance of hygienic rules, waken when filling a bladder and so forth. However at a delay of functional maturing of TsNS formation of conscious control of an urination is late that leads to development of enuresis in children. Spontaneous disappearance of enuresis at children demonstrates completion of formation of processes of control over an urination. In support of this hypothesis the fact that enuresis at children is often accompanied by other manifestations of delay of development of the child demonstrates: violation of any control of defecation, delay of motor and speech development.
Besides, researchers pay attention that at children with enuresis quite often is broken hormonal regulation of water exchange, namely – a normal daily rhythm of secretion of antidiuretichesky hormone (antidiuretic hormone). It leads to formation of rather large volume of urine at night that in the conditions of lack of control of an urination is followed by the involuntary expiration of urine.
Enuresis symptoms at children
As the leading symptom of enuresis at children serves the involuntary urination during sleep, is more rare – wakefulnesses. Episodes of an involuntary urination can seldom arise, but is constant (several times a month or in a week) or to repeat repeatedly during the night. Usually not deduction of urine happens in the first half of night, in a phase of a deep sleep. , children usually do not wake up.
At the complicated enuresis at children, except a night or day incontience of urine, the speeded-up or rare urination, imperative desires or lack of desires on an urination, a weak stream of urine, etc. can be noted.
Locks or , emotional lability, the increased uneasiness and vulnerability, isolation, shyness, various sleep disorders (long falling asleep, uneasy superficial or excessively deep sleep, awakening violations) are characteristic of some children having enuresis. Nevrozopodobny enuresis at children is often combined with stutter, tics, SDVG, fears.
Diagnosis of enuresis at children
As enuresis at children is not only an urological problem, various experts can take part in diagnostics of violation: pediatrician, children's neurologist, children's endocrinologist, children's psychiatrist, etc. However the leading role at the initial stages, undoubtedly, belongs to the children's urologist.
When collecting the anamnesis the perinatal and family otyagoshchennost, the postponed diseases, features of a course of enuresis at the child is specified, provocative factors, etc. Fizikalny inspection of the child assumes a stomach palpation, survey of genitalia, a crotch and lumbar and sacral area, carrying out a rectal research for the purpose of detection of anomalies of development. Parents of the children having enuresis are offered to keep the diary in which it is necessary to fix quantity of urinations and episodes of an incontience of urine at the child per day, time of an involuntary urination, the accompanying frustration.
For an exception of an uric infection the general analysis of urine and blood, biochemical blood tests and urine, a bacteriological research of urine on flora is made. For the purpose of identification of anatomic changes of urinary tract ultrasonography of kidneys and a bladder is carried out. By means of urodinamichesky researches (an urofloumetriya, an electromyography, a tsistometriya, a sfinkterometriya, a profilometriya) infravezikalny obstruction and instability of function of a detruzor comes to light.
According to indications to children with enuresis electrophysiological researches (electroencephalography) can be conducted endoscopic (an uretroskopiya, a tsistoskopiya), radiological (an uretrografiya, a tsistografiya, a X-ray analysis of the Turkish saddle, a X-ray analysis of lumbar and sacral department of a backbone, etc.).
All range of diagnostic search allows to exclude or confirm presence at children with enuresis of anomalies of development of uric ways and a backbone, infections of an urinary system, endokrinopatiya, TsNS diseases.
Treatment of enuresis at children
At the complicated enuresis at children first of all correction of organic pathology of urinogenital or nervous system is necessary. The complex of medical actions at simple enuresis at children includes behavioural and medicamentous therapy, physical therapy, psychotherapy.
Understand elaboration of control over an urination as behavioural therapy. For this purpose limit liquid reception in the evening, regulate a diet, accustom the child to empty a bladder before going to bed etc. In the first half of night of the child it is recommended to land on a pot; for the purpose of development of a reflex of awakening it is possible to use the special detectors ("uric alarm clocks") signaling about emergence of the first drops of urine during sleep and forcing the child to wake up.
The psychotherapy as method of treatment of enuresis, is appointed at children 10 years are more senior and it is carried out by the qualified psychotherapists and children's psychologists. For younger children autogenic trainings, motivational psychotherapy can be used (encouragement for each "dry" night). Among physiotherapeutic methods at enuresis at children magnetotherapy, laser therapy, an electrophoresis, an induktotermiya, electrostimulation, galvanization, thermal procedures, acupuncture, LFK well proved.
The choice of pharmacotherapy depends on an enuresis form at children. High efficiency is shown by purpose of antikholinergichesky medicines (oksibutinin), tritsiklichesky antidepressants (imipramin) and analogs of antidiuretichesky hormone (desmopressin). These means increase the functional capacity of a bladder, reduce the volume of night urine, reduce activities of a bladder at night.
The forecast and prevention of enuresis at children
Enuresis has rather good-quality current: annually at 15% of children spontaneous remission is reached, and by 15-18 years enuresis comes to light only at 1-2% of persons. In other cases by means of therapy it is possible to reach the termination of enuresis at 9 children from 10. It is necessary to speak about full treatment in case of lack of episodes of an incontience of urine within 2 years.
Prevention of enuresis at children consists in earlier elimination of the reasons of an incontience of urine; creation of the favorable emotional situation surrounding the child; timely schooling of the child to a pot and refusal (no later than 2 years) from use of disposable diapers. Treatment of enuresis demands persistence and patience from physicians from children, parents and teachers, benevolent and at the same time exacting attitude towards the child. Lack of attention to an enuresis problem at children is fraught with development in them in the future of secondary mental stratifications and an inferiority complex.