Enuresis – a syndrome of an involuntary, uncontrollable urination, an urine incontience, mainly during sleep. Meets at the children of preschool and early school age having the accompanying neurologic pathology in the anamnesis more often. Causes psychological injuries in the child, the conflicts with peers in collective, punishments by parents in a family, neurosises that aggravates the course of enuresis even more. Often proceeds together with other urological diseases (cystitis, pyelonephritis). The main objective of diagnosis of enuresis is identification of its reason. Full urological examination, and also neurologic and psychological testing of the patient is for this purpose conducted.
Enuresis – an involuntary urination. As a rule, mean an involuntary night urination at children (night enuresis) by this term. Night enuresis the involuntary urination at children at such age when any control over activity of a bladder already has to be established is considered. Many researchers in the field of urology believe that night enuresis is not a disease, and represents a transitional stage between lack of control and complete control over physiological departures.
According to various data, enuresis is observed at 15-20% of children at the age of 5 years and at 7-12% of children at the age of 6 years. Enuresis 3% of children at the age of 12 years and 1% of children aged up to 18 years have. At boys night enuresis develops in one and a half-two times more often than at girls. At 2-3% of patients who in the childhood were observed concerning enuresis during all life the periodic involuntary night urination is noted.
Still accurately the age bracket separating an involuntary urination, normal for the child, from pathological enuresis is not defined. It is considered to be that night enuresis gains the clinical importance when the child is 5 years old. From this point the problem has to be regarded as a pathological state, to draw attention of parents and doctors. Doctors of many specialties take part in treatment of night enuresis: pediatricians, neurologists, psychotherapists, psychiatrists, urologists, nephrologists, etc. Participation of various experts is caused by a variety of the reasons leading to development of enuresis.
Classification of enuresis
Allocate the following forms of enuresis:
- Depending on existence or absence in the past of the "dry" period without involuntary urinations.
Persistiruyushchy (primary) enuresis. Primary enuresis is called bed wetting at the child 5 years are more senior if one Sukhoi is not in the past at least the period lasting more than 6 months.
Recurrent (secondary) enuresis – a state at which the child begins to urinate in a bed after the dry period lasting from several months up to several years. In cases of recurrent enuresis communication with between an involuntary urination and urological, endocrinological, neurologic or mental diseases is quite often traced.
- Depending on time of an involuntary urination.
Allocate the night, day and mixed enuresis. Night enuresis is observed at 85%, day – at 5% and mixed – at 10% of the children suffering from an involuntary urination. Night enuresis quite often develops at children who sleep (profundosomniya) very tight. The day and mixed enuresis can signal that the child has problems of the neurologic or emotional plan.
- Depending on existence or absence of the accompanying pathology.
The enuresis developing in the absence of symptoms of an infection or pathological changes of bodies of urinogenital system is considered uncomplicated.
At detection of an infection of uric ways, anatomo-functional changes of urinary tract or pathological neurologic states the complicated enuresis is diagnosed. The accepted terminology does not reflect cause and effect of pathological states. In this case the above-stated states should be considered more likely as the urine incontience reason, but not as enuresis complications.
The existing classification cannot reflect all features of development and the course of enuresis. A number of researchers allocates neurotic and nevrozopodobny enuresis. Neurotic enuresis usually develops at timid, timid patients and is followed by heavy experiences of the child. The children having nevrozopodobny enuresis unlike the previous group, to teenage age are indifferent to the state.
Some researchers suggest to allocate in separate group the monosympathetic night enuresis which is found at 85% of patients and including subgroups with existence and absence of a night polyuria, with positive and negative reaction to treatment desmopressiny with dysfunctions of a bladder and violation of awakening.
Allocate the following reasons of enuresis:
- Arrest of development of the cerebral centers of an urination
At small children the urination is regulated by the spinal center and carried out involuntarily. When the child reaches age of 2-5 years, in a brain the centers of an urination are formed. Normal at this age cooperation between the cerebral and spinal centers then the urination becomes completely operated is gradually established. If normal relationship is absent between centers, the tone of a bladder is broken and primary enuresis develops.
- Violation of secretion of ADG
Normal at night antidiuretic hormone secretion (the hormone regulating density and amount of the emitted urine) increases. Production of urine decreases, urine becomes more concentrated. At patients with night enuresis change of a rhythm of secretion of antidiuretic hormone quite often comes to light. The lack of antidiuretic hormone causes secretion of a large amount of urine, overflow of a bladder, and, as a result, night enuresis at night.
- Infections of urinary tract and urological diseases
Some congenital (striktura and obliterations of an urethra) and infectious (helminthic invasions, vulvovaginita at girls and a balanopostita at boys) diseases can become the reason of a chronic delay of urine against the background of which the mixed enuresis develops.
- Hereditary predisposition
Hereditary predisposition to enuresis is confirmed. If one parent had enuresis, the urine incontience at children develops in 45% of cases if both are in 75% of cases. Boys are more subject to influence of hereditary factors.
- Stress and adverse psychological factors
Influence of psychological injuries on development of secondary enuresis is noted. In this case the night incontience develops after influence of a certain stressful factor (a divorce of parents, moving, transfer to other school, etc.). Sometimes the child begins to urinate in a bed after the birth of the brother or the sister that is connected with the need to return the lost attention of parents.
Very sound sleep of the child can become the reason of enuresis. Some children are almost incapable to wake up independently at a desire on an urination that leads to development of enuresis.
Night enuresis can result from influence of one factor or several factors in various combinations. Definition of an etiology of enuresis is quite often connected with the considerable difficulties caused by reserve of the child or specifics of manifestation of some factors.
Diagnosis of enuresis
The diagnosis "night enuresis" is established if at the child the involuntary night urination within three and more months is noted. In the beginning the patient is carefully interviewed, finding out history of a disease, a detail of an incontience and amount of the water consumed for the night. The stomach palpation, a rectal research, ultrasonography of a bladder and ultrasonography of abdominal organs is carried out. It is necessary to exclude congenital anomalies of development of bodies of urinogenital system, a basin tumor, not sugar and diabetes.
Experts investigate the volume and a rhythm of urinations. At suspicion of pathology of bodies of an urinary system the nefrostsintigrafiya, intravenous urography, a tsistografiya, an urofluomentriya and a tsistoskopiya can be appointed. For an exception of pathology of a spinal cord of the child the neurologist surveys. Assessment of an emotional condition of the patient and detection of possible mental pathology requires consultation of the psychiatrist or psychotherapist.
The cortical centers of an urination are located near pharyngeal almonds. In some cases increase in almonds can lead to difficulty of breath in a dream, to distribution of signals on the cortical centers and to an involuntary urination. For an exception of inflammatory diseases and increase in almonds patients with night enuresis have to be examined by the otolaryngologist.
Treatment of enuresis
To the patient appoint the special drinking mode. It is recommended not to accept liquid within two hours before going to bed. It is necessary to control that the child during the day received enough liquid. Primary enuresis is often caused by violation of a rhythm of release of antidiuretic hormone therefore to patients with a night incontience appoint a synthetic analog of this hormone – . The dose of medicine is selected individually. Independent application of a desmopressin is inadmissible as enuresis can be caused by other pathology (for example, pathology of development or an infection of uric bodies).
To patients with the raised tone of a bladder appoint . Medicine influences smooth muscles of a bladder, increasing its volume and reducing spasms. In some cases therapy driptany is combined with reception of a desmopressin. The patient with the lowered tone of a bladder recommend to urinate every 2-3 hour, appoint the medicines raising a tone of smooth muscles ().
Psychological correction is shown to the patients having neurotic enuresis. At neurosises and nevrozopodobny states recommend the vitamin therapy courses, medicines improving exchange processes in a brain (phytomedicines, , piracetam). Complex treatment of enuresis includes physiotherapeutic procedures (thermal procedures, ultrasound, treatment by currents), remedial gymnastics for strengthening of muscles of a pelvic bottom and the all-strengthening massage.
For development of a conditioned reflex recommend to use special devices. At emergence of the first drops of urine the device gives a sound signal which awakes the patient and accustoms him to wake up at a desire on an urination. Use of devices gives good effect if parents manage to develop the correct tactics of behavior and to agree with the child. The conflict situations arising at repeated night awakening can lead to refusal of the child to use the device.
It is necessary to remember that treatment of enuresis practically of any etiology – long process. Parents need to stock up with patience and not to wait for immediate results of therapy. Pressure upon the child and the increased expectations can lead to a nevrotization of the child and complicate treatment process.
Enuresis changes mentality of the child, conducts to an aggravation of feeling of own inferiority. Patients hesitate of peers, become reserved, aspire to a privacy. The chronic psychoinjuring situation can become the reason of a low self-assessment, shyness, isolation, indecision. Sometimes children become aggressive. Changes of character can take place unnoticed for parents and come to light only at teenage age. To minimize negative impact of enuresis on mentality, it is necessary to support the child in every possible way. Any manifestations of condemnation or fastidiousness are inadmissible.