Introduction :-
Nocturnal Enuresis commonly known as bed wetting , it is a type of voiding disorders in children, upto the age of 5 years as a part of normal childhood development. But in adults, it may occur due to alcohol intoxication. Normally at the age of 3 to 5 year, child becomes continent. Day continence comes early than night continence.
There are also other types of voiding disorders, like –
• Diurnal Incontinence
• Pollakiuria ( Frequency of urination increases )
• Dysuria
• Nocturnal Enuresis
Here, we will discuss mainly about nocturnal enuresis.
Causes :-
Benign causes-
These causes are not very serious so are known as benign causes, they includes
1) Genetic Causes– Sometimes there may be delaying in the cortical maturation , which is causing nocturnal enuresis, we may find familial history of bed wetting.
2) Sleep Variation- Some child have deep sleep due to which they can’t wake up from the sleep causing bed wetting .
3) Personal problem– In this case there’s no family history but may be due to some psychological stress child is unable to wake up and pee.
Pathological Causes-
1) CNS related Causes- Some CNS related diseases like, Spina bifida, spine TB, Hydrocephalus may cause nocturnal enuresis.
2) Hormonal problem– Generally ADH ( anti diuretic hormone ) causes the body to make less urine at night.But sometimes this ADH deficiency responds to body which causes too much urine formation. Also some diseases like Diabetes mellitus, Diabetes insipidus may be the cause behind this bed wetting.
3) Respiratory system Causes– Sometimes Adenoids & tonsil enlargement causes the child to snore which leads to sleep apnea (i.e suddenly child chokes) , due to which child wakes and passes urine in the bed.
4) GIT & Urinary tract Causes– Constipation, urinary tract abnormalities ( problem with the structure of a person’s urinary tract ) & urinary tract infection may cause nocturnal enuresis.
5) Bladder problems– In some children too many muscle spasms can prevent the bladder from holding a normal amount of urine in bladder. Also sometime , individuals have relatively smaller bladder that can’t hold a lot of urine.
How to examine child for pathological causes ?
1) Hydrocephalus – If child is suffering from Hydrocephalus then we observe head size , also we examine or ask the child’s parent that is the child having any trouble in walking, running , etc. Because we know that in hydrocephalus ventricles dilate which applies pressure on nerves innervating to legs which may cause difficulty in walking , running, etc.
2) Spina bifida– In this case, we may find probelm in legs + tuft of hair or depression in the back of child
3) Adenoid & Tonsil enlargement- Chronic tonsilitis causes obstruction in the air pathway, causing snoring which may lead to sleep apnea and hence control on body by brain gets disturbed and child urinates on bed itself.
4) Constipation– Due to constipation rectum of the child remains full which applies pressure on bladder causing nocturnal enuresis.
Although we have discussed many causes but one should keep in mind that mostly nocturnal enuresis occurs due to benign causes.
Investigations:-
– MRI brain
– USG abdomen
– ADH level
– Blood glucose level
– CT spine
Management:-
1) Diagnose and treat the pathological causes like, constipation, Spina bifida, DM, etc.
For Benign causes ( Delayed cortical maturation ) :-
It is very much important that we reassure parent and ask them to don’t scold child , always treat the child with love and affection
Also we ask the parent to always reward the child whenever he / she doesn’t do bed wetting as this sense of affection and reward stimulates the cortical maturation.
Some other points to keep in mind –
• Avoid Tea- coffee at night
• Avoid sweets at evening/night
• Slightly reduce intake of water at night
• Always ensure that child voids before going to bed, also when child sleeps parent should wake him/her and ask to void again.
For child > 6 year
Imipramine in small doses may be used, but usually drug is avoided.
