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Abstract
Nocturnal enuresis affects 10–15% of 7-year-old children, making them one of the most important health problems in children worldwide. Until recently, NE was often considered as a self-limiting and therefore benign process. However, epidemiological studies have shown that 1% of adults also have these problems. Thus, if bedwetting is still a problem at the age of 7 years, the child has a 5–10% risk of having this problem in adulthood.
According to the International Children’s Continence Society, enuresis is defined as normal voiding occurring at a socially inappropriate time and place, in children aged >5 years. NE is voiding in bed without awakening; monosymptomatic NE is defined as enuresis with no daytime symptoms.
The problem has a negative impact on enuretic children and their families children with PNE were embarrassed by bedwetting while their parents had mixed-feeling of being worried (about organic illness), angry, sad and ashamed. A punitive attitude was still common in our local community and this may adversely affect the parent-child relationship and their commitment to treatment. Children with PNE have lower self-esteem, which lead to loss of confidence, poor school achievement and difficulty in making friends.
The impact of bedwetting as an adverse life event was comparable to poor academic attainment and the experience of being teased frequently. These adverse effects occurs in the younger as well as the older children.
Even the parents feel guilty and anxious of losing confidence in their parenting skills and of parent child relationship. In addition, parents usually worry about organic or psychological disorders as a cause of bedwetting. This worry was present whether they had a positive family history of PNE, and whatever their educational level was. The majority did not seek proper medical advice. This reflected the general public’s ignorance about PNE. The parents feel ashamed, troublesome and angry towards the bedwetting events as these meant extra spending for buying nappies, extra work for washing clothes, and disturbed sleep for lifting children to toilet. Such perceived burden has been reported to be associated with greater parental intolerance, which led parents to blame their children and punish them.
Indeed, bedwetting has been reported as the second commonest reason of child abuse, second to persistent crying.
This punitive approach and poor family relationship makes it unlikely to provide a supportive emotional climate for the young person to learn the skill of becoming dry, and in turn leads to further frustration and helplessness. And was found to be a predictor of poor treatment outcome when alarm was used.
Western studies have suggested that bedwetting confers a bad social and emotional stigma, stress and inconvenience to the child and family.
Most studies confirmed that enuretic children tend to be immature, less self-reliant, less ambitious or secure. They are less motivated for achievements, or less adaptable to different environments. They are also at increased risk of emotional or physical abuse.
Studies also found an increased incidence of behaviour problems in enuretic children:
They have more aggressive behaviour, greater motor hyperactivity; conduct problems, attention-deficit behaviours, anxiety or withdrawal symptoms than control groups. However most studies did not find any formal psychiatric disturbances in enuretic children.
Several pathophysiological mechanisms have been proposed example a small bladder volume , bladder dysfunction, abnormal circadian rhythm of vasopressin levels, nocturnal polyuria, abnormal sleep patterns and arousability
It is important to be aware of the possibility of detrusor overactivity as a cause of a child’s nocturnal enuresis. Possible pointers to it include daytime frequency (voiding more than seven times a day), urgency, holding manoeuvres (such as squatting), low functional capacity (small voided volumes on a frequency volume chart) and urinary urge incontinence (UUI). Multiple wetting episodes each night, variability in the amount of urine in pads and waking during or immediately after wetting are all other indications pointing to an underlying diagnosis of detrusor overactivity.
Several studies reveal that almost all patients with monosymptomatic nocturnal enuresis have a normally functioning bladder and bladder capacity. In contrast, 78% of children with polysymptomatic nocturnal enuresis have functional bladder abnormalities. However, the balance between bladder capacity and the amount of urine produced at night is also an important variable. In some children withnocturnal enuresis, the inadequate antidiuretic hormone production in the evening results in large volumes of dilute urine production while asleep. which exceeds the child’s functional bladder capacity.
Relative lack of Arginine Vasopressin (Antidiuretic hormone) during night leading to nocturnal polyuria.
Whether a patient has underlying detrusor overactivity or lack of vasopressin release, resulting in the overproduction of urine, the enuresis event results from the inability to awaken from sleep.
The point of bladder fullness for most enuretic patients therefore coincides with a time when they find it most difficult to wake from sleep.
Sleep Disdordered Breathing (SDB) is a term that describes a spectrum of upper airway obstruction in sleep from primary snoring, to obstructive sleep apnoea . There is a recognized link between SDB and polyuria/nocturia by increasing nocturnal atrial naturetic peptide (ANP) secretion. Children with habitual snoring were 4 times more likely than those who did not regularly snore to have primary enuresis. And those who underwent tonsillectomy and/or adenoidectomy had improved.
Nocturnal enuresis has been considered as a developmental disorder not influenced by environmental factors such as the mode or age of toilet training. Developmental delay does not seem to be restricted to bladder control, but has been found in other areas including motor and speech development and growth.
Breastfeeding longer than 3 months may protect against bed-wetting during childhood. by providing neurodevelopmental advantages to the child which are a result of higher n-3 and n-6 long-chain fatty acids found in breast milk compared with infant formula.
It was found a high incidence of spinal bifida occulta (which is a is nonfusion of the spinous processes and the posterior arches of the lumbar and sacral vertebrae) in persistent PNE.
Familial and twin studies have suggested a genetic background for NE. The incidence of NE is highest in families in which both parents have been enuretic (77%).
Bacteriuria seems to have a major etiologic role in children with secondary nocturnal enuresis and enuresis resolves after appropriate antibiotic therapy. However, treatment and clearance of the bacteriuria in children with primary monosymptomatic or polysymptomatic nocturnal enuresis rarely, if ever, result in the onset of urinary continence.
Constipation, was found that some children with nocturnal enuresis had constipation, and it was also reported that enuresis ceased in patients who were treated aggressively for constipation.
It is suggested that the parasympathetic nervous system hyperactivity be a cause of vesical hyperactivity in enuretic children.
In a small minority of patients, nocturnal enuresis may be linked to dietary allergies that provoke bladder instability. Specific IgE study showed that there may be a relationship between nocturnal enuresis and soybean and hazelnut food allergens. In some cases treated with SSRI, Clozapine and Respirdone enuresis was induced.
Psychological difficulties are likely a result rather than a cause of PNE. For SNE, emotional factors such as stress, abuse, and divorce may often play an important mediating role.
PGs also increase the tone of the detrusor muscle, relax the urethra and reduce intraurethral pressure, and enhance micturition. Accordingly Carbamazepine, which strongly inhibits PG, was also used to treat nocturnal enuresis, and those not responding to carbamazepine responded well to stronger PG inhibitors such as indomethacin and diclofenac.
In managing a case of nocturnal enuresis a thorough history and physical examination are essential. Parents should be questioned about their family history and the child’s medical history. The type of enuresis and a possible cause or contributing factors, possible functional bladder disorder from nocturnal polyuria have to be distinguished. How parents have handled bed-wetting have to be determined. A voiding diary may need to be maintained for a week or more. The family should keep track of how many times the child voids during the day and how many nights the child wets the bed. Children with nocturnal enuresis have a normal physical examination.
However, the physician needs to check carefully for signs that might signal other problems that can present with bed-wetting as; Gait should be evaluated for evidence of a subtle neurologic deficit, the flanks and abdomen should be palpated for masses, including an enlarged bladder. The lower back should be inspected for cutaneous lesions or an asymmetric gluteal cleft, which could suggest spinal dysraphism, a variant of spina bifida.
The investigations that can be performed are: urinalysis is to assess specific gravity and urinary glucose level. It also can determine the presence of infection or blood in the urine.
If the findings of the physical examination and urinalysis are negative and the history does not suggest a secondary cause of nocturnal enuresis, no further work-up is needed. If urinalysis reveals evidence of infection, the child should be evaluated for vesicoureteral reflux. The currently recommended work-up is: a voiding cystourethrogram and renal ultrasound examination.
Treatment can include reassurance and support, behavioural interventions other than alarms, lifting, waking, reward systems (positive reinforcement systems) as “star charts” and “connect-the-dots picture”, retention control training, stop-start training, dry bed training and responsibility training.
The enuresis alarms are very effective but we have to study first the cost, the possible predictors of poor response and the acceptability of alarms within the family context.
Drug therapy is not usually appropriate for children under seven years of age and is reserved for when alternative measures have failed. It also recommends that the possible side effects of the various drugs should be considered and that any prescription should not be continued for longer than three months without stopping for a full re-assessment.
Available drugs are Desmopressin (or DDAVP), tricyclic antidepressants as Imipramine, anticholinergics as Oxybutynin and at last prostaglandin inhibitors as Carbamazepine, Indomethacin and declofenac. In addition, specific adjunctive therapies are: hypnosis, acupuncture, chiropractic, energy/ultrasound, diet restriction, and the usage of some herbs.