(Defined as an involuntary discharge of urine that occur at night during sleep)
Bed wetting at night has become night mare to patients,to the parents of children and also to many physicians. But do not worry about this, most of the cases are benign condition and easy to manage these problems.
I am trying to discuss the causes,pathological changes of its and how to deal this condition by plotting some questions and answer, for your better understandings.
Ans : The daytime urinary frequency syndrome is a benign condition, which occurs in normal children who have no associated daytime incontinence or nighttime symptoms. The etiology is generally unknown. Conservative approach is justified. Symptoms usually resolve in 2 to 4 months and are characteristically unaffected by anticholinergic drugs.
The usual sequence of development is-
15% of normal children will still wet at night at 5 years of age.
Nocturnal enuresis occurring after the age of 5 or by the time the child enters grade school is generally considered a cause for concern.
15% per year.
Between 50% and 75%.
The most effective therapy of treating enuresis is = conditioning therapy, as in the bell alarm (buzzer alarm) method. Superior results have been reported with this method compared to other forms of behavioral therapy, as well as pharmacologic therapy with DDAVP.
Imipramine is used as a second-line therapy.
Bladder training was developed to increase functional bladder capacity, but has not seen much success.
Another method of alternative behavior modification is responsibility reinforcement, such as reward and motivation. This also requires active and willing participation of the child to succeed.
3 major actions of imipramine in the urinary tract are antimuscarinic action, direct inhibition of bladder smooth muscle, and analgesic effect.
It also causes CNS sedation and blockade of norepinephrine reuptake.
The most important bladder action is the direct relaxant effect.
Imipramine significantly alters sleep patterns by decreasing the time spent in REM sleep and increasing the time spent in light NREM sleep.
Primary enuresis. The diagnosis of enuresis can only be made after 5 years of age.
In most cases, spontaneous improvement is the rule.
Imipramine, a tricyclic antidepressant, is the most widely used antienuretic agent worldwide, but it’s currently recommended only as a secondary agent.
Enuresis can be eliminated in more than 50% of children and will be improved in another 15% to 20%, however, up to 60% of patients will relapse upon discontinuation.
Its peripheral effects increase bladder capacity by
This patient has primary enuresis. Enuresis is found in more than 1% of the adult population, often with overt abnormalities on urodynamic studies such as uninhibited bladder activity.
Cessation of compounds that might increase nocturnal urine output, such as caffeine, should be strongly advised before recommending other forms of treatment.
Recent studies indicate that enuretic sleep patterns are not different form the sleep patterns of normal children, and that most enuretics do not wet as a consequence of sleeping too deeply.
The most widely accepted formula for the predicted bladder capacity in children is:
Bladder capacity (mL) = [age (years) + 2] × 30.
Anticholinergic medication in this setting will have greatest impact on uninhibited bladder contractions but will probably not help his nocturnal enuresis very much.
Pure nocturnal enuresis.
Anticholinergic drug therapy has only been effective for enuresis in just 5% to 40%.
Simply limiting fluids to reduce urine output is not generally effective.
Measurements of urinary and serum ADH demonstrate an absence or reversal of the normal circadian rhythm in enuretics who have lower than normal excretion of nocturnal ADH.
Desmopressin (DDAVP), a synthetic analog of ADH, effect lasting 7 to 10 hours.
DDAVP has effective rate up to 60%, especially in older children.
Patients on DDAVP are 4.5 times as likely to stay dry overnight as controls.
Limitations: high cost of the drug and the potential for recurrence upon discontinuation.
Ultrasound examination of the kidneys,ureters and bladder before and after voiding.
Diurnal enuresis occurs in 5% of 7-year-old children.
In most children, the underlying problem is = infrequent voiding.
Timed voiding programs alone will be successful in the majority of children but require several months to be effective.
Anticholinergics such as oxybutynin can be tried along with timed voiding.
This girl presents typical findings of 'dysfunctional elimination syndrome'.
Large fecal impaction may induce significant detrusor instability and other bladder dysfunctions, which in turn will result in urgency, UTI and reflux.
A high incidence of enuresis in children with UTIs and constipation has been reported.
Timed voiding along with treatment of constipation can improve not only fecal soiling but also diurnal enuresis.
Anticholinergics in this condition are not recommended as they are likely to aggravate constipation and may causeurinary tract infections.
The most likely diagnosis is vesicovaginal reflux.
This best describes postvoid dribbling, which is typically when urine gets trapped in the vagina during voiding and dribbles out soon after standing.
Vesicovaginal reflux itself is harmless and tends to resolve with age but it can create a damp environment prone to infection.
Therefore, the child may be taught to empty her vagina by simply voiding with her thighs apart and leaning forward after voiding before getting up.
50%. Anxiety-provoking factors predominate.
20% of ADHD cases also have enuresis.
Both problems are believed to involve the same brain stem area abnormality so it's likely they would occur together.
Buzzer alarm behavioral therapy works best, except in children who also have ADHD.