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BED WETTING IN\r\nCHILDREN
This is a common condition occurring in some children.\r\nBedwetting at night during sleep in a child above the age of 5 years is\r\nconsidered abnormal and called Nocturnal Eneuresis. Originally it was always\r\nthought that the cause is psychological but today it is known that there may be\r\nmore than one reason for this anomaly.
There are 2 classifications of this condition. The first\r\nis Primary and Secondary nocturnal eneuresis. Primary nocturnal\r\neneuresis is when the child has been bed wetting since younger days and\r\ncontinues to do so even after 5 years. Secondary nocturnal eneuresis is when\r\nthe child had stopped bedwetting for a continuous period of at least 6 months\r\nand again begins bed wetting. This is important \r\nfor the possible cause and also the treatment of this condition. The\r\nsecond classification has also 2 types, one is Isolated/Monosymptomatic\r\nnocturnal eneuresis\r\n– here the bedwetting is the only problem in micturition in the child. The\r\nother type is nocturnal eneuresis with dysfunctional\r\nvoiding symptoms-\r\nhere , besides having bedwetting, the child has other daytime complaints like\r\nfrequency, urgency, hesitancy in passing urine. Again, the importance is in the\r\ncause and the therapy to be recommended for that particular child.
Why does a child have nocturnal eneuresis? There may be\r\nmultiple reasons like – a small functional capacity of the urinary bladder –\r\nthe amount of urine that a bladder can hold without discomfort to the child or\r\nthe child having to evacuate the bladder for relief; a delay in maturation of\r\nthe development of the bladder growth, the nerves to and from the bladder; deep\r\nsleeper with difficulty in arousing the child from sleep, thus causing the\r\nchild to pass urine in deep sleep unaware of the problem; abnormal intermittent\r\ncontractions of the bladder muscle causing evacuation of the bladder before it\r\nis full; or improper secretion of Anti Diuretic hormone in the body at night.\r\nThis hormone decreases the volume of urine excreted at night, and less filling\r\nof the bladder, if there is a deficiency of this hormone, the kidneys throw out\r\na lot of urine at night that fills the bladder and urine is passed out at\r\nnight. There is a very strong hereditary role in transmission of the condition.\r\nThere is a very high chance of occurrence in a child with both parents who were\r\nnocturnal eneuretics, lessor in those with one parent , and about 15% in a\r\nchild whose parents were normal too. Race may also have a role to play. Thus\r\nnocturnal enuresis is a mismatch between urine production and urine storage\r\nfunction. There may be be one or more reasons for bedwetting in a given child\r\nand treatment becomes more diverse in such cases.Such a child must be shown to a properly trained doctor\r\nif bed wetting continues beyond the age of 4 years. A detailed history and a\r\nthorough examination followed by relevant investigations\r\nare a must to get to the root cause of the condition. In some children a whole\r\nlot of investigations are required, in others very few need be done.
Treatment is begun after taking the child into full\r\nconfidence ensuring full cooperation and\r\ninvolvement. Parents must realize that getting angry or punishing/ ridiculing\r\nthe child alone or in front of relatives or friends is the worst thing to do.\r\nNo child purposely likes bedwetting, and thus understanding, empathy and\r\nemotional support is most important for getting early and excellent\r\nresults. Treatments are of different\r\ntypes like: behavior modification; bio feedback; use of alarms; selective and\r\nsupervised use of drugs and a prolonged but regular follow up for 3 years at\r\nleast. Use of an alarm clock to wake the\r\nchild 4 hours after going to bed and make the child pass urine in the bathroom\r\ndaily for a few months till the child is able to get up on his/her own. Use of\r\nthe hormone drug – Desmopressin in\r\nselected cases will decrease the volume of urine formed at night and avoid wet\r\nnights. This drug is continued for long periods with gradual tapering off. This\r\ndrug can be given thru a nasal spray, oral tablets or soon melt tabs will be\r\navailable in India, and the dose needs to be adjusted. Children who have an\r\nunstable bladders, that contract intermittently: drugs like Oxybutynin \r\nhelp in correction and normalization of the bladder function. A note of\r\ncaution here is that proving this abnormality requires a thorough Urodynamic study on the child before starting the\r\ntherapy and a follow up is essential, but not practical in all cases. The child\r\nbeing actively involved in each step of the therapy and the result acts as an\r\nincentive for a rapid improvement and rise in self esteem of the child. The improvement will be\r\nsustained with a regular follow up and\r\npep talks to the child from time to time – to keep it up. The therapy of this\r\ncondition depends on understanding, and a total involvement of the patient,\r\ndoctor and the parents to give the best\r\nresults.
I am conducting a Speciality Clinic for this conditions\r\nand have got consistently excellent results in almost all cases even those who\r\nhave taken therapy elsewhere before coming to me. The session starts with the\r\nparents having to answer a questionnaire of about 50 odd questions before a\r\nplan for that individual child is formed. Thus the therapy is custom made for a\r\nparticular child and not the same in all cases. Follow up is required to tweak\r\nthe therapy from time to time, either increasing doses of the drugs, or\r\ndecreasing the same, reinforcing the motivation for following instructions and\r\nreviewing the progress or lack of.
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