What is Enuresis?
Enuresis is a medical term for a disorder generally known as bed wetting. This is a common elimination disorder and very familiar worldwide problem of childhood. It is important to know about the symptoms, types, diagnosis and treatment of enuresis to be able to manage the condition well.
Studies advocate that about 7% of boys and 5% of girl child in their fifth year of age suffer with enuresis. As they grow this occurrence reduces to 3 to 2 % in the age of 10 years. Usually enuresis or bedwetting reduces as children grow. Only few cases have been reported of enuresis after the age of 18 years.
World Health Organization (WHO) and American Psychiatric Association (APA) define enuresis as an involuntary that is unintentional and sometimes intentional wetting in children of age of 5 years or more in absence of other organic or pathological cause. To find the status of disorder the wetting problem should be persistent for minimum period of three months. Bedwetting that lasts for less than 3 months of period cannot be considered as enuresis. Other criteria to consider before confirming enuresis is that wetting should be present at least two times a month in children below 7 years of age and once in a month for age 7 years or above. Summarily child should be of minimum five years of age and wetting frequency should be at least one or two times in a month, to be diagnosed as enuresis.
It is usually noted that the prevalence of enuresis is high in boys than girls. Studies suggest that rate of wetting is about 1.5 to 2 times higher in boys. Contrarily, day time wetting is more common in girls. As the age increases tendency of bed wetting decreases.
Symptoms of Enuresis
The main symptoms of enuresis include
- Nocturnal bed wetting
- Wetting of clothes
- Excessive sleepiness, also during the daytime
- Frequency of wetting minimum two times a month
- History of wetting for at least three months.
Types of Enuresis
On the basis of time of occurrence, some of the types of enuresis are
- Nocturnal Enuresis - This is the real form and the commonest type of enuresis. Wetting is observed at night mostly during sleeping time in children. This has nothing to do with dreaming as most of the bed wetting occurs in non REM phase of sleep or in first half of sleep.
- Day time wetting – This is another form where wetting, which is caused by some pathological organic causes. In this type of enuresis, there is no bed wetting at night.
Combined – This type of enuresis, the person experiences both the above forms.
On the basis of longest dry period or absence of wetting, enuresis may be of two types:
- Primary Enuresis – In this condition, the longest dry period for a patient is less than six months or total absence of dry period.
- Secondary Enuresis – When a relapse of wetting is observed after a dry period of 6 months, the condition is termed as secondary enuresis.
On the basis of the condition of bladder function, the types of enuresis include,
- Monosymptomatic Enuresis – This type of enuresis is purely nocturnal bed wetting. Though patients wet at night in their sleep, but the bladder function is absolutely normal. They do not show any episodes of day time wetting. There are no complaints of the urinary tract, pain when urination or difficulty in passing urine, etc. are not present.
- Non-monosymptomatic Enuresis- In this type of enuresis, the patient shows combined form of wetting problem; wetting during the night and day both are present. Other urinary tract disturbances symptoms may also be present. For example, pain during urination, urge symptoms, bladder storage or emptying problem or postponement of urination etc. Along with these, gastrointestinal symptoms like constipation etc. may also be experienced by some patients.
Causes of Enuresis
Medically, enuresis is described primarily as a functional disorder, which has a physical impact and impairment of body functions without having any visible organic or structural defect. Exact cause for functional disease is unknown, emotional and mental factors contribute in the progress of these types of disorders. Hence the exact cause of enuresis is also not clear.
But being a functional disease causes of enuresis are mainly related to psychological and emotional impact. Day time wetting is associated with some organic causes as neurological defects, structural defects or other form of physical impairments. But this is urinary incontinence and not included in pure form of enuresis.
Some of the possible causes of enuresis are :
- Emotional stress, anxiety, behavioral disorder or other forms of psychological ailments.
- UTI (urinary tract infection) of persistent nature can sometimes cause enuresis.
- Structural problems of the bladder or urethral defects too are also a common cause of enuresis.
- Faulty toilet training and developmental delays.
- Kids who are fast asleep or very sleepy do not notice the sign of full bladder and avoid awakening at night for toilet.
- Enuresis can sometimes even be hereditary.
Diagnosis of Enuresis
An accurate diagnosis of enuresis totally depends upon how carefully case history has been taken. A thorough clear history taking not only leads the expert to correct diagnosis but other factors and conditions are also revealed. Age of the patient is another diagnostic tool for enuresis. As stated earlier wetting only in child 5 years and above falls in category of enuresis. Psychiatric assessment also helps in diagnosis. Therefore thorough assessment for a proper diagnosis is must.
Following are the major tools that help in making a diagnosis of enuresis
- Careful history taking.
- Questionnaires for physical and psychological assessment as per requirement.
- Chart for urine frequency and volume per day.
- Urine tests if needed.
- Ultra-sonography, radiological examinations etc. to rule out other impairments.
Treatment of Enuresis
Treatment of enuresis depends upon the factors associated with it. This requires co-operation, patience and proper time of patient child and parents as well. Studies has proved that non medicinal form of therapy for this disease are much effective and medicinal therapy is required only when criteria of non-medicinal therapy is not fulfilled.
Non Medicinal Therapy – In this type of treatment of enuresis medicines are not described. Patient is treated with counselling and behavioral therapy.
Counselling in Enuresis
Counselling of both the parent and the child is must. Enuresis generates emotional distress and feeling guilty attitude that aggravates the problem of wetting much more. Therefore counselling should be done to relieve the stress, to give the support and to provide the required information to both child and parents.
Objectives of counselling in enuresis are –
- Motivation to ease the guilt feeling and enhance self-worth and self-confidence.
- Information regarding proper toilet training.
- Instructions like telling children to go to toilet before seeping.
- To praise the child and motivate them if they show positive response.
- To stop other futile measures like fluid restriction, punishment to children etc.
- Education regarding proper food intake and drinking habits.
Alarm Treatment for Enuresis
This is the most effective treatment for enuresis. Here a metal sensor is used for alarm. When the sensor happens to wet, the inside circuit starts alarm audible signals causing the child to wake up. The alarm is advised to be used daily for up to 16 weeks. During this period children learn themselves to awaken when the bladder is full. They also learn to control their muscles. This alarm therapy works faster and in some children only 4 to 5 weeks are required while some others needed 8 to 10 weeks of alarm training. It is advised to stop alarm system after 14 dry nights. If relapse occurs alarm treatment is again started.
- Two types of alarm generally used are body worn and bedside alarms.
- In body worn alarms sensors are fitted inside underpants or diapers.
- In bedside alarms sensor is placed under the bed sheet.
- According to the comfort the type of alarm may be used. Both types have shown good results.
Medicinal Therapy for Enuresis
As the name suggests, in this form of therapy medicines are prescribed to treat the disease. It is less effective and shows reoccurrence of disease when the medicine is stopped. Hence it is advised to pursue this form only when the non-medicinal therapy cannot be followed or it can be sometimes started in combined form.
Situation where medicinal therapy is required are -
- Lack of taking responsibility and motivation in parents and children.
- Feeling discomfort with alarm treatment.
- Personal issues as work load etc. where alarm treatment cannot be carried out.
Medicines prescribed are – Desmopressin and Tricyclic antidepressants. Desmopressin with less side effect is mostly preferred. Medicines for enuresis should be taken under supervision of experts only.