Bedwetting, also defined in clinical practice as enuresis (enourin: to urinate in Greek); It is defined as the child’s wetting his or her bed during the day or night. It can be accepted as a treatment condition if it occurs at least twice a week for at least three months or when bedwetting causes serious distress to the child and the family.
It can only happen at night, it can be both day and night, it can only happen during daylight hours. Situations in which the child does not achieve toilet control at all are considered primary (primary) type. If the child has been able to control the toilet for a period of six months or a year and has started to wet the bed afterwards, it is considered as the secondary (secondary) type.
Primary type of urinary bladder (bladder) control is never gained, it constitutes eighty percent of all cases, it is usually experienced at night, and it is mostly attributed to genetic, biological and developmental causes.
Secondary type of bladder control is gained but subsequently lost, it constitutes twenty percent of all cases, it is usually attributed to organic and psychological causes.
It is two times more common in boys than girls. It is seen in one-fifth of five-year-olds, one-eighth of six-year-olds, one-tenth of seven-year-olds, and one-twentieth of ten-year-olds.
REASONS
The causes of bedwetting are varied
– Genetic predisposition: The child’s first-degree relatives also have a history of bedwetting (enuresis) in childhood. In some studies, abnormalities were detected in the 12th, 13th and 22nd chromosomes. Although a definitive genetic focus has not been found, roughly eighty percent of children with enuresis have a family history. If one of the parents has it, the probability for the child is hand, if both parents have it, it is seven percent.
– Its relation with sleep has been researched. Bedwetting occurs most often in the first third of sleep and during the deep sleep phase. Research results suggesting that children with bedwetting are more difficult to wake up from, and that they do not feel bladder fullness. Adenoid hypertrophy (adenoid swelling) can cause sleep apnea and urinary incontinence.
– Anatomical and physiological problems in the structure of the urinary tract and bladder (bladder) have been investigated and it has been shown that the functional bladder capacity (volume at the time of ejaculation) decreases in these children, and there may be inconsistencies in the function of the detrusor muscle in the bladder.
– In some cases, it has been suggested that there may be abnormalities in the daily release process of antidiuretic hormone, intraday abnormalities in urinary sodium and potassium excretion, and endogenous arginine vasopressin production.
– Psychiatric factors play a greater role in secondary type enuresis, but they are also common in primary type. In societies with low socioeconomic status and large families, the frequency of enuresis is higher in children with a history of trauma. Enuresis; It can be one of the symptoms of many psychiatric diseases such as depression, social phobia, obsessive-compulsive disorder that can be seen in children. Inadequate toilet training, lack of discipline, and behavioral problems may also increase the frequency of enuresis.
– Diabetes mellitus and insipidus, sickle cell anemia, epilepsy, alcohol, coffee, cola, extreme cold weather, excessive fluid intake, bacterial and fungal infections of the urinary tract (thirty percent of the secondary type), renal failure, neurogenic bladder, myelomeningocele, spinal cord tumors can also be counted among the causes of enuresis.
DIAGNOSIS
First of all, a detailed anamnesis (patient history) is taken. Whether the enuresis is primary or secondary, its frequency and intensity, the period of staying dry, the amount of fluid taken, the urination practices and its pattern, as well as the feeding regime, urinary pain, burning, odor, frequent urination, etc., whether accompanied by other behavioral problems, general mental status, whether there is a physiological disease and the treatments applied, the child’s toilet training, the family’s approach to the problem are learned.
Physical examination of children with enuresis is usually normal. However, in doubtful cases, detailed examination of the abdomen, inguinal region, genital organs and neurological examination should be performed.
Some laboratory scans may be performed when further investigations are required. Many examination methods such as urine analysis, urine culture, functional bladder capacity measurement, parasite examination in stool, lumbosacral graphy, urodynamic evaluation, ultrasonography, voiding cystourethrogram, intravenous pyelogram, etc. can be used.
DIFFERENTIAL DIAGNOSIS
Enuresis is usually monosymptomatic, that is, it occurs alone. However, all diseases that may cause enuresis should be considered and the necessary diagnostic tools should be applied.
After excluding physiological diseases that may cause enuresis, it should be evaluated in detail from a psychiatric point of view.
Enuresis; It is a situation that destroys the self-confidence of the child, disturbs all day long, and raises anxiety. Rarely, the child’s awareness is weak, he does not care much. Enuresis is usually seen alone, but it may appear as one of the symptoms accompanying the disease in many cases such as depression, obsessive compulsive disorder, mental retardation, social phobia, selective mutism, specific phobia (not being able to sleep alone, fear of closed spaces, etc.).
TREATMENT
If the cause of enuresis is due to physiological diseases such as diabetes, kidney disease, etc., the appropriate treatment for that disease is performed by the relevant branch physicians.
Enuresis treatment in psychiatry clinics is versatile.
The primary treatment approach is to increase the motivation of the child and the parent and the treatment cooperation with behavioral therapy techniques. To parents; They are taught to encourage the child to stay dry with a determined and consistent approach without offending. The child’s daily water intake and toilet training are arranged. The absolute benefit of restricting fluid intake has not been demonstrated, but nocturnal urination can be reduced by transferring most of the daily fluid requirement to daylight hours. It can be ensured that the child wakes up dry by being taken to the toilet shortly before the soaking time, and the days when the child gets up dry can be rewarded, and the number of days he wakes up without wetting can be increased.
There are various drugs used in the treatment of enuresis and their usefulness is very high. The mechanism of action of the most commonly used drug, imipramine, is unknown, it is believed to reduce urinary output and osmolality by reducing sodium and potassium excretion, and its effectiveness is high. Another commonly used drug is known as desmopressin, it reduces the amount of urine at night. Less frequently, drugs such as prostaglandin synthesis inhibitors, mesterolone, anticholinergic calcium antagonist, carbamazepine, oxybutyrin hydrochloride have also been used with limited benefits.
Your child; Various exercises are recommended in order to teach him to better control his bladder (bladder). Behaviors such as delaying urination as much as possible during the daytime and emptying the bladder several times during urination are taught.
Alarm devices that wake up the child by alarming when they wet the bed are one of the treatments that are not very common, although their usefulness is high.
Some treatments such as hypnosis and acupuncture have also been used with limited use.
Specialist Ahmet Çevikaslan
Child and Adolescent Psychiatrist
