ENURESIS
Enuresis comes from the Greek word ‘enourein’ meaning to urinate. Today, enuresis is used to mean the continuation of involuntary and inappropriate urine discharge at an age where micturition control is expected to be established developmentally. Urinary incontinence due to an organic cause is called ‘incontinence’, incontinence at night while sleeping is called ‘enuresis nocturna’ (EN), incontinence while awake during the day is called ‘enuresis diurna’ (ED), and both nocturnal and daytime urinary incontinence is called ‘enuresis continue’.
EN is divided into two according to its initial form and course;
1.Primary EN: Enuresis has been present since infancy and there is no dry period in between.
2.Secondary (secondary) EN: Enuresis started after at least one year of bladder control and dryness period. It is most common at the age of 5-8 years. If it occurs later, for example, in adolescence, organic causes should be investigated.
In the normal development process, bowel and bladder control occurs in turn in children. These are, in order;
1.Nocturnal fecal continence
2.Diurnal fecal continence
3.Diurnal bladder control
4.Nocturnal bladder control.
To diagnose enuresis, the calendar age must be at least 5 years old (or an equivalent developmental level). EN is seen in 15% of children aged 5 years and 1.5-7.5% in children aged 7 years. Enuresis persists in only 1% of cases in adulthood. Enuresis diurna is more common in girls younger than 5 years of age.
80-90% of enuresis is primary.
Causes
1. Delay in the development of the central nervous system
Although the mechanism is not fully known, findings related to central nervous system delay in most children with primary enuresis nocturnal (eg, motor developmental delay, language) growth retardation, short stature, low bone age). In a statement about the delay in maturation in the central nervous system may be effective in enuresis; It has been reported that maturation is later in boys than in girls, which may lead to inability both in the control of the elimination sphincters and in the sleep cycle (such as inability to wake up during voiding), which may eventually be a factor for enuresis. In a study conducted to determine brainstem dysfunction, which is the center of bladder and voiding functions, findings supporting brainstem dysfunction and maturation delay were obtained in enuretic children.
It is thought that with advancing age in children, arginine vasopressin begins to be released according to the normal circadian rhythm, and enuresis nocturna may improve, which may be an explanatory finding for the developmental delay of enuresis nocturna.
It has been reported that attention deficit hyperactivity disorder (ADHD) is more common in children with enuresis nocturnal and diurna. Considering that delayed maturation of the central nervous system may be a factor in the development of the disorder in ADHD, this result is not surprising.
2. Genetic causes
It has been known for many years that genetics is an important factor in enuresis. It has been reported that if both parents have a history of enuresis, approximately 70-75% of children can have enuresis, and if one parent has enuresis, enuresis can be seen at a rate of 40-50% in children.
3. Arginine vasopressin (=antidiuretic hormone=ADH) insufficiency in circadian rhythm
Arginine vasopressin is a hormone that determines renal water excretion as a circadian rhythm. Thanks to the regular circadian rhythm of this hormone, less than 50% of the 24-hour urine is excreted at night. Sometimes, in enuretic children, the circadian rhythm is disrupted, vasopressin is released at the same level day and night, and as a result, the child may develop enuresis nocturna.
4.Drugs
Enuresis can be seen as a side effect of drugs such as lithium, valproic acid, clozapine, neuroleptics (eg thioridazine, risperidone), theophylline.
5.Psychodynamic causes
In the literature, enuresis has been evaluated as the equivalent of masturbation as an explanation for bisexuality, and the somatic (body) explanation of body image disorders, a manifestation of castration anxiety, the reflection of suppressed sexual and aggressive emotions, and/or It has been reported that it can be a source of immature pleasure.
6. Genitourinary system diseases
Urinary system obstruction, hydronephrosis, incomplete emptying bladder, abnormal bladder wall thickness, detrusor instability, urinary system infection, enterebius vermicularis (wormwood) infection,… can open.
8.Diabetes mellitus, diabetes insipidus
9.Excessive fluid intake due to psychogenic cause
10.Neurological diseases
Multiple sclerosis, Guillain-Barre syndrome Enuresis can also be seen in neurological diseases such as spinal cord injuries, cerebral tumors, spinal cord tumors.
11. Causes related to psychosocial stresses
a. Expression of aggressive feelings towards enuresis newborn sibling,
b. Passive-aggressive against pressure toilet training of an overly clean, meticulous, organized mother a reaction,
c. Anxiety symptom that develops as a result of stressful life events such as death in the family, divorce, immigration, school-related traumas, hospitalization, child neglect and abuse,
d. Overprotective and the tendency to remain infantile in children brought up in tolerant families,
e. Negative and inadequate mother-child relationship may play a role in the development of enuresis in children as regressive symptoms that develop as a result of mental disorders in the parents. In secondary enuresis, especially if there are 4 or more stressful life events in a year, the risk increases even more.
12. Reasons related to sleep
In the 70’s, enuresis was generally seen in the first 1/3 period of sleep, during the transition from stage 4 nonREM sleep to REM sleep, narcolepsy, sleep apnea syndrome, deep sleep It has been reported that it may be associated with specific sleep disorders such as difficulty in waking from sleep. However, later studies have shown that sleep patterns in enuretic children are not different from those without enuresis, and that enuresis can be seen at any stage of sleep.
13. Allergenic phenomenon
Although it has been determined that there is no direct relationship between allergy and enuresis in recent years, it was reported in the seventies that bladder hyperactivity may occur in people with food allergies, which may reduce bladder capacity.
14. Other causes
Enuresis is more common in children with low socioeconomic status, many children, living in crowded families and institutions, and those with a history of low birth weight.
Partnership situations
Mental problems are observed in approximately 20% of enuretic children. Negative attitudes and behaviors by parents such as adaptation problems, behavioral problems, attention deficit hyperactivity disorder, encopresis, low school success, decrease in self-confidence over time, social isolation and social adaptation problems, exclusion by peers, feeling hopeless and pessimistic, punishment and rejection. exposure, attention deficit hyperactivity disorder, … have been reported.
What should be done first?
First of all, it is important to say that it is important for parents to start toilet training in their growing child at the right time before moving on to treatment approaches for enuresis. If the parents start toilet training as a result of some cues they receive from the child (for example, when the child voluntarily begins to have sphincter control, to make an effort and interest in developing toilet habits, to imitate the behaviors of the parents), they can prevent elimination disorders that may develop as a result of incorrect or early toilet training in the future. Toilet training can generally be started at the age of 1.5-2 years. Although starting toilet training takes a similar time for boys and girls, girls usually complete the training earlier. While the environmental influence and support are at the forefront during toilet training in girls, physiological maturation is more prominent in boys. If there are psychosocial stress factors at the time of starting toilet training (eg migration, birth of siblings, starting a new school, changing caregivers), training should be postponed and the child should be expected to adapt to these.
Departure
The prognosis is generally good. Enuresis nocturna shows spontaneous remission at a rate of 10-20% each year. Spontaneous remission rate is high in those aged 5-7 years and older than 12 years. The prognosis is adversely affected in the presence of another mental disorder and psychosocial stress factors as comorbidity in the child.
ENCOPREZIS
Fecal incontinence “soiling” is the involuntary leakage of stool and different terms are used in relation to it. Of these, incontinence is used when there is an underlying disease (eg anatomical, organic or inflammatory, meningomyelocele, mass pressing on the spinal cord, ulcerative colitis). This condition is responsible for less than 5% of children with incontinence. Encopresis means the continuation of involuntary and inappropriate defecation at an age where defecation control is expected to be developed developmentally. For encopresis, the calendar age must be at least 4 years old.
In general, more than 95% of children over the age of 4 and 99% of those over the age of 5 have gained bowel control. Primary encopresis is seen at a rate of 1-3% at the age of 7-8 years. It is 4-5 times more common in boys than girls. Encopresis and overflow incontinence with constipation are the most common types (85-95%). These children sometimes do not gain any bowel control at all, and sometimes they overflow from constipation (usually more than 2 times a day). Encopresis, which does not go away with constipation, is associated with defensive behavior and means the expression of anger.
Causes
When the cause of encopresis is investigated, no physiological cause is found in more than 95% of children. The remaining 5% have different causes.
1. Inadequate toilet training
2. Not being aware of defecation:
Under normal conditions, the rectum is empty and stool entering the rectum creates the need for defecation. In chronic constipation, which develops due to the child’s voluntary holding of his poop or delayed due to painful defecation, the rectum is enlarged (megarectum) in children and is full of stool. The rectum of these children becomes insensitive to the stool that comes over time and the child does not need to defecate (desensitization). Thus, the child does not realize that his poop is coming, and when the accumulated stool reaches a pressure higher than the anal sphincter can handle, the stool will spontaneously escape, soiling the underwear (overflow incontinence).
3. Abnormal anal sphincter contractions
4. Negative parental attitudes:
The stubbornness between parent and child, sometimes in response to the stress experienced in inappropriate places and storage of stool in children who provide adequate bowel control. may cause them to do so. The ambivalence attitude developed by the mother against the child’s gaining autonomy, the mother’s strict perfectionism, and challenging trials may be important factors. Self-stimulation development in the anal region, encopresis can be seen especially in the neglect of the child by the depressed parents who cannot communicate adequately with their children. Culture-specific early or late initiation of toilet training may also lead to encopresis.
5.Posttraumatic encopresis
Encopresis can occur as a result of sexual abuse.
6. Organic conditions that cause constipation can lead to encopresis:
a. Anatomical causes (eg Imperforated anus, anal stenosis, anterior location of the anus, pelvic mass; teratoma)
b. Metabolic and gastrointestinal causes (eg, hypothyroidism, hypercalcemia, hypokalemia, cystic fibrosis, diabetes mellitus, multiple endocrine neoplasia type 2B, celiac disease, renal tubular acidosis)
c. Neuropathic diseases (eg, spinal cord abnormalities, spinal cord trauma, neurofibromatosis, encephalopathy, cerebral palsy)
d. Intestinal nerve and muscle disorders (eg Hirschsprung’s disease, intestinal neuronal dysplasia, intestinal pseudoobstruction, visceral myopathies, visceral neuropathies)
e. Abnormal abdominal musculature (eg Prune-Belly syndrome, gastroschisis, down syndrome)
f. Connective tissue diseases (eg Scleroderma, systemic lupus erythematosus, Ehlers-Danlos syndrome)
g. Medications: Such as opiates, phenobarbital, sucralfate, antacids, codeine, antihypertensives, anticholinergics, antidepressants, sympathomimetics.
h. Other: Heavy metal poisoning (lead), Vitamin D poisoning, Botulism, Cow’s milk protein intolerance
i. dehydration.
7.Toilet conditions
Depending on the age, the child may want to delay the need to defecate when he/she engages in activities that he/she enjoys, such as playing with toys, playing games on the computer, or when he/she cannot use his/her own toilet. Especially at school age, the inadequacy of school toilets (eg, cleanliness, number of toilets, lack of separation between boys and girls in some places) may cause the toilet not to be used by children and this may lead to many problems including constipation.
8.Psychoanalytical model
The fact that it was especially in boys suggested that encopresis might be an indicator of castration anxiety.
9. Other causes:
Diarrhea, neurological diseases (eg neuromuscular diseases, meningomyelocele, Hirschprung’s disease, chronic intestinal pseudoobstruction, spinal cord disorders, cerebral palsy/hypotonia, spinal cord diseases; sacral lipoma, spinal cord tumor), anal anomalies (eg, rectal abscess, anal fissure, stenosis/atresia with fissure, anterior located anus, trauma and post-surgical complications, rectoperitoneal fistula accompanying imperforated anus), pelvic mass, abdominal wall anomalies, Cystic fibrosis can lead to encopresis.
Concomitant situations
Most primary encopretic children do not have a serious underlying psychopathology. However, negativities related to the prolongation of the problem (eg punishment, exclusion, humiliation) may contribute to the development of psychopathology in addition to the child. With encopresis, easy distraction, short attention span, low frustration threshold, hyperactivity and coordination disorder, decreased self-confidence, and problems in peer relationships can be seen.
Secondary encopresis is more likely to develop psychopathology. Psychosocial factors that may play a role in the development of enuresis can also be seen in the development of enuresis.
Outgoing
Spontaneous remission is seen in encopresis as the central nervous system maturation develops. Encopresis peaks at 6 years of age in boys and 8 years of age in girls. Generally speaking, about 1/3 of the cases are chronic. After the age of 16, encopresis is very rare. If there is abduction at night, the departure is worse than during the day. If conduct disorder is co-diagnosed and encopresis is an expression of aggression, the prognosis is poor.
