ENURESIS
Enuresis comes from the Greek word 'enourein', which means urination. Today, enuresis is used to mean the continuation of involuntary and inappropriate urine discharge at an age when urination control is expected to be achieved developmentally. . Leaking urine due to an organic cause is called 'incontinence', leaking urine at night while sleeping is called 'enuresis nocturna' (EN), leaking urine while awake during the day is called 'enuresis diurna' (ED), leaking urine both at night and during the day 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 a year of bladder control and dryness. It is most common between the ages of 5-8. If it occurs later, for example in adolescence, organic causes should be investigated.
In the normal development process, bowel and bladder control in children occurs sequentially. These are as follows:
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 (or an equivalent level of development). EN is generally seen in 15% of 5-year-old children and 1.5-7.5% in 7-year-old children. Enuresis continues in only 1% of cases in adulthood. Enuresis diuresis is more common in girls and children 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, in most children with primary enuresis nocturna, findings related to central nervous system delay (e.g. motor development delay, language developmental delay, short stature, low bone age). In a statement that maturation delay in the central nervous system may be effective in enuresis; Maturation in boys is later than in girls, and this may lead to insufficiency in both the control of the sphincters related to elimination and the sleep cycle (such as inability to wake up during urination), and eventually enuresis. It has been reported that it may be a factor for smut. In a study conducted to determine brainstem dysfunction, which is the center of bladder and urination functions, findings supporting brainstem dysfunction and maturation delay in enuretic children were obtained.
With advancing age in the child, arginine vasopressin begins to be released according to the normal circadian rhythm, and enuresis nocturna may improve. It is thought that enuresis nocturna may be an explanatory finding for the developmental delay.
It is reported that attention deficit hyperactivity disorder (ADHD) is more common in children with enuresis nocturna and diurna. Considering that the maturation delay of the central nervous system may be a factor in the development of the disorder in ADHD, this result is not surprising, and it is stated that this association may be a finding showing that the maturation delay may also play a role in enuresis.
2.Genetic causes
strong>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, enuresis can be seen in approximately 70-75% of children, and if one parent has enuresis, enuresis can be seen in 40-50% of children.
3.Arginine vasopressin (=antidiuretic hormone=ADH). ) deficiency in circadian rhythm
Arginine vasopressin is a hormone that determines the excretion of water from the kidney as a circadian rhythm. Thanks to the regular circadian rhythm of this hormone, less than 50% of 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, enuresis nocturna may occur in the child.
4.Drugs
Lithium, valproic acid. Enuresis may be seen as a side effect of drugs such as , clozapine, neuroleptics (e.g. thioridazine, risperidone), theophylline.
5. Psychodynamic causes
In the literature, enuresis, It has been evaluated as the equivalent of masturbation as an explanation of bisexuality and has been reported to be a somatic (bodily) explanation of body image disorders, an indicator of castration anxiety, a reflection of repressed sexual and aggressive emotions and/or a source of immature pleasure.
6.Genitourinary system diseases
Obstruction in the urinary system, hydronephrosis, incompletely emptying bladder, abnormal bladder wall thickness, detrusor instability, urinary system infection, enterebius vermicularis (pinworm) infection,… may lead to the development of enuresis.
8. Diabetes mellitus, diabetes insipidus
9.Excessive fluid intake due to psychogenic cause
10.Neurological diseases
Enuresis can also be seen in neurological diseases such as multiple sclerosis, Guillain-Barre syndrome, spinal cord injuries, cerebral tumors, spinal cord tumors.
11. Causes related to psychosocial stress
strong>a.Enuresis is the expression of aggressive feelings towards the newborn sibling,
b.A passive-aggressive reaction to the pressured toilet training of the overly clean, meticulous and tidy mother,
c.Anxiety symptom that develops as a result of stressful life events such as death in the family, divorce, migration, school-related traumas, hospitalization, child neglect and abuse,
d.Infant-like behavior in a child growing up in an overly protective and tolerant family Negative and inadequate mother-child relationship, as regressive symptoms that develop as a result of mental disorders in the parents, may play a role in the development of enuresis in the child. The risk of secondary enuresis increases especially if there are 4 or more stressful life events in a year.
12. Sleep-related causes
70' In the 1990s, it was reported that enuresis was generally seen in the first 1/3 of sleep, during the transition from stage 4 non-REM sleep to REM sleep, and that it may be associated with specific sleep disorders such as narcolepsy, sleep apnea syndrome, and difficulty in waking up from deep sleep. However, later studies have shown that sleep patterns in enuretic children are no different from children without enuresis, and that enuresis can be seen in every period of sleep.
13. Allergenic phenomenon
In recent years, allergy Although it was determined that there was no direct relationship between food allergies and enuresis, 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 low socioeconomic At the micro-level, it is more common in children with many children, living in crowded families and institutions, and in those with a history of low birth weight. It is observed in 20% of cases. It is mostly caused by parents' negative attitudes and behaviors 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. It has been reported that exposure to attention deficit hyperactivity disorder,… It should be said that it is important for them to start their education at the right time. If parents start toilet training as a result of some clues they receive from the child (e.g. when the child begins to have voluntary sphincter control, to show effort and interest in developing toilet habits, to imitate the behavior of parents), they can prevent elimination disorders that may develop in the future as a result of incorrect or early toilet training. Toilet training can generally start at the age of 1.5-2. Although starting toilet training usually takes a similar amount of time for boys and girls, girls usually complete the training earlier. While environmental influence and support are at the forefront during toilet training in girls, physiological maturation is more at the forefront in boys. If there are psychosocial stress factors at the time of starting toilet training (e.g. migration, birth of a sibling, starting a new school, change of caregiver), the training should be postponed and the child should be waited to adapt to them.
Departure
Prognosis is generally good. Enuresis nocturna shows spontaneous remission at a rate of 10-20% each year. The rate of spontaneous remission is high in those aged 5-7 years and older than 12 years. In the presence of another mental disorder or psychosocial stress factors as a comorbidity in the child, the prognosis is negatively affected.
ENCOPRESIS
Fecal incontinence (soiling) is the involuntary loss of feces. and different terms are used regarding it. Of these, incontinence is used when there is an underlying disease (e.g. anatomical, organic or inflammatory, meningomyelocele, mass compressing the spinal cord, ulcerative colitis). This condition is responsible for less than 5% of children with fecal incontinence. Encopresis means the continuation of involuntary and inappropriate evacuation of feces at an age when defecation control is expected to be developed developmentally. The calendar age for encopresis must be at least 4.
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 in 1-3% of children aged 7-8 years. It is 4-5 times more common in boys than in girls. Encopresis and overflow incontinence accompanied by constipation are the most common types (85-95%). These children sometimes do not gain bowel control at all, and sometimes overflow occurs due to constipation (usually more than 2 times a day). Encopresis, which does not occur with constipation, is accompanied by defensive behavior and means expressing anger.
Causes
When the cause of encopresis is investigated, no physiological cause is found in more than 95% of children. . The remaining 5% have various reasons.
1.Inadequate toilet training
2.Not realizing defecation:
Under normal conditions, the rectum is empty and the entry of feces into the rectum causes the need to defecate. In chronic constipation, which develops due to the child's voluntary retention of defecation or postponement due to painful defecation, the rectum in children is enlarged (megarectum) and full of feces. The rectum of these children becomes insensitive to incoming stool over time, and the child does not need to defecate (desensitization). Thus, the child does not realize that the poop is coming, and when the accumulated feces reach more pressure than the anal sphincter can hold, the feces spontaneously escapes, soiling the underwear (overflow incontinence).
3.Abnormal anal sphincter contractions
4.Negative parental attitudes:
Stubbornness between parent and child can sometimes lead to fecal storage and inappropriate bowel movements in children with adequate bowel control.
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