Minoculation disorder is a condition that manifests itself with lower urinary tract symptoms, including urgency, urinary incontinence, weak urine flow, frequent urination and urinary tract infections, without any obvious underlying disease. Some of the relevant terms are as follows:
Enuresis nocturna (nocturnal urinary incontinence): It is defined as involuntary bedwetting at night in children over the age of 5 who do not have any congenital or acquired disorder in the central nervous system. .
Primary Enuresis: Lack of dryness for more than six months.
Secondary Enuresis: Six bedwetting that occurs after a period of dryness lasting a month or more
Monosymptomatic enuresis (simple); There are no symptoms during the day other than wetting the bed at night. There are no symptoms such as daytime urinary incontinence, urinary retention, going to the toilet at the last moment, or urgent need to go to the toilet.
Non-monosymptomatic enuresis (polysymptomatic, complicated); It is a condition accompanied by urination problems such as infrequent urination, daytime urinary incontinence, sudden feeling of urgency during the day, and chronic constipation. These patients may also be accompanied by hesitation, straining, weak stream intermittent urination, holding maneuvers, a feeling of incomplete voiding, post-micturition dribbling and genital pain.
Daytime incontinence: It is the incontinence of urine during the daytime. In children with urination, daytime urinary incontinence is more common than nighttime urinary incontinence. The reason for this is incorrect urination habits, excessive urination retention, constipation and recurrent urinary tract infections in children with urination disorders.
Urgent urge incontinence: Frequent and sudden It is urinary incontinence that causes the feeling of urination. It is a term used in children over the age of five who have established urinary control. These children bring their legs together (scissoring) to hold their urine.
Very frequent urination: It is usually seen in children between the ages of 3-8. The patient complains of urination every 15-20 minutes. This condition may be triggered by stress and chemical-related urinary tract infections (such as swimming in an excessively chlorinated pool).
Laughing incontinence:It is urinary incontinence, which is often seen in girls, and occurs while giggling or laughing. During laughter, all urine is discharged. It may continue into adulthood. It is completely normal for these children to urinate except for laughing incontinence. Although the exact cause is not known, they may benefit from drug treatment.
Stress incontinence: It is the leakage of small amounts of urine during exercise or activity. It is the occurrence of small amounts of urine leakage due to increased intra-abdominal pressure. It is more common in adolescence.
Post-voiding dribbling: This is a condition that is often seen in obese girls and develops due to urine accumulation in the lower part of the vagina. After urination is finished, urine is dripped when the child stands up. It is related to the urination position and can be prevented by sitting upright on the toilet and spreading the legs wide.
Lazy bladder (less effective bladder): Urinary bladder capacity is large according to their age and urinating 2-3 times a day. are children. Urinary incontinence between urination is common. The feeling of bladder filling is diminished. Since the urine flow is weak and the contractions of the bladder muscles are very low, they cannot urinate fully, and when they urinate, they cannot fully empty the bladder. Urinary tract infections are common because some urine remains in the bladder after urination. Constipation is also common in these children. Behavioral therapy (double urination, clocked urination) is recommended for treatment. In some cases, the bladder must be emptied with a catheter at regular intervals.
Overactive bladder: It is the most common urination disorder in children. It is common between the ages of 5-15. During the filling of the bladder, there is a contraction in the bladder muscles. These patients present with daytime urinary incontinence, urgency, frequent urination of small amounts, constipation and urinary tract infection, manifested by holding maneuvers (a special movement characterized by crossing the legs and bending slightly forward while trying to hold the urine (Figure 1). Urination Incontinence is usually mild, often with wet underwear.In the treatment, urination is regulated and the activity of the bladder muscles is reduced. n anticholinergic treatment is recommended.
Urge syndrome (urgent urgency): It is the feeling of urgency in the early filling phase of the bladder. It occurs with irregular contractions of the urinary bladder muscles. Voiding training, especially timed voiding and positive feedback, are very important in treatment. Anticholinergic treatment may be given to reduce the activity of the bladder muscles.
Dysfunctional urination: It refers to the inability of the pelvic floor muscles and urinary sphincter to fully relax during urination, without a neurological pathology. It is caused by a disorder in the excretory phase of urine. The storage phase is normal. There is increased activity in the pelvic floor muscles and sphincter that need to relax during urination, and the child uses the anterior abdominal wall muscles to suppress this resistance. As the urine flow time increases, the flow rate increases, and since some of the urine in the bladder cannot be emptied, the risk of urinary tract infection increases. Practical errors during the toilet training period reveal urination disorders. Sudden feeling of urination and urinary incontinence may occur.
Hinmann Syndrome (Non-neurogenic neurogenic bladder): It is the most severe form of urination disorder. Patients experience neurogenic bladder symptoms. However, there are no neurological findings. It occurs due to inappropriate voluntary contraction of the external urethral sphincter during urination. It is a functional bladder outlet narrowing caused by the incompatibility between bladder contractions and sphincter relaxation and may progress to renal failure. Patients experience inability to urinate, incontinence during the day and night, and recurrent urinary tract infections are common. It can be treated with regular urination and, in some cases, intermittent emptying of the bladder with a catheter (clean intermittent catheterization (TAC).
Ochoa syndrome: A special facial shape defined as urofacial syndrome. These patients look like they are crying when they smile. These patients can also be treated with regular urination and, in some cases, intermittent emptying of the bladder with a catheter (TAC).
WHO HAS NIGHTLY URINARY INCONTINUE?
It is very common, especially in primary school age children. is a problem. Its incidence decreases with age. The spontaneous recovery rate is 15% each year. The prevalence is higher in large families with lower socioeconomic and educational levels. Its incidence is higher in the first children of the family, and its incidence decreases in adulthood.
WHAT ARE THE CAUSES OF URINATION DISORDER?
There is no single cause for all urination disorders. In some of them, no cause can be found. Voiding disorder may be neurogenic (such as cerebral palsy, meningomyelocele, tethered cord, spinal tumor, transverse myelitis, spinal trauma) or non-neurogenic (functional). To show that it is functional, all organic causes must be excluded.
In the absence of any neurological or anatomical findings, urination patterns in urination disorders are generally thought to be related to behavior. These behavioral problems may develop due to adverse events during toilet training and/or personal stresses. Starting toilet training at a very early or late age and the accompanying stresses trigger the development of urination disorders.
The fear that occurs in the child as a result of painful urination caused by reasons such as recurrent urinary tract infections (UTIs) and constipation causes contraction of the external sphincter and It causes uncontrolled bladder contractions. With infrequent urination and increased bladder capacity, signs of urination disorder occur.
Sexual abuse should be considered when no cause can be found, especially in girls with sudden urination disorders.
In children with attention deficit, urinary incontinence, constipation. and other urination symptoms have been found to be seen at higher rates.
WHAT QUESTIONS SHOULD WE ASK IN THE HISTORY?
For the diagnosis of childhood urination disorders, first of all, a well-taken history and A careful physical examination is required. History of incontinence is very important and sufficient to make the diagnosis. The onset of bedridden episodes, their severity, and current conditions should be questioned. Children should also be included in the interview, depending on the child's age. Age of starting toilet training, urgent urgency or crossing legs and slightly forward while trying to hold urine A specific movement characterized by bending, accompanied by fecal incontinence or constipation should be investigated and a history of urinary tract infection should be learned. It should be determined whether the urination disorder has just started or whether the urinary incontinence has always occurred since toilet training was completed. The amount and distribution of fluid intake should be measured during the day. Dietary fiber intake should be evaluated. The child's developmental stages starting from birth should be questioned, family history of urinary incontinence, socioeconomic level of the family, and communication within the family should be investigated. It is useful to evaluate the frequency and amount of urination by keeping a three-day urination calendar. In addition, previous infections, neurological diseases, medication use, family diseases (epilepsy, diabetes mellitus), previous surgeries, snoring and apnea attacks are questioned. Situations that need to be questioned in detail in the story are stated in table 1.
Table 1. Variables that need to be questioned in detail in the story
During the day Frequency of going to the toilet
Amount of urine in each urination
Frequency of urinary incontinence
Time between wet and dry periods
Erection / if any, given to it answer
Mineration pattern (continuous / intermittent)
Does the underwear get wet after urination?
Is there wetness on the hips and calves of girls after urination?
Is the stool accompanied by scratching?
WHAT SHOULD BE CONSIDERED DURING THE PHYSICAL EXAMINATION?
A detailed physical examination will reveal urination disorders. It should be done in every child with Growth development curves should be evaluated. During the examination, neurological evaluation of the abdomen, genital system, lower back and lower extremities should be performed. Rectal examination should be performed in boys with secondary urination dysfunction who have difficulty urinating and have weak urine flow and/or complaints of hesitation while urinating. In genital examination; In girls, vulvitis, vaginitis, abnormal genitals, labial adhesion, and in boys, phimosis, epispadias and hypospadias should be checked, and the child's urination should be observed.
WHAT EXAMS SHOULD WE HAVE?
Complete urinalysis, urine culture, serum electrolytes, urea, crease in all patients
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