Nocturnal bedwetting or enuresis nocturna is defined by the International Children's Continence Society (ICCS) as intermittent incontinence while sleeping in children over 5 years of age. Enuresis; It is the occurrence of the normal urination cycle at a socially inappropriate place and time. Nocturnal enuresis (bedwetting at night); In general, nighttime urinary control is urination that occurs during sleep at the age of 5 and above. It is twice as common in boys as in girls. It is a very common and disturbing condition that can profoundly affect a young person or child's behaviour, emotional health and social life. It is also a very serious source of stress for the family and caregivers.
AT WHAT AGES AND HOW OFTEN IS ENURESIS NOCTURNA OBSERVED?
Enuresis nocturna (nightly bedwetting) is very common in our country. p>
• 1 in every 12 children aged four and a half hasbedwetting
• 1 in every 40 children aged seven and a half has bedwetting
• 1 in every 65 children aged nine and a half years has bedwetting
• 1 in every 100 adults has bedwetting
HOW IS ENURESIS DIAGNOSED?
In order to diagnose enuresis nocturna, the child's calendar age must be 5 years old and he/she has repeated urinary incontinence in bed or pajamas (at least 3 consecutive months, twice a week). occurring at a frequency), and this behavior should not be due to the physiological effects of a drug or a general medical condition (type-1 diabetes, spina bifida, etc.).
HOW IS ENURESIS NOCTURNA CLASSIFIED?
a- MONOSYMPTOMATIC ENURESIS NOCTURNA
There are no other findings other than bedwetting at night. The child does not experience any problems during the day and does not have any lower urinary tract symptoms. Monosymptomatic enuresis nocturna also occurs in two ways.
1-Primary Enuresis Nocturna: Children who have not been able to stay dry at night since infancy are called the primary group. This group constitutes 80-85% of all enuretics. Children who have not been able to stay dry for at least 6 months are the primary group. The most common cause of nocturna enuresis is
2-Secondary Enuresis Nocturna: This is the group that managed to stay dry at night for about 6 months and then started to incontinence again. This group constitutes 20-15% of all enuretics. Psychological reasons are more common in secondary enuresis nocturna. The group that wets the bed due to attention deficit and hyperactivity disorder is the secondary group. In addition, children who wet the bed at night due to reasons such as emotional behavior disorder, respiratory tract obstruction, constipation and obesity are also in the secondary group.
b- NON-MONOSYMPTOMATIC ENURESIS NOCTURNA
Daytime findings are also added to the table here. The child experiences various problems during the day. Therefore, the incident takes on a more serious dimension. Detailed examination is required for the underlying cause.
WHAT ARE THE DAYTIME SYMPTOMS?
• Increased / decreased urination frequency
• Daytime urinary incontinence
• Urinary retention movements (when the child is stuck, he tries to hold his pee with different maneuvers, such as crossing his legs, holding the end of his penis in boys, shaking his butt left and right, etc.)
• Sudden feeling of urgency (urinary incontinence if he cannot reach the toilet)
• Feeling of insufficient bladder emptying
• Intermittent urination
• Post-void dribbling incontinence
• Pain in the genital or lower urinary tract
WHAT ARE THE CAUSES OF ENURESIS NOCTURNA?
The general opinion of many mothers and fathers is that bedwetting is a medical or psychological problem. Often patients are subjected to extensive and unnecessary medical evaluations without any findings. However, a medical, neurological, or urological problem is the primary diagnosis in only 1% of enuretics. Psychological reasons such as family problems, social adaptation or fears are factors in 10% of patients. In fact, the majority of those who have urinary incontinence at night (90%) do not experience an anatomical or psychological problem.
There are a wide variety of opinions and theories regarding the causes of enuresis nocturna. It is the 3 system model that has been accepted as the most classical in recent times
3 SYSTEM MODEL
1- Decrease in the release of ADH (Antidiuretic hormone): Another name is vasopressin One of the most important functions of this hormone is to regulate water retention in the body. It is secreted when the body is dehydrated and at night. It allows the kidneys to retain water. Thus, urine with low volume and high density is formed. Normally, the amount of urine produced at night decreases by 3 times compared to daytime. This is because vasopressin, secreted from the posterior pituitary in the dark at night, reduces urine production at night. Vasopressin insufficiency has been shown with some enuretics. For this reason, at night, especially in the first hours of sleep, the kidneys of these children produce more urine than normal. The child, who cannot perceive the fullness of the bladder, which is filled with excessively produced urine and stretched, due to difficulty in waking up, wets the bed. This is enuresis due to diuresis (increase in the amount of urine). ADH deficiency alone is not the cause of enuresis nocturna (bedwetting at night). However, when it is accompanied by difficulty in waking up, it manifests itself as bedwetting at night.
2- Involuntary bladder contractions during sleep and small bladder capacity: While the child is asleep at night, he tends to urinate before his bladder is full. unnecessary signals reach the brain. In fact, the bladder is not fully filled yet, so no signal should be sent to the brain to urinate. But some children have restless bladders and may experience this problem day and/or night. These children feel the need to urinate very frequently, and their bladder capacity decreases over time as the bladder empties before it is fully filled. In children who have difficulty waking up, this problem is the cause of enuresis nocturna. These children have normal nocturnal urine production, but they have problems with storage. Enuretic children with an irritable bladder wet their beds more than once a night, and the wet area in the bed is usually small. While some children experience this problem only during the day, others deal with this problem only at night. There are also children who experience this problem both at night and during the day.
3- Difficulty in waking up, which prevents them from perceiving the fullness of the bladder: Difficulty in waking up is observed in all children with enuresis nocturna. The last hypothesis explaining this relationship is; The activity of the arousal center in the brain (Locus Coeruleus) changes with bladder fullness. In other words, the awakening center is the center of changes that occur in the bladder at night. is affected by conflicts. Whether the problem is excessive urine production at night, restless bladder or a decrease in functional bladder capacity, the problem appears as bedwetting along with the difficulty in waking up due to the impact of the waking center. Nighttime bedwetting can occur at any stage of sleep. The sleep pattern of children with enuresis is no different from normal children. These are normal, healthy children who have not learned to properly activate the reflex system during sleep.
Normally, when a child feels the need to urinate during sleep, a signal is sent to the brain by the bladder. Sensing this signal, the child wakes up and gets out of bed to urinate and goes to the toilet. Children who have urinary incontinence at night do not perceive this signal.
97% of the families of children with urinary incontinence stated that their children sleep abnormally deeply. Families describe their attempts to take their children to the toilet at night as dragging a sack of potatoes. They state that their children are disoriented, do not feel that they are being lifted, and do not remember anything about what happened at night in the morning.
WHAT ARE THE OTHER CAUSES OF ENURESIS NOCTURNA EXCEPT FOR THE 3 SYSTEM MODEL?
1-Central nervous system maturation. Delay: One of the most current hypotheses is the late development of the normal inhibitory mechanism due to the delay in the maturation of the central nervous system. Much evidence has been put forward to support this. According to some researchers, it is not right to talk about the existence of such a thing in an enuretic child who has gained daytime urinary control.
2-Genetic factors (familial predisposition): If the mother and father do not have a similar story. The probability of having enuresis nocturna in the child is 15%, the risk of having enuresis nocturna in the child if there is a similar story in either mother or father is 43%, and the risk of having enuresis nocturna in the child as a result of the presence of a similar story in both parents is as high as 77%.
3- If the child consumes excessive amounts of liquid all evening long, especially if their bladder capacity is low, this will cause bedwetting at night. Coke, cha Beverages containing caffeine such as coffee and coffee also stimulate an increase in urine production.
4-Sleep breathing disorders:In some enuretic children with sleep apnea and snoring, these symptoms occur due to enlarged tonsils. caused by blockage of the pathway. When the airway is blocked, atrial natriuretic factor secreted from the atria of the heart prevents the secretion of vasopressin at night and there is an increase in urine production at night. This may cause enuresis in children who have difficulty waking up.
5-Psycho-pathological disorders:Enuresis is very rare. However, a child who wets the bed at night may have psychological problems due to his/her experiences. In other words, psychological factors are generally seen as a result rather than a cause in enuresis. Secondary enuresis may develop in a child who is exposed to temporary stress during a critical period. This behavior is a regression behavior aimed at attracting attention and being loved like a baby.
6-Attention deficit hyperactivity disorder:Daytime and/or nighttime incontinence is more common in children with ADHD than in the general population.
7-Constipation: Poo remaining in the intestines puts pressure on the bladder, disturbing the bladder. It prevents the bladder from filling completely. For this reason, constipation must be prevented.
8-Food allergy: Food allergy has been observed in 10% of children with enuresis nocturna. It has been shown in many studies that especially the effects of cow's milk allergy, caffeine and cocoa affect the bladder.
HOW DOES ENURESIS NOCTURNA AFFECT THE FAMILY AND THE CHILD?
What do children who wet the bed think?
• He may think that he is different from other children.
• He may be afraid that these complaints will not end and this situation will be understood by his friends.
• He may not want to wear diapers at night.
• May not be able to participate in school trips.
• May not be able to stay with anyone outside the home.
• Since night sleep is interrupted too much, sleep quality deteriorates. This may affect school success.
• He/she may feel fed up, embarrassed, guilty, helpless, anxious and angry.
What does the family think?
• Think the child is lazy
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