Urinary incontinence in children is one of the most common problems of childhood. Enuresis (urinary incontinence) is involuntary urinary leakage that occurs after the age when urinary control must be achieved. It is an important problem that affects the patient, his family and his environment.
Enuresis reduces the child's self-confidence, can cause embarrassment and psychological problems. In addition, the fact that our society does not have sufficient information on this subject causes the subject to be exploited. Wrong attitudes of families and society cause more harm than enuresis itself. The punishment methods used leave lifelong scars on the child. For these reasons, the basis of the approach to the child with enuresis should be to overcome the problem without damaging the child's sense of self. Although the most important responsibility falls on the family, it must be handled and treated in a multidisciplinary manner.
Brief Determinations
20% of five-year-old children wet their beds at least once a month
5% of boys, 1% of girls leak urine every night.
Enuresis nocturna (night incontinence) can be defined as wetting the bed twice a month or more in children aged 5-6, and once a month or more in children over the age of 6.
Night incontinence can be considered normal until children turn 5 years old.
Urinary incontinence in children is involuntary.
It affects the child and the family, the wrong attitude of the family can cause loss of self-confidence and psychological problems in the child.
Nocturnal. Enuresis;
It is divided into 2 groups: primary and secondary.
1. Primary Enuresis: Bladder control is never gained. It accounts for 80% of cases. It is generally seen only at night and is often found alone. In this group, genetic predisposition, biological and developmental factors are mostly held responsible.
2. Secondary enuresis: It is the situation where urinary incontinence begins again after being dry for at least 6 months. It accounts for 20% of enuresis. It is mostly seen between the ages of 5-8. Organic and psychological causes are generally responsible for secondary NE (4). It may be monosymptomatic or polysymptomatic depending on the presence of bladder-related symptoms along with enuresis. Nighttime bedwetting in monosymptomatic nocturnal enuresis There are no symptoms. Patients with polysymptomatic enuresis nocturna have symptoms such as sudden urgency, urgent need to urinate, and frequent urination.
Prevalence
Enuresis is more common in societies with low socioeconomic levels and crowded families, and in children who have experienced social and psychological trauma. .
The frequency of enuresis varies depending on the age of the child. 15-25% of five-year-old children wet the bed. Nocturnal enuresis is seen in 13% at age 6, 10% at age 7, 7% at age 8, and 5% at age 10. As can be seen, the frequency of nocturnal incontinence decreases as age increases. With increasing age, children become spontaneously dry at a rate of 15% each year. Monosymptomatic enuresis nocturna is 1.5-2 times more common in boys. For this reason, 8% of boys and 4% of girls remain enuretic. However, 1-3% of adolescents continue to wet the bed.
Boy/Girl= 1.5
• 15% at age 5, 5% at age 10, 1% at age 15
• 15% of enuretics Encopresis (Poop Incontinence) in
• 15% of enuretics resolve spontaneously every year. > What are the Causes of Nocturnal Incontinence?
Genetic factors, psychological factors, sleep disorders, hormonal factors, bladder-related factors may cause enuresis.
A) Causes of Primary Nocturnal Enuresis
1. Genetic and Familial Factors: A positive family history has been found in 65-85% of children with nocturnal incontinence. It has been reported that if one of the parents has a history of incontinence, the risk is 50%, if both parents have a history of incontinence, the risk is 77%, and if the parents are not enuretic, the risk is 15%. • It is seen in parents, siblings and close relatives; 2-6 times increased risk. • 68% in monozygotic twins, 36% in fraternal twins. >2. Psychological Factors: Originally, urinary incontinence (nocturnal enuresis) in children was considered a psychological disease. However, it has recently been suggested that psychological problems are a result rather than a cause.
3. Sleep b Disorders: It has been reported that enuretic children respond less to warnings to wake them up from sleep than normal children. Most of these children cannot wake up on their own, but they can wake up after wetting the bed. In most children, the ability to wake up improves with central nervous system maturation.
4. Maturation delay: It is the late development of the normal inhibitory control mechanism due to the delay in the maturation of the central nervous system (Maturational delay hypothesis)
5 . Bladder-related factors: It has been shown that functional bladder capacity is reduced in the majority of patients with enuresis. Decrease in bladder function causes symptoms such as frequent urination during the day and bedwetting every night. Additionally, urodynamic studies in patients with monosymptomatic nocturnal enuresis have shown that there is a 30% rate of detrusor instability in the bladder. 6. Nocturnal polyuria: Bladder distention may affect the nocturnal release of intidiuretic hormone. Some studies have shown that ADH secretion increases in response to bladder distention and decreases with bladder emptying.
b) Secondary Enuresis Causes
An underlying organic cause may be found in children who wet their beds.
1. Insufficient emptying of the bladder
2. Polyuria:
3. Parasites:
4. Urinary Tract Infections (UTI):
5. Chronic renal failure:
6. Neurological disorders:
7. Upper airway obstruction
Evaluation of the Child with Nocturnal Enuresis
Primary nocturnal enuresis constitutes 80% of all enuresis patients. However, an organic cause can be found in 20% of patients. In primary enuresis, no organic cause can be detected. Most of them have nocturnal urinary incontinence. Daytime incontinence is either absent or very rare. It is not accompanied by defecation disorder. 70% of patients have a family history. There may be frequent urination. Laboratory tests and neurological examination are normal. Complicated enuresis is accompanied by an organic disorder in 20% of cases. There is a urination disorder. It may be accompanied by encopresis and constipation. There is usually a history of UTI.
In the evaluation of nocturnal enuresis, the causes that may lead to complicated enuresis are questioned. A detailed history should be taken and a complete physical examination should be performed.
Treatment
The aim of treatment should be to eliminate enuresis. It is important to minimize the child's feelings of shame and anxiety in treatment. A child with incontinence may feel alone with his problem. Parents with a history of kidnapping should share their experiences with the child and encourage him or her to recover. The patient should be given moral support. A child with enuresis only benefits from the positive attitudes and behaviors of parents. Punishment has no place in treatment. The doctor's positive attitude towards the child and instilling trust increases the child's adaptation. Approach to a child with nocturnal enuresis can be done in two ways: non-pharmacological and drug treatment.
Behavioral motivation: A positive attitude towards the patient and motivating him/her to stay dry are part of the treatment. constitutes a significant part of it. The child should be encouraged to stay dry. The child's daily urination pattern is carefully evaluated. The child should be encouraged to urinate before going to bed and within 1.5-2 hours after going to bed. The child should be encouraged to urinate before leaving home in the morning, at school and on the way home. The patient should be advised not to drink excessive water with dinner and to reduce fluid intake after dinner. Waking the child up and going to the toilet within 1-1.5 hours after sleeping increases the success of fluid restriction. Record keeping and rewarding techniques in treatment are both methods that increase the child's motivation and give responsibility. The child marks wet and dry nights on a calendar or notes them down.
Alarm device: Alarm therapy can be used for up to 15 weeks. However, 10 to 30% of children give up this treatment on their own. Unstable bladder, complex family structure, excessive anxiety in the family, lack of knowledge about bedwetting by parents or the child may be the reasons for failure in this practice. In addition, the low education level of the families is also a reason for poor response (6-8).
Other approaches: Various approaches to the treatment of urinary incontinence in children such as elimination diet, hypnosis, bladder stretching exercises (holding urine for increasingly longer periods of time), acupuncture. Nonpharmacological treatments can also be applied.
Drug therapy
Ç Another step in the treatment of urinary incontinence in children is medication. Medicines that expand bladder volume, regulate bladder function, and reduce nighttime urine production are added to the treatment after the problem causing urinary incontinence in children is identified.
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