Nocturnal Enuresis can be classified in to
1. Primary Nocturnal enuresis – If the child has not been dry for more than six months in his life. About 75% of all patients with nocturnal enuresis are primary.
Physiological Enuresis: Most children who have primary nocturnal enuresis have no disease mechanism to explain the enuresis and they are considered to have physiological enuresis. Enuresis results from inability to recognize the sensation of full bladder during sleep and to awaken from sleep to urinate into the toilet. Those children who wet nightly usually have small bladder capacity which is unable to hold all the urine produced during night clues to a small capacity are day time frequency and wetness every night.
2. Secondary nocturnal enuresis is termed as secondary if bed wetting start after a dry period of six months. 25% of all patients with nocturnal enuresis are secondary. The proportion of patient with nocturnal enuresis who have secondary enuresis increases as the age increases.
Incontinence: Day time wetting with or without bed wetting. 75% of children with enuresis are wet only at night where as 25% are wet day and night. The physical cause for nocturnal enuresis is unusual in those children who wet bed only at night, however a physical cause like urinary tract infection or pathology in urinary tract or trouble with bowel control may be present in incontinence so needing thorough investigations.
MANAGEMENT OF NOCTURNAL ENURESIS
Intervension is important to minimize the negative effect on the self esteem and behaviour of child. A wait and watch policy is incorrect. Motivation of parents and the child is important for the therapy to succeed. A positive approach is important to instill confidence and enhance confidence of the patient. There is no role of punishment which is often counter productive. The therapy has to be tailored according to individual patient taking into consideration the motivation and preference of the family
The following preventive measures are advised to the parents and child.
- Waking child repeatedly during night
a) it interferes with sleep
b) aggravates child and parent
- Postponing the child’s bed time to decrease bedwetting
- Milk at bed time
- Excess water, two hours before sleep.
- Air conditioned room
- Using diaper for children after the age of 2 yrs., which may arrest or delay habit development of using toilets.
Build habit of
- Taking 1.5 liters (caffeine-free) fluid daily
- Drinking at regular interval throughout whole day slowing down in the evening
- Void at least 5-6 times per day
- Relax while voiding or empty completely
- Urinating before going to bed.
- Regular Bowel movement
- Waking up at a regular time with alarm
- Taking diets of greens and vegetables which are rich in vitamins, zinc and magnesium.
Apis Mel: Burning urination. Dysuria with stinging pain ,urine profuse more than he drinks. Incontinence of urine < night. Albuminuria. child is hot, thirstless. Awkward drops things. Fussy and fidgety; hard to please. Screams during sleep and suddenly starts from sleep. Kicks off covering during sleep child is always restless, always wants to keep himself busy. Fruitless activity; very jealous.
Argentum Met: nocturnal enuresis due to diabetes copious and frequent urination, urine is turbid, pale, foetid, profuse, sweet odour. Child is lean, thin, robust anemic chilly and thirstless sleep is restless with anxious, frightful dreams, scream. Child has anticipatory anxiety, fear, depressed and irritability.
Argentum Nit: Incontinence of urine day and night urine is highly colored dark red with albumin. Dreams of snakes. Patient look like withered old man. Progressive emaciation more marked in lower limbs. Child is hot, craves sugar child is hurried. Impulsive, anxious and timid fear of crowd and public places. Examination funk, lack of confidence. Fear of undertaking anything.
Baryta Carb : nocturnal enuresis. urine is dark brown scanty/copious. urging to urinate cannot retain the urine. Child is chilly, thirsty. Dwarfish, retarded, absent minded timid with enlarged abdomen and emaciation of limbs. Child talks in sleep, twitching, lies on one side. Drooping of saliva in sleep. Over sensitive to all impression. Tendency to take cold.
Bellodona: Enuresis generally after midnight or towards early morning. Cause is due to eating too much sugar; paralysis of bladder. urine is yellow and scanty. Turbid, Dark red, profuse deposit of phosphate. Strongly acidic. Child is chilly and thirsty for cold water, desires lemonode or lemon (which agrees), strawberry tongue child is very quarrel some, restless, bites, strikes spits on face of other people. Extroverted. Easy perspiration, faeces escape while urinating. Sensation of worms in the bladder. Child sleeps with half open eyes. Restless sleep with sudden starts, moaning and screaming grinding of teeth during sleep. Sleep with hands under the head.
Benzoic Acid: Enuresis during midnight in girls urine is high coloured ,hot ,dark brown, strong odour of foul ammoniacal or odour of horse urine child starts up during sleep. Awakes with breathlessness and palpitation child is cross, confused ideas. Bed sheets are unusually brown stained.
Calc.carb: Enuresis in bed, after midnight ailment after masturbation, fright, Egotism, urine is dark brown, strong odour white sediment, offensive. child is chilly and thirstly , profuse sweat on head, fat, fair flabby with red faces, tendency to catch cold, craves eggs. Mentally child is dull, delayed, confused, fearful, forgetful, timid, lethargic tastelessness in dressing. Child may suffer from pituitary and thyroid dysfunctions. Child sreams during sleep and cannot be pacified. Nightmares. Fearful and fantastic dream, snoring.
Causticum : Bed wetting during first sleep, cold weather, cold nights, from fright, grief, night watching, Retension urine has deposits of urates, black, cloudy, white child is chilly and thirsty. Children are slow learning to talk and walk. Timid, nervous and fearful especially at night. Dictatorial, defiant positiveness. Sleep is restless with frequent movement of arms and legs, laughs and cries during sleep, very drowsy can hardly keep awake warts stool passed in standing position.
Cina: Bed wetting during second half of sleep, in every full moon ,due to worms urine is copious turns milky on standing, turbid white. child is chilly and thirsty, emaciated, hungry, big fat, rosy and scrofulous. Very restless, touchy, capricious. Grinds teeth during sleep. convulsions. sleep is restless, sleep on abdomen or hands & knee, cries, screams, talks in sleep wakes frightened. Hangs his head to one side will not sleep unless rocked.
Equisetum Hyemale : Nocturnal Enuresis of children without cause except habit urine is clear light coloured profuse, child dreams of seeing crowds of people. Very sleepy, eye side heavy. Very irritable and easily fatigued.
Ferrum Metallicum: Involuntary urination especially during day only, when standing, from sudden movement, walking in children cause is weakness of sphincter vesicae and worms. urine stains the sheet very dark with strong ammonia smell, hot, profuse with mucus, sediments. patient is chilly, thirsty, obese and are predispose to nose bleeds, anemic who flush easily and feel fatigue from any active effort. Child irritable, nervous, hysterical, slight noise intolerable, dominating, dictatorial and positiveness, Haughty, looks self contented. Falls sleep; from debility, sitting and studying. Dreams vivid, unpleasant, fell into water.
Ferrum Phos: Diurnal enuresis < lying down, urinates after every drink, urine spurts with every cough, chilly, thirsty, nervous, sensitive, anaemic constitution, great prostration, aversion to company, fear of going into crowd, indifferent to pleasurable things. Sleep is restless, anxious dreams, night sweats of anaemia. Eyes half open in sleep (clark).
Gelsemium: Incontinence from excitement, from paralysis of sphincter, urine is profuse, clear, watery urine. Alternate dysuria and enuresis. Patient is hot and thirstless. Dull, sluggish and slow with weakness and soreness of muscle. Reserved, timid anticipatory anxiety, confused cannot think properly. Drowsiness start on falling to sleep. Heavy stupid sleep.
Kali Brom: Nocturnal enuresis at 2 AM, newmoon, from night mare, worries. Urine is pale and profuse. Child is obese, hot and thirsty, Fidgety, busy hands, fumbles, plays with fingers. Child is depressed, forgetful and weepy . Night terror, somnambulism, Deep sleep, moans, cries ,grinding, horrible dreams. Diabetes mellitus.
Kali Phos: Nocturnal enuresis of obstinate nervous excitable children. Enuresis in bigger children and obstinate cases of enuresis. Urine is saffron, yellow, milky. Child is chilly, craves ice water, vinegar, sweets, cold drinks, Hungry soon after eating. Child is forgetful, weak memory, easily frightened, fear of crowd, of diseases, of death, of solitiude, of open spaces, started easily when touched., night terrors, somnambulism .amorous dreams, restlessness wakes up with fright.
Kreosote: Children wet the bed during Ist sleep with the dream of urination. He wakes up by the act of urinating but is unable to arrest the flow, urine is copious, pale, offensive, brown, red sediment. Child is chilly, old looking wrinkled scrofulous overgrown poorly developed children. Very tall for her age. Child is cross, willful and obstinate, capricious teeth decay very early with spongy bleeding gums and foul odour from mouth. Sleep is restless, tosses would not sleep until caressed and fondled. Dreams of falling, poisoned, fire, of urinating in a descent manner.
Lac Can: Bed wetting in children while dreaming of urination at night, Urine is scanty dark, thick, reddish sediments. Child is hot craves milk, great hunger for large quantity and often, has dark hair, eyes and skin. child is very forgetful, cross, irritable, fear of falling down stairs, of being alone, of snake. extroverted, aggressive. Sleep with one leg flexed and other stretched or sleep curled tightly on the side with face almost touching the knee. Dream of snakes. Dreams of urinating.
Medorrhinum: Nocturnal enuresis, Passes abnormally great quantity of high coloured ammonical urine in bed every night. Child is hot and thirsty with strong tendency to bite finger nails and toe nails. Body odour is extremely offensive. Child is selfish, destructive forgetful, anxious, liar, cross during day and cheerful at night, sensitive to reprimand, criticism reproaches, rudeness. Sleep in knee chest position with dreams of drinking something.
Merc sol: Nocturnal enuresis at 3 a.m. from paralysis, urine is copious/scanty, urinates more than he drinks mixed with blood white sediment strong smelling. Staining diaper, hot, acrid. child is chilly, thirsty, excessive salivation with moist, indended tongue, profuse perspiration light hair with lax skin and muscles .child is hurried and rapid speech, withdrawn and introverted, timid, shy and nervous aversion being touched or looked at. Sleep is restless, dream of water, thieves, animals.
Nat Mur: Nocturnal enuresis on alternate day, full moon. Cause- fright, grief, urine is clear watery, red sediments, turbid, dark. Child is hot, thirsty, lean, thin, scrofulous, brown hair, blue eyes, dark complexion. Tongue mapped with red insular patches like ring worm on sides. Craves salt, fish, Aversion to bread. Child is cross, angry about trifles more irritable when consoled, tendency to make mistake in speaking and writing. Aversion to presence of strangers, reserved, revengeful distracted awkward, drops things from hands, somnambulism, starts and talks in sleep. dreams of robbers, vivid, frightful.
Phosphoricum Acidium: Nocturnal enuresis in first sleep. Diabetes, urine frequent, profuse, watery, milky phosphaturia. Child is chilly ,emaciated ,desire for refreshing and juicy things, desire for cold milk. Child is quiet, indifferent, difficult concentration mental debility appear first than physical. sleepy by day, hot and wakeful at night short sleep > weakness
Phosphorus: Nocturnal enuresis results from anger, grief, diabetes, during typhoid, urine is profuse, pale haematuria, albumin, watery, turbid, brick dust sediments, offensive. Patient is chilly, thirsty, lean, thin, tall, beautiful grow too rapidly, scrofulous. Fair dedicate eye lashes and smooth hair, haemorrhagic. Craves salt and cold drinks, ravenous hunger. Mentally child is open lively, extrovert, desire sympathy sensitive to noise, odour, light, fear of ghost, being alone, clairvoyant, desire to be magnitised , restless, moves constantly. Starts in sleep, lies on rightside. Dreams of fire, lewd, vivid, business, somnambulism.
Plantago major: Nocturnal enuresis between midnight and morning. Urine is pale and passes in large quantity. Sleep: Gloomy, dreams exciting tears.
Pulsatilla: Nocturnal enuresis in little girls and autumn: causes: anger, spasm, after measles. Urine is scanty, red brown, mucus, profuse, child is hot, thirstless, fair complexioned, sandy hair, blue eyes, pale face, scrofulous, robust. Mental child is mild, timid, weepy, indecisive, slow, phlegmatic, hysterical, easily offended, desire consolation, fear to be alone, of dark, of ghost in evening avarice, selfish, effeminate. Sleeps with hands over head or crossed on abdomen and feet drawn up, talks and screams, restless tosses, dreamy confused, brightful.
Rhustox: Nocturnal enuresis in boys about midnight urine is dark, turbid, scanty, hot. child is chilly, thirsty, brown complexion, lean small stature, tall slender with aggravation in damp rainy weather child is very anxious, restless, confused. Sleep is restless, tossing, dreams of exertion, fire ,blood.
Sepia: Nocturnal enuresis in first sleep urine is foul sour, white, milky, red scanty, cloudy. Ailment from anger and vexation. Child is chilly thirstless, delicate, plethoric, yellow complexion, dark hair, rigid fibres. Puffed flabby child with dirty brown or blotched skin. Child is nervous, irritable, jealous, easily offended, aversion to play, fear to see the doctor. Indifference to loved ones. presence of strangers aggravate. talk loudly during sleep, wakes up, restless dreams of urinating.
Silicea: Nocturnal enuresis in children from worms, blow upon head, diabetes, urine is purulent, bloody profuse. Child is chilly, thirsty, emaciated, large head, open fontanels, scrofulous, rachitis, enlarged abdomen with thin legs. Profuse sweat on head at night. Offensive foot sweat, constipated. child is sensitive, want of grit, slow, obstinate, stunborn, fear of pins, timid, yielding mild. Sleep is restless, wakes up frightened, somnambulism, talk loudly, laughs. Dreams lascivious, pleasant murders.
Sulphur: Bedwetting in scrofulous, untidy children urine contain mucus and pus. Great quantities of colourless urine, greasy particles upon it. Child is hot thirsty, untidy, big head, big belly with emaciated limbs, kicks of the clothes at night, have worms, with aversion to bath. Child is very selfish, have no regards for others religious, aversion to play, boasting about his belongings, his toys, extroverted, foolish behaviour , happiness and pride. Sleep in catnap, talks, jerks and twitches in sleep wakes up singing, vivid dreams.
Thuja: Foamy urine. Child is hot, thirsty, obese, hypoactive hydrogenoid. Child is nervous, hurried, fixed ideas, irritable, jealous, quarrelsome towards mother, control himself among strangers and doctors. Closed yet well mannered and polite. Drems of death, falling from a height.
Thyroidinum: Enuresis of weakly children. Increase flow of urine. Urine smells of violets arrested development of child, craving for sweets.
Tub Bov: Betwetting sticky urine sediment. child is hot, thirsty, light complexioned with blue eyes, narrow chested, tall stature, of slim figure, emaciation with increased apitite, desire cold drink and milk sweat easily.
Mentally child is dissatisfied and restless, desire for change, travel, wander; obstinate, disobedient malicious, destructive, contrary to parents. Sleep is restless, tosses, screams, awakes in horror Dreams vidid, of shame, frightful.
Verbascum: Bed wetting at night, worse coughing constant dribbling, burning urination, increase with pressure in bladder. Unusual hilarity, with continuous flow of ideas, catarrhs and colds accompanied by neuralgia and a hoarse, barking cough. General lassitude and sleepiness in morning after rising. Restless sleep at night. He cannot awake immediately after dinner, lids close. Sensation as if ears were blocked.
Zincum: Bed wetting, Involuntary urination when walking coughing or sneezing. Child is chilly, thirsty, insatiable hunger at 11 a.m. or 12 a.m. Fogged condition, tissues are worn out faster than they can be repaired. Fidgety feet. Child started easily, excited, dull, absence of ideas, complaining and dissatisfied, yielding and quiet disposition. Weeps when angry sleep loud screaming without being aware of it jerks and starts on falling to sleep. Somnambulism after suppressed emotions.