Enuresis is the occurrence of involuntary urination during the day or night after the age of 5 years in children. There are three types of enuresis: nocturnal enuresis, diurnal enuresis and diurnal enuresis. Nocturnal enuresis is more common in children 5 years of age or older who are able to control urination during the day, but wet the bed almost every night. It occurs in about 10% of children aged 4-14 years, is more common in boys than girls, and in some cases can persist into youth or adulthood.
I. Etiology and pathogenesis
Organic pathology causes enuresis in no more than 10% of cases, and can be seen in congenital anomalies such as spina bifida and urethral stenosis, recurrent urinary tract infections, diabetes mellitus, urolithiasis, chronic renal failure, seizures, mental retardation and post-morbid weakness. Constant dribbling often indicates spina bifida. Boys should be checked for bladder neck obstruction, and girls should be checked for ectopic ureteral entry into the vagina. Children with enuresis may be combined with mental retardation, and children with mental retardation acquire bladder sphincter control significantly later.
Functional or neurogenic enuresis accounts for the majority of cases. Poor training or psychiatric factors are important causes of enuresis, and children often have a family history of enuresis. Children do not develop the habit of automatic control of urination due to overindulgence by parents, loss of care by both parents, failure to wake the child at night, or overexertion from daytime games and activities, causing loss of urinary alertness from too deep a sleep. Neurologists believe that delayed development of bladder control function in the spinal reflex center during sleep can also lead to enuresis.
II. Epidemiology
Enuresis is involuntary urination, and more than 80% of enuresis occurs only at night. About 15% of normal infants and children have nocturnal bedwetting by the age of 5 years. The annual natural elimination rate is about 15%. 99% of children no longer have nocturnal bedwetting by age 15. Enuresis occurs more commonly in boys than in girls.
Clinical manifestations
1. Medical history: Find out the daytime and nighttime urination, age, urine loss (degree and relationship with sleep), urinary tract infection and family history of urine loss. Patients can be divided into 3 groups.
Asymptomatic nocturnal enuresis. No further examination is needed.
With infection or significant neuropathy, further examination is required.
No infection and neurological symptoms, and no other urinary abnormalities, anatomical problems should be excluded.
2. Physical examination: the presence of prepuce, prepuce, urethral stenosis; pay attention to the presence of hair or lipoma in the lumbosacral region with a view to detecting the presence of occult sacral spina bifida and spinal canal closure insufficiency.
IV. Examination
Laboratory examination.
General urine routine is normal, and urine culture is free of bacterial growth. Measure the amount of arginine pressor pressor secreted by the pituitary gland in the urine during both daytime and nighttime hours. Normally it is increased at night compared to daytime, and its antidiuretic effect reduces nocturnal urine output. In enuresis, nocturnal AVP secretion is not increased due to delayed development of the thalamus and pituitary gland, resulting in increased nocturnal urine output.
Other ancillary tests.
1. Ultrasound, IVU and cystourethrography during voiding: to understand the condition of the kidneys, ureters and bladder, and there are usually no abnormal findings. There was no congenital spina bifida or spondylolisthesis on X-ray plain radiographs.
2. Urodynamic examination: Urodynamic examination should be performed for all suspected neurological disorders, daytime incontinence without combined pathological changes, adolescent nocturnal enuresis where conventional treatment is ineffective, incontinence of both urination and defecation, persistent difficulty in urination despite infection control, recurrent urinary tract infections despite continuous antibiotic application, and voiding cystourethrography showing bladder trabeculae formation or sphincter spasm.
V. Diagnosis
The most common habitual, training and mental factors, local irritant damage, endocrine disorders, neurological disorders, urethral lesions, and mental developmental status need to be understood before diagnosis. Observe the nocturnal sleep activities of the child, such as turning over, limb movement, sound response and eye movement. Apply sleep polysomnography to observe EEG, ECG, oculopotentiogram, etc. to determine sleep disorders and distinguish organic from functional lesions.
Differential diagnosis
1.Urinary incontinence: It refers to the loss of control of urine and random flow without subjective will, usually there is no obvious difference between daytime and nighttime.
2.Ureteral ectopic opening: In women with ureteral ectopic opening, in addition to normal urethral urination, urine leakage from other parts of the urethra can be found, and abnormalities of the urinary system can be seen in IVU and other examinations.
VII. Treatment
1.Promotion and responsibility training treatment: promotion treatment is to cultivate the child’s initiative to accept treatment for enuresis, that is, gradually cultivate the child’s initiative to actively request treatment for enuresis by means of urination diary and encouragement. Responsibility training treatment is to let the child know that urine loss not only brings a lot of trouble to himself but also to his parents, and that he should try to reduce the number of urine loss.
2. Bladder training: The aim is to increase the functional capacity of the bladder and enhance the control ability of the bladder sphincter. The specific method is to encourage the child to gradually extend the interval between urination. At the beginning, the child can urinate once every half hour, and after several successes, it will be changed to 1h/1 time, and then gradually increase to 1 time in 3-4h. Often, the number of nocturnal enuresis can be reduced after the symptoms of daytime frequency of urination improve. At night, it is possible to wake up once every 2 hours after falling asleep and gradually extend the time to once every 4-5 hours to urinate. Bladder training plays an important role in the treatment of enuresis.
3.Conditioned reflex training: The main purpose is to wake up the brain and establish conditioned reflexes. For children over 7 years old who can cooperate, an ultrasound alarm for monitoring bladder capacity should be attached to them. When the bladder volume is close to the alert value, the child can wake up by himself or be woken up by parents to urinate.
4.Actively deal with the primary disease: such as infection and obstruction, etc.
5.Drug treatment.
(1) Promethazine (promethazine): it can excite the brain to facilitate arousal, it has anticholinergic and antitussive effects, it can expand the bladder capacity, it excites the proximal α-receptors of the urethra to increase urethral pressure, it can also increase pituitary hormone secretion and reduce urine volume. 1-2h before bedtime at 0.9-1.5mg/(kg? d) for 1 week for 6 months. Mild side effects of this drug are anxiety, insomnia, dry mouth and nausea. If overdose can cause cardiac arrhythmia, hypotension and convulsions, so the child should be monitored by parents and guided to take the drug. It should not be used for children under 6 years old.
(2) Propantheline: It can relax the detrusor muscle and reduce uninhibited contractions. 25-75mg orally before bedtime or 15mg, 3 times/d. Adverse effects are dry mouth and nausea.
(3) Ephedrine: The mechanism of action is to increase posterior bladder urethral tone and reduce sleep depth. 25-40mg orally at bedtime.
(4) Oxybutynin: anticholinergic drug with antitussive effect, can release the uninhibited contraction of bladder and expand the capacity of functional bladder, especially suitable for children with frequent and urgent urination and small capacity of functional bladder. 5mg, 2 times/d or 3 times/d for those over 6 years old, side effects are: dry mouth, flushing, fever, overdose may cause blurred vision and hallucination.
(5) 1-Deamino-D-arginine pressor-pressor: desmopressin, a natural antidiuretic hormone of the same kind, is divided into two kinds of spray and tablet. The general dosage of the spray is 20μg to each nostril before bedtime, and the tablet is 200-400μg to be taken orally before bedtime, which is effective for children with high nocturnal urine output and genetic tendency.
(6) Treatment of secondary enuresis needs to be tailored to the specific situation.
(7) Chinese medicine and acupuncture treatment.