Portal about the problem of treating childhood enuresis enurezu. Doctor Komarovsky about the treatment of enuresis in children Nocturnal enuresis in children 10 years old treatment

The problem of urinary incontinence is one of the most important in pediatrics. Doctors have been studying and treating it for a very long time. There is even an International Children's Continence Society (ICCS). The significance of the disease is determined not only and not so much by the seriousness of the problem from a medical point of view, but by the social and psychological aspect: children suffering from enuresis have to face reproach and punishment from adults, with ridicule from peers, and as they grow older, they themselves begin to experience pronounced psychological discomfort and difficulties in adapting to society.

By the term “enuresis,” nephrologists and urologists mean urinary incontinence at night, and the term “daytime enuresis” is considered not entirely correct. In this article we will talk specifically about bedwetting.

The ICCS defines urinary incontinence as urination at inappropriate times and places in a child 5 years of age or older. Accordingly, urination in bed during night sleep is considered enuresis. But the age limit (5 years) is quite arbitrary, since neuropsychic maturation and the ability to control urination during sleep in children occurs at different times and can vary widely (for several years - from 3 to 6-7). Therefore, it is more appropriate to diagnose enuresis in a child who is already beginning to understand the unacceptability of urinary incontinence, who himself is concerned about nocturnal episodes of incontinence and is interested in eliminating them.

Classification of enuresis

Enuresis can be primary and secondary, isolated and combined, monosymptomatic and polysymptomatic.

Primary enuresis occurs from an early age of the child, when there is no so-called period of “dry nights”, there are no symptoms of the disease or psycho-emotional stress. Secondary enuresis is diagnosed when urinary incontinence occurs in a child who has already begun to control nighttime sleep and wakes up to urinate. Secondary enuresis occurs after a period of “dry nights” that lasted at least six months, and in children there is a clear connection between the occurrence of bedwetting and the effects of any diseases, stress, mental factors and other pathological conditions.

Enuresis is called isolated enuresis, in which there is no daytime urinary incontinence. With combined enuresis, there is a combination of night and daytime incontinence.

Monosymptomatic enuresis is diagnosed in the absence of symptoms of other diseases and disorders. Polysymptomatic enuresis is defined in the presence of:

• urological disorders (neurogenic bladder dysfunction, congenital anomalies of the urinary system);
• neurological, psychiatric and psychological disorders;
• endocrine diseases.

Causes of enuresis

Enuresis can occur as a result of the following causes and provoking factors:

1. Hereditary predisposition: more than Half of children with enuresis have close relatives with the same problem. According to statistics, if one of the parents suffered from bedwetting in childhood, the probability of enuresis in the child is approximately 40%; If both parents suffered from urinary incontinence, then the likelihood of developing enuresis in their children increases to 70-80%. With genetically determined enuresis, there is a violation of the secretion of antidiuretic hormone (vasopressin), which normally ensures the reabsorption of primary urine, or a decrease in the sensitivity of the kidneys to vasopressin. As a result, children excrete large amounts of low-concentration urine at night.
2. Low functional bladder capacity. Functional capacity is the volume of urine that a person can hold before an irresistible urge to urinate arises. In children under 12 years of age, functional capacity is calculated using the formula: 30+30 × child’s age (in years), and is considered low if it is less than 65% of the age norm. With low functional capacity, the bladder is unable to hold all the urine produced during the night.
3. Polysymptomatic enuresis can develop against the background of various pathologies: residual effects after perinatal encephalopathy, head injuries, neuroinfections; lesions of the brain and spinal cord; ; urological diseases; for some allergic diseases (severe forms, eczema); endocrine diseases (and). And in such situations, enuresis is regarded not as a separate condition, but as one of the symptoms of the disease.

Possible causes of enuresis

Diagnosis of enuresis

It is not difficult to establish enuresis in a child: this is done on the basis of complaints of constant or frequent episodes of urinary incontinence at night in children over 5 years of age. However, to successfully eliminate urinary incontinence in children, it is necessary to find out the form and causes of enuresis, since for drug treatment, for example, hereditary (monosymptomatic) enuresis and enuresis against the background of an overactive bladder (polysymptomatic), fundamentally different methods are used.

The diagnostic criteria for hereditary urinary incontinence are:

• a history of enuresis in one of the child’s close relatives;
• constant urinary incontinence from the first years of life - without “dry nights”;
• nocturia - the predominance of nighttime diuresis over daytime - that is, at night the child produces more urine than during the day;
• low specific gravity of night urine;
• the child is thirsty in the evening;
• blood test data for hormones (low activity of the antidiuretic hormone - vasopressin - at night);
• genetic analysis data (detection of gene mutation);
• absence of organic or neuropsychic disorders.

In the process of diagnosing enuresis, the following is carried out:

• consultations with a pediatrician, neurologist, nephrologist, urologist, endocrinologist, child psychiatrist and psychologist;
• be sure to keep a diary of urination for several days (it records how many times and in what volume the child urinated per day, and whether there were episodes of incontinence day and night);
• laboratory tests (general blood tests and blood tests, urine and blood tests for sugar, blood tests for hormones, biochemical tests of blood and urine to exclude kidney pathology);
• Ultrasound of the kidneys and bladder;
• uroflowmetry (study of urinary flow rate during the entire time of voluntary urination);
• Additionally, X-rays of the spine, excretory urography, voiding cystoureterography and other studies may be prescribed.

Treatment of enuresis

A calm atmosphere in the family, adherence to the correct regime and daily routine will help to cope with the problem.

In the treatment of all forms of enuresis, non-drug measures are of the greatest importance: regimen, diet, bladder training, motivation of the child.

Regime and diet

Seven tips for parents if their child has enuresis:

1. Create the most peaceful environment in your family. The atmosphere in the evening hours is especially important: exclude quarrels, punishing the child in the evening, active games, computer, and watching TV are extremely undesirable.
2. Never scold or punish a child for peeing in the bed - this will not solve the problem, but will only develop complexes in the child.
3. Organize your sleeping area correctly: your child’s bed should be smooth and fairly rigid. If a child sleeps on an oilcloth, it should be completely covered with a sheet that does not wrinkle or move when moving during sleep. The room should be warm, without drafts (ventilate only before bedtime), but not too stuffy so that you don’t feel the urge to drink when falling asleep or at night. Teach your baby to sleep on his back. A cushion placed under the knees or an elevated foot end of the bed can help prevent involuntary urination when the functional capacity of the bladder is low.
4. Going to bed should be at the same time every day.
5. Dinner and drinks should be given no later than 3 hours before bedtime. This excludes products that have a diuretic effect (dairy products; strong tea, coffee, Coca-Cola and other caffeine-containing drinks; juicy vegetables and fruits - watermelon, melon, apples, cucumbers, strawberries). For dinner, hard-boiled eggs, crumbly porridge, stewed fish or meat, and weak tea with a small amount of sugar are recommended. Immediately before bedtime, the child can be given a small amount of food that promotes fluid retention (a piece of salted herring, bread with salt, cheese, honey).
6. Make sure your child pees at least 3 times in the hour before going to bed.
7. Leave a source of dim light (a night light) in your child's bedroom so that he is not afraid of the dark and can calmly go to the potty or toilet when he wakes up with the urge to urinate.

To wake up or not to wake up?

Doctors have different opinions about whether or not to wake up a small child at night to urinate: some believe that artificial awakening with putting him on the potty helps to develop a stable reflex followed by independent awakening when the bladder is full, other experts are of the opinion that such a reflex can be developed It’s difficult for preschoolers, and he quickly gets lost. But if you wake up your child, then wake him up 2-3 hours after he goes to bed, and be sure to wake him up completely - so that he wakes up, goes to the potty or toilet on his own, and returns back on his own. Showing pity and carrying a sleepy child in your arms to the toilet and back is useless: this in no way contributes to the development of the awakening reflex, children do not realize what they are doing, and in the morning they usually do not remember that they were woken up. But if the child has already wet himself, it is definitely necessary to wake him up, change him into dry clothes (even better if he changes his clothes himself), and remake the bed: these activities will form in the child the concept of comfortable sleep, like sleeping in a dry bed, and accustom him to the need keep your bed and clothes dry.

It is recommended to wake up older children (schoolchildren) at night, and this is done according to a certain pattern (“scheduled awakening”):

• the first week the child is woken up every hour after falling asleep;
• in the following days, the interval between awakenings is gradually increased (they wake up after 2 hours, then after 3, then only once at night).

Treatment with “scheduled awakening” continues for a month. If after a month the effect is not achieved (episodes of enuresis are repeated more often than 1-2 times a week), you can repeat the course once, or proceed to other methods of combating enuresis. It should be borne in mind that “waking up on a schedule” disrupts the child’s normal nighttime sleep, and this leads to serious stress on the nervous system. As a result, the child will be tired, lethargic, capricious during the day, and will have difficulty learning new information, which may result in a decrease in his performance at school. Therefore, it is advisable to use the method during the holidays.

Bladder training

The method gives a positive result only in children with low functional bladder capacity. The essence of the method: during the day, the child is given a lot of liquid to drink and asked not to urinate for as long as possible.

Motivational therapy

In the fight against enuresis, a good positive effect comes from the child’s own desire to succeed. Therefore, it is important for parents to encourage their child, praise him for “dry nights” (but not punish him when incontinence occurs), and teach him responsibility for his behavior (teach him to urinate before bed and not drink at night).

Development of conditioned reflexes to awaken with a full bladder (“urinary alarms”)

There are non-drug methods for treating enuresis using the development of conditioned reflexes in children. A special alarm device (enuresis alarm clock) is placed at the child’s bed, which responds to a humidity sensor that is sensitive to just a few drops of urine. The sensor in the pad is placed in the child's underwear (in modern alarm clocks, sensors can be attached to the outside of the underwear - where the first drop of urine is most likely to appear) - and at the very beginning of involuntary urination, the sensor reacts, the device emits a loud signal.

At the signal, the child wakes up and goes to the toilet. If the child is under 10 years old, then the parents must also get up: they help the child change into clean underwear and put him to bed again. This technique was invented in 1907 and is considered effective (it gives positive results in more than 70% of children with enuresis), but relapses are possible after its use. Success can be achieved after about a month of using the signal method, and for another two weeks after the cessation of enuresis, the humidity sensor is left in the child’s underwear. If there is no effect within 2 months of using the enuresis alarm clock, treatment using the “urinary alarm” method is stopped.

Physiotherapy

In parallel with drug therapy, courses of physiotherapeutic measures are often prescribed: laser, acupuncture, electrophoresis, etc. But their effectiveness is quite low, and when used in isolation (separate from other methods), physiotherapy usually does not produce positive results.

Other methods

In older children (from about 10 years old), psychotherapy (including family therapy) and auto-training are widely used in the treatment of enuresis and produce good results - the child is taught to independently tune in to “dry nights” and awakening when the bladder is full by repeating phrases every night before bedtime like “I want to sleep in a dry bed. I’ll definitely feel it if I want to go to the toilet and I’ll definitely wake up,” etc.

Drug treatment of enuresis

Hereditary form

To treat a hereditary form of enuresis, desmopressin (minirin) is prescribed at night in courses of 3 months with breaks of 1 month. The drug is a synthetic analogue of vasopressin and leads to relief of nocturia, and subsequently enuresis. During the period of treatment with Minirin, a strict drinking regime is simultaneously observed: liquid is strictly limited in the evening and at night (the child is given drinks only to quench thirst).

Enuresis due to neurogenic bladder dysfunction

Enuresis due to an overactive bladder, which is manifested by the presence in a child of an “imperative” urge to urinate, which he is unable to restrain, is treated using several groups of drugs.

The article reflects modern ideas about nocturnal enuresis, the prevalence of which among 6-year-old children reaches 10%. The existing classification options for this condition are presented, the etiology and probable pathogenetic mechanisms of nocturnal enuresis are described. A separate section is devoted to the problem of controlling bladder function in children, including such multidisciplinary aspects as genetic factors of nocturnal enuresis, the circadian rhythm of secretion of some of the most important hormones that regulate the excretion of water and salts (vasopressin, atrial natriuretic hormone, etc.), as well as the role of urological disorders and psychopathological/psychosocial factors. For doctors of various specialties, the part of the article that is devoted to the diagnosis of nocturnal enuresis, as well as differential diagnosis and modern approaches to the treatment of this type of pathology in children (both medicinal and non-medicinal) is of interest. This article summarizes the authors’ own experience and data from domestic and foreign research in recent years in the field of studying various aspects of nocturnal enuresis in children.

Key words: enuresis, nocturnal enuresis, desmopressin

Disorders of the act of urination such as enuresis have been known since ancient times. The first mentions of this condition are found in ancient Egyptian papyri and date back to 1550 BC. The term “enuresis” (from the Greek “enureo” - to urinate) refers to urinary incontinence. Nocturnal enuresis is defined as urinary incontinence after the age at which bladder control is expected to be achieved. Currently, 6 years of age is defined as such a criterion.

Boys suffer from nocturnal enuresis twice as often as girls; according to other sources, this ratio is 3: 2.

In general, it is believed that bedwetting is not a disease, but rather represents a stage in the development of control over physiological waste. Various aspects of the treatment of enuresis are dealt with by doctors of various specialties: pediatric neurologists, pediatricians, psychiatrists, endocrinologists, nephrologists, urologists, homeopaths, physiotherapists, etc. Such an abundance of specialists involved in solving the problem of nocturnal enuresis reflects the diversity of causes leading to urinary incontinence in children.

Prevalence. Nocturnal enuresis is an extremely common occurrence in the pediatric population and is classified as an age-dependent condition. It is generally accepted that 10% of children suffer from this condition at the age of 5 years, and 5% by the age of 10 years.

Subsequently, as people get older, the prevalence of bedwetting decreases significantly; Among 14-year-old adolescents, about 2% suffer from enuresis, and by the age of 18, only every hundredth individual suffers from enuresis. Although these rates indicate a high rate of spontaneous remission, even among adults, nocturnal enuresis affects about 0.5% of the general population. The incidence of enuresis depends not only on the age, but also on the gender of the child.

Classification. It is customary to distinguish between primary (persistent) nocturnal enuresis (if the patient has never had bladder control) and secondary (acquired if nocturnal enuresis appears after a period of stable urinary control), as well as complicated and uncomplicated (uncomplicated cases include cases of nocturnal enuresis, in which there are objectively no deviations in somatic and neurological status, as well as changes in urine tests). Thus, in patients with primary nocturnal enuresis, the physiological reflex of inhibition of urination (“sentinel”) is not initially formed and episodes of “missing” urine persist as the child grows up, and with secondary enuresis, night urination occurs after a long “dry” period (over 6 months ) . It is noted that primary nocturnal enuresis occurs 3-4 times more often than secondary. In addition, previously the so-called “functional” and “organic” forms of enuresis were often distinguished. In the latter case, it was implied that there were pathological changes in the spinal cord due to developmental defects. Functional forms of enuresis included nighttime (less often daytime) urinary incontinence due to the influence of psychogenic factors, defects in upbringing, trauma (including mental) and infectious diseases (including urinary tract infections).

Apparently, this classification is somewhat arbitrary. H. Watanabe (1995), after examining a representative group of patients using EEG and cystometrogram (1033 children), proposes to distinguish 3 types of nocturnal enuresis: 1) type I (characterized by an EEG response to bladder distension and a stable cystometrogram), 2) type IIa ( characterized by the absence of an EEG response to bladder overflow, a stable cystometrogram), 3) type IIb (characterized by the absence of an EEG response to bladder distension and an unstable cystometrogram only during sleep). This author regards nocturnal enuresis types I and IIa as, respectively, moderate to severe arousal dysfunction, and nocturnal enuresis type IIb as latent neurogenic bladder.

If a child has urinary incontinence not only at night, but also during the day, this may mean that he is experiencing some kind of emotional or neurological problem. As for nocturnal enuresis, it is often observed in children who sleep exceptionally soundly (the so-called “profundosomnia”).

Neurotic enuresis is more common among shy, fearful, “downtrodden” children with shallow, unstable sleep (such patients are usually very worried about the existing defect). Neurosis-like enuresis (can be primary or secondary) is characterized by a relatively indifferent attitude towards episodes of enuresis for a long time (until adolescence), and subsequently increased worries about this.

The existing classification of enuresis does not fully correspond to modern ideas about this pathological condition. Therefore, J. Noorgard and co-authors propose to distinguish the concept of “monosymptomatic nocturnal enuresis,” which occurs in 85% of patients. Patients with monosymptomatic nocturnal enuresis are divided into groups with or without nocturnal polyuria, responsive or unresponsive to desmopressin therapy, and, finally, subgroups with arousal disturbances or bladder dysfunction.

Etiology and pathogenesis. In nocturnal enuresis, the etiology is extremely multifactorial. It cannot be excluded that this pathological condition includes several subtypes, distinguished by the following characteristics: 1) time of onset (from birth or at least after a 6-month period of stable bladder control), 2) symptomatology (nocturnal enuresis only - monosymptomatic or combined night and daytime urinary incontinence), 3) response to desmopressin (good or bad response), 4) nocturnal polyuria (presence or absence). It has been suggested that nocturnal enuresis represents a whole group of pathological conditions with different etiologies. Nevertheless, it is customary to consider 4 main etiological mechanisms of urinary incontinence: 1) congenital impairment of the mechanisms of formation of the conditioned “sentinel” reflex, 2) delayed development of urinary regulation skills, 3) impairment of the acquired urinary reflex due to the influence of unfavorable factors, 4) hereditary burden.

Main causes of enuresis. Among the causes of nocturnal enuresis, the following can be listed: 1) infections, 2) malformations and dysfunctions of the kidneys, bladder and urinary tract, 3) damage to the nervous system, 4) psychological stress, 5) neuroses, 6) mental disorders (less often) . That is why, first of all, it is necessary to make sure that a child with urinary incontinence does not have signs of inflammation in the bladder (cystitis) or any other disorders of the urinary system (you need to do the appropriate urine tests and carry out all the necessary examinations as prescribed by a nephrologist or urologist ). If the child’s genitourinary system does not have pathology, then it can be assumed that the transmission of information to the brain about the fullness of the bladder is disrupted, that is, there is partial immaturity of the central nervous system.

The appearance of a second (or next) child in a family can quite expectedly lead to “wet nights” for his older brother (or sister). At the same time, the older child seems to “infantilize” and forgets how to control urination in the form of a conscious or unconscious protest against the apparent lack of attention, love and affection on the part of the parents, who are entirely concerned, first of all, with the “new” child. A similar situation sometimes occurs in such typical situations as moving to another school, transferring to another kindergarten, or even moving to a new apartment.

Quarrels between parents or divorce can also lead to a similar situation, as can excessive strictness in upbringing and physical punishment of children.

Monitoring bladder function. There are significant individual variations in the timing of the development of stable independent control of urination. Numerous studies by domestic and foreign authors show that control over the act of urination during night sleep is formed later than a similar function when awake during the day: in approximately 70% of children - by 3 years, in 75% of children - by 4 years, over 80 % of children - by the age of 5, in 90% of children - by the age of 8.5 years.

There is no doubt that control of bladder function (and nocturnal enuresis) depends on a number of factors: 1) genetic, 2) circadian rhythm of secretion of a number of hormones (vasopressin, etc.), 3) the presence of urological disorders, 4) delayed maturation of the nervous system , as well as 5) psychosocial stress and certain types of psychopathology.

Genetic factors. Among the genetic factors, family history, type of inheritance, as well as the location of the pathological (defective) gene deserve attention.

Scandinavian researchers found that if both parents had a history of enuresis, the risk of nocturnal enuresis in their children was 77%, and if only one parent suffered from enuresis - 43%.

The genealogical method of studying twins showed that concordance levels for enuresis for monozygotic twins are almost 2 times higher than for dizygotic twins: 68 and 36%, respectively. Relatively recently, appropriate genotyping was carried out and genetic heterogeneity in enuresis was established with probable loci of genetic disorders on chromosome 13 (13q13 and 13q14.2), - this region is currently known as “ENUR1”, as well as on chromosome 12q. H. Eiberg (1995) indicates that one autosomal dominant gene with reduced penetrance is involved in the formation of nocturnal enuresis, that is, susceptible to influence from environmental factors and/or other genes.

Among boys, 70% of monozygotic twins were concordant for nocturnal enuresis versus 31% of dizygotic male twins. Among girls, this ratio was 65 and 44%, respectively (no statistically significant differences were found). Apparently, among girls the genetic influence is not as significant as for boys.

Circadian rhythm in the secretion of certain hormones (regulating the excretion of water and salts). Normally, individuals exhibit marked circadian (circadian) variations in urine production and osmolality, with smaller volumes of (concentrated) urine being produced at night. In childhood, this circadian pattern is regulated partly by vasopressin and partly by atrial natriuretic hormone and the renin-angiotensin-aldosterone system.

Vasopressin. Studies on volunteers have demonstrated that reduced urine production at night (about half of that during the day) is due to increased secretion of vasopressin. More recently, it has been discovered that some patients with nocturnal enuresis and polyuria respond well to desmopressin therapy. But among these children there is a small group of patients with a normal circadian rhythm of vasopressin secretion (they do not respond to this therapy, like children with no nocturnal polyuria). It is possible that these children have impaired renal sensitivity to vasopressin and desmopressin, as do patients without nocturnal polyuria (with normal circadian fluctuations in urine production, urine osmolality, and vasopressin secretion).

Other osmoregulatory hormones. Increased secretion of atrial natriuretic hormone and decreased secretion of renin and aldosterone in obstructive sleep apnea explain the increase in urinary output and sodium excretion at night. It has been suggested that a similar mechanism may occur in nocturnal enuresis in children.

However, available data indicate that in children with nocturnal enuresis, the secretion of atrial natriuretic hormone is characterized by a normal circadian rhythm, and the renin-angiotensin-aldosterone system also does not undergo changes.

Urological disorders. There is no doubt that urinary incontinence (including nighttime) often accompanies diseases and structural abnormalities of the organs of the urinary system, acting as the main or accompanying symptom. The nature of these urological disorders can be inflammatory, congenital, traumatic and combined.

A trivial urinary tract infection (eg, cystitis) can contribute to enuresis (this is especially common in girls).

Delayed maturation of the nervous system. Numerous epidemiological studies indicate that enuresis is more common among children with delayed maturation of the nervous system. Often, nocturnal enuresis develops in children against the background of organic brain lesions and so-called “minimal cerebral dysfunction” due to the influence of unfavorable factors and pathology during pregnancy and childbirth (antenatal and intranatal pathological effects). It is noteworthy that in addition to a delay in the rate of maturation of the nervous system, children with enuresis often experience reduced indicators of physical development (body weight, height, etc.), as well as a delay in puberty and a discrepancy between bone age and calendar age (“lag” of ossification nuclei ).

As for patients in whom enuresis is noted against the background of mental retardation (they are generally characterized by a significant delay or lack of formation of adequate neatness skills), when subsequently prescribing therapy, greater importance should be given to the psychological age of the children (rather than the calendar age).

Psychopathology and psychosocial stress in patients with nocturnal enuresis. Previously, the presence of nocturnal enuresis was directly associated with psychological disorders. Although nocturnal enuresis may be combined with the presence of psychiatric pathology in some patients, this more often occurs with secondary enuresis with episodes of daytime urinary incontinence. The prevalence of nocturnal enuresis is higher among children with mental retardation, autism, attention deficit hyperactivity disorder, and motor and perceptual disorders. It is believed that the risk of developing psychiatric disorders among girls suffering from enuresis is significantly higher than for boys.

There is no doubt that psychosocial factors (belonging to low-income socio-economic groups, large families with poor housing conditions, children staying in specialized institutions, etc.) can influence enuresis. Although the exact mechanisms of this influence remain unclear, enuresis is undoubtedly more common in conditions of psychosocial deprivation.

It is interesting to note that growth hormone production is impaired under these conditions, and it has been suggested that vasopressin production may be similarly inhibited (resulting in excess urine production at night). The fact that enuresis is often associated with short stature may support this hypothesis of a combined depression of growth hormone and vasopressin.

Diagnostics. Nocturnal enuresis is a diagnosis that is established primarily on the basis of existing complaints, as well as individual and family history. It is important to remember that in 75% of cases, relatives of patients with nocturnal enuresis (first degree relatives) also had this disease in the past. It was previously found that the presence of episodes of enuresis in the father or mother increases the risk of the child developing this condition by at least 3 times.

Anamnesis. When collecting anamnesis, first of all, you should find out the nature of the child’s upbringing and the formation of his neatness skills. Find out the frequency of episodes of urinary incontinence, the type of enuresis, the nature of urination (weakness of the stream during voiding, frequent or rare urges, pain when urinating), a history of indications of urinary tract infections, as well as encopresis or constipation. Always clarify the hereditary burden of enuresis. Attention is paid to the presence of airway obstruction, as well as attacks of sleep apnea and epileptic seizures (or non-epileptic paroxysms). Food and drug allergies, urticaria (urticaria), atopic dermatitis, allergic rhinitis and bronchial asthma in children in some cases can contribute to increased excitability of the bladder. When interviewing parents, it is necessary to find out whether among relatives there are endocrine diseases such as diabetes mellitus or diabetes insipidus, dysfunction of the thyroid gland (and other endocrine glands). Since the vegetative status is closely dependent on the functions of the endocrine glands, any violations of them can cause enuresis.

In some cases, urinary incontinence can be induced by the side effects of tranquilizers and anticonvulsants (Sonopax, valproic acid drugs, phenytoin, etc.).

Therefore, it is necessary to find out which of these drugs and in what dosage the patient receives (or received previously).

Physical examination. When examining a patient (assessment of somatic status), in addition to identifying the above-mentioned disorders on the part of various organs and systems, attention is paid to the condition of the endocrine glands, abdominal organs, and urogenital system. It is mandatory to assess physical development indicators.

Psychoneurological status. When assessing the psychoneurological status of a child, congenital anomalies of the spine and spinal cord, motor and sensory disorders are excluded. Sensitivity in the perineal area and the tone of the anal sphincter must be examined. It is important to clarify the state of the psycho-emotional sphere: characterological characteristics (pathological), the presence of bad habits (onychophagia, bruxism, etc.), sleep disorders, various paroxysmal and neurosis-like conditions. A thorough defectological examination is carried out using the Wechsler method or using computer test systems (“Rhythmotest”, “Mnemotest”, “Binatest”) to determine the state of the child’s intellectual development and the status of basic cognitive functions.

Laboratory and paraclinical studies. Since urological disorders play a significant role in the occurrence of enuresis (congenital or acquired anomalies of the genitourinary system: detrusor and sphincter dyssynergia, hyper- and hyporeflex bladder syndromes, low bladder capacity, the presence of obstructive changes in the lower parts of the urinary tract: strictures, contractures, valves; urinary tract infections, household injuries, etc.), first of all, it is necessary to exclude pathology of the urinary system. From laboratory tests, great importance is attached to the study of urine (including general analysis, bacteriological, determination of the functionality of the bladder, etc.). An ultrasound examination of the kidneys and bladder is mandatory. If necessary, additional studies of the urinary system are carried out (cystoscopy, cystourethrography, excretory urography, etc.).

If abnormalities in the development of the spine or spinal cord are suspected, it is necessary to conduct an X-ray examination (in 2 projections), computed tomography or magnetic resonance imaging (CT or MRI), as well as neuroelectromyography (NEMG).

Differential diagnosis. Bedwetting should be differentiated from the following pathological conditions: 1) nocturnal epileptic seizures, 2) some allergic diseases (skin, food and drug allergies, urticaria, etc.), 3) some endocrine diseases (diabetes mellitus and diabetes insipidus, hypothyroidism , hyperthyroidism, etc.), 4) night apnea and partial airway obstruction, 5) side effects due to medications (in particular, thioridazine and valproic acid preparations, etc.).

Treatment of nocturnal enuresis. Although in some children nocturnal enuresis goes away with age without any treatment, there are no guarantees in this regard. Therefore, if episodes or persistent nighttime urinary incontinence persist, therapy is necessary. Effective therapy for nocturnal enuresis is determined by the etiology of this condition. In this regard, approaches to the treatment of this pathological condition are extremely variable, therefore, over the years, doctors have used a variety of therapeutic methods. In the past, the presence of enuresis was often attributed to late potty training; today, disposable diapers are often the “culprit”, although both of these ideas are incorrect.

Although today, unfortunately, none of the known treatment methods provides a 100% guarantee of curing nocturnal enuresis, some therapeutic methods are considered highly effective. They can be divided into: 1) medicinal (using various pharmacological drugs), 2) non-medicinal (psychotherapeutic, physiotherapeutic, etc.), 3) regime. Methods and extent of therapy depend on specific situational circumstances. In any case, successful treatment of enuresis is possible only with the active, interested participation of the children themselves and their parents.

Drug treatments. In cases where nocturnal enuresis is a consequence of a urinary tract infection, it is necessary to carry out a full course of treatment with antibacterial drugs under the control of urine tests (taking into account the sensitivity of the isolated microflora to antibiotics and uroseptics).

The “psychiatric” approach to the treatment of nocturnal enuresis includes the prescription of tranquilizers with a hypnotic effect to normalize the depth of sleep (Radedorm, Eunoctin); in case of resistance to them, it is recommended (usually in neurosis-like forms of enuresis) to take stimulants (Sidnocarb) or thymoleptic drugs (amitriptyline, milepramine, etc.) . Amitriptyline (Amizol, Tryptisol, Elivel) is usually prescribed in a dose of 12.5–25 mg 1–3 times a day (available in tablets and dragees of 10 mg, 25 mg, 50 mg). When there is confirmation that urinary incontinence is not associated with inflammatory diseases of the genitourinary system, preference is given to imipramine (milepramine), available in the form of tablets of 10 mg and 25 mg. It is not recommended to prescribe the above-mentioned drug to children under 6 years of age for the treatment of enuresis. If prescribed, it is dosed as follows: up to 7 years of age, from 0.01 g is gradually increased to 0.02 g per day, at the age of 8-14 years: 0.03–0.05 g per day. There are treatment regimens in which the child receives 25 mg of the drug 1 hour before going to bed; if there is no visible effect, after 1 month the dose is doubled. After achieving “dry” nights, the dose of milepramine is gradually reduced until completely discontinued.

When treating neurotic enuresis, they resort to prescribing tranquilizers: 1) hydroxyzine (Atarax) - tablets of 0.01 and 0.025 g, as well as syrup (5 ml contains 0.01 g): for children over 30 months, 1 mg/kg body weight /day in 2-3 doses, 2) medazepam (Rudotel) - tablets of 0.01 g and capsules of 0.005 and 0.001 g: daily dose of 2 mg/kg body weight (in 2 doses), 3) trimetozin (Trioxazine) – tablets of 0.3 g: daily dose of 0.6 g in 2 divided doses (6-year-old children), 7 – 12-year-olds – about 1.2 g in 2 divided doses, 4) meprobamate (tablets of 0.2 g ) 0.1–0.2 g in 2 doses: 1/3 dose in the morning, 2/3 dose in the evening (course lasting about 4 weeks).

Taking into account the fact that the immaturity of the child’s nervous system, developmental delay, as well as pronounced manifestations of neuroticism play a large role in the pathogenesis of enuresis, nootropic drugs (calcium hopanthenate, glycine, piracetam, phenibut, picamilon, Semax, Instenon, gliatilin, etc.). Nootropic drugs are prescribed in courses of 4–8 weeks in combination with other types of therapy in an age-specific dosage.

Driptan (oxybutynin hydrochloride) in tablets of 0.005 g (5 mg) can be used in children over 5 years of age in the treatment of nocturnal enuresis resulting from 1) instability of bladder function, 2) urinary disorders due to disorders of neurogenic origin (detrusor hyperreflexia), 3) idiopathic dysfunction of the detrusor (motor urinary incontinence). For nocturnal enuresis, the drug is usually prescribed 5 mg 2-3 times a day, starting with half the dose to avoid the development of unwanted side effects (with the last dose taken immediately before bedtime).

Among the most effective medications is desmopressin (which is an artificial analogue of the hormone vasopressin, which regulates the release and absorption of free water in the body).

Today, its most common and popular form is called Adiuretin-SD drops.

One bottle of the drug contains 5 ml of solution (1 drop applied from a pipette contains 5 mcg of desmopressin - 1-deamino-8-D-arginine vasopressin). The drug is administered into the nose (or rather, applied to the nasal septum) according to the following scheme: initial dose (children under 8 years old - 2 drops per day, children over 8 years old - 3 drops per day) - for 7 days, then, when “dry” nights, the course of treatment continues for 3 months (with subsequent discontinuation of the drug), but if “wet” nights persist, then the dose of Adiuretin-SD is systematically increased by 1 drop per week until a stable effect is obtained (maximum dose for children up to 8 years old is 3 drops per day, and for children over 8 years old - up to 12 drops per day), the course of treatment is 3 months at a selected dose, then discontinuation of the drug. If episodes of enuresis return, it is practiced to repeat a 3-month course of treatment in an individually selected dose.

Experience shows that when using Adiuretin-SD, the desired antidiuretic effect occurs within 15–30 minutes after taking the drug, and taking 10–20 mcg of desmopressin intranasally provides an antidiuretic effect lasting 8–12 hours in most patients. Along with the higher therapeutic effectiveness of Adiuretin compared to melipramine, the literature notes a lower frequency of relapses of nocturnal enuresis upon completion of therapy with this drug.

Non-drug treatments. Urinary alarms (another name is “urine alarms”) are designed to interrupt sleep when the first drops of urine appear so that the child can finish urinating in the potty or in the toilet (at the same time, a normal stereotype of physiological functions is formed). It often turns out that these devices awaken not the child himself (if his sleep is too deep), but all other family members.

An alternative to “urinary alarms” is the technique of scheduled night awakenings. In accordance with it, the child is woken up every hour after midnight for a week. After 7 days, he is woken up several times during the night (strictly at certain hours after falling asleep), selecting them in such a way that the patient does not wet himself during the remaining time of the night. Gradually, this period of time is systematically reduced from three hours to two and a half, two, one and a half, and finally to 1 hour after falling asleep.

For repeated episodes of nocturnal enuresis twice a week, the entire cycle is repeated again.

Physiotherapy. If we list just a few other, less common methods of treating nocturnal enuresis, they would include acupuncture (acupuncture), magnetic therapy, laser therapy and even music therapy, as well as a number of other techniques. Their effectiveness depends on the specific situation, age and individual characteristics of the patient. These methods of physiotherapy are usually used in combination with medications.

Psychotherapy. Special psychotherapy is carried out by qualified psychotherapists (psychiatrist or medical psychologist) and is aimed at correcting general neurotic disorders. In this case, hypnosuggestive and behavioral techniques are used. For children over 10 years of age, the use of suggestion and self-hypnosis (before going to bed), the so-called “formulas” for waking up independently when there is an urge to urinate, is applicable. Every evening before going to bed, the child tries for several minutes to mentally imagine the feeling of fullness of the bladder and the sequence of his own further actions. Immediately before falling asleep, the patient should, for the purpose of self-hypnosis, repeat several times the “formula” with approximately the following content: “I want to always wake up in a dry bed. While I sleep, the urine is tightly locked in my body. When I want to urinate, I quickly get up on my own.”

The so-called “family” psychotherapy is also important. Parents can successfully use a system of rewarding their child for “dry” nights. To do this, the child himself must systematically keep a special (“urine”) diary, which is filled out daily (for example, “dry” nights are indicated by “sun”, and “wet” nights by “clouds”). At the same time, it is necessary to explain to the child that if the nights are “dry” for 5–10 days in a row, a prize awaits him.

After episodes of urinary incontinence, it is necessary to change bed and underwear (it will be better if the child does this on his own).

It should be especially noted that a positive effect from the listed psychotherapeutic measures can only be expected in children with intact intelligence.

Diet therapy. In general, fluids in the diet are significantly limited (see “Regimen measures” below). Of the special diets for nocturnal enuresis, the diet of N.I. Krasnogorsky is considered the most common, which increases the osmotic pressure of the blood and promotes water retention in the tissues, which reduces urination.

Regular events. When treating nocturnal enuresis, parents and other family members of children suffering from this condition are advised to adhere to some general rules (be tolerant, balanced, avoid rudeness and punishment of children, etc.). It is necessary to achieve compliance with the daily routine. It is important to constantly instill in children suffering from enuresis confidence in their own strength and the effectiveness of the treatment.

1). You should limit your child's intake of any liquid after dinner as much as possible. Apparently, it is not advisable to not give children anything to drink, but the total volume of liquid after the last meal should be reduced by at least half (versus what is used). Limit not only drinking, but also dishes with a high liquid content (soups, cereals, juicy vegetables and fruits). At the same time, nutrition should remain complete.

2). The bed of a child suffering from nocturnal enuresis should be quite hard, and if the child is in deep sleep, the child must be turned over several times during the night in his sleep.

3). Avoid stress reactions, psycho-emotional disturbances (both positive and negative), as well as overwork.

4). Avoid hypothermia throughout the day and night.

5). It is advisable throughout the day to avoid giving your child foods and drinks that contain caffeine or have a diuretic effect (these include chocolate, coffee, cocoa, all types of cola, forfeits, seven-up, watermelon, etc.). P.). If it is not possible to avoid their use completely, it is recommended to abstain from consuming these types of food and drinks for at least three to four hours before going to bed.

6). It is necessary to insist on the child visiting the toilet or “planting” him on the potty before going to bed.

7). It is often effective to artificially interrupt sleep 2-3 hours after falling asleep so that the child can empty the bladder. However, if the child urinates in a sleepy state (not fully awake), such actions can only lead to a further deterioration of the situation.

8). It is better to leave a dim light source in the children's room at night. Then the child will not be afraid of the dark and leaving the bed if he suddenly decides to use the potty.

9). In cases where there is increased urine pressure on the sphincter, elevating the pelvic area or creating a raised area under the knees (placing an appropriately sized bolster) can help.

Prevention. Measures to prevent nocturnal enuresis in children are reduced to the following basic actions:

• Timely refusal to use any diapers (standard reusable and disposable).
  Usually, diapers are completely stopped when the child reaches the age of two, teaching children basic neatness skills.
• Control over the amount of fluid consumed during the day (taking into account the air temperature and time of year).
• Sanitary and hygienic education of children (including training in observing the rules of hygienic care of the external genitalia).
• Treatment of urinary tract infections.

Once a child suffering from enuresis reaches 6 years of age, further “wait-and-see” tactics (with refusal of any therapeutic measures) cannot be considered justified. Six-year-old children with nocturnal enuresis should receive adequate treatment.

The most important factor determining the development of enuresis is the relationship between the functional capacity of the bladder and nocturnal urine production. If the latter exceeds the capacity of the bladder, then nocturnal enuresis appears. It is possible that some of the symptoms regarded as abnormal in children with nocturnal enuresis are not such, since episodes of urinary incontinence are periodically observed in healthy children.

Literature

1. Norgaard J.P., Djurhuus J.C., Watanabe H., Stenberg A. et al.

Experience and current status of research into the pathophysiology of nocturnal enuresis. Br. J. Urology, 1997, vol. 79, r. 825–835.

2. Lebedev B.V., Freidkov V.I., Shanko G.G. etc. Handbook of childhood neurology. Ed. B.V. Lebedeva. M., Medicine, 1995, p. 362–364.

3. Perlmutter A.D. Enuresis. In: Clinical Pediatric Urology (Kelalis P.P., King L.R., Belman A.B., eds.) Philadelphia, W.B. Saunders, 1985, vol. I, p. 311–325.

4. Zigelman D. Bed-wetting. In: The Pocket Pediatrician. New YorkAuckland.Main Street Books/Doubleday, p. 22–25.

5. Pediatrician's Handbook. Ed. M.Ya.Studenikina. M., Poliform3, “Publisher-press”, 1997, p. 210–213.

6. Adiuretin in the treatment of nocturnal enuresis in children. Edited by M.Ya. Studenikin. 2000, c. 210.

7. Zavadenko N.N., Petrukhin A.S., Pylaeva O.A. Enuresis in children: classification, pathogenesis, diagnosis, treatment. Bulletin of Practical Neurology, 1998, No. 4, p. 133–137.

8. Watanabe H. Sleep patterns in children with nocturnal enuresis.

Scand. J. Urol. Nephrol., 1995, vol. 173, p. 55–57.

9. Hallgren B. Enuresis. A clinical and genetic study. Psychiatr. Neurol.

Scand., 1957, vol. 144,(suppl.), p. 27–44.

10. Butler R.J. Nocturnal Enuresis: The Child's Experience. Oxford: Butterworth Heinemann, 1994, 342 r.

11. Buyanov M.I. Systemic psychoneurological disorders in children and adolescents. M., 1995, p. 168–180.

12. Rushton H.G. Nocturnal enuresis: epidemiology, evaluation and currently available treatment options. J Pediatrics, 1989, vol. 114, suppl., p. 691–696.

13. Bakwin H. Enuresis in twins. Am. J Dis Child, 1971, vol. 121, p. 222–225.

14. Jarvelin M.R., Vikevainen-Tervonen L., Moilanen I., Huttenen N.P.

Enuresis in seven year old children. Acta Paediatr. Scand., 1988, vol. 77, p. 148–153.

15. Eiberg H. Nocturnal enuresis is linked to a specific gene. Scand. J.

Urol. Nephrol., 1995, suppl., vol. 173, p. 15–18.

16. Rittig S., Matthiesen T.B., Hunsdale J.M., Pedersen E.B. et al. Agerelated changes in the circadian control of urine output. Scand. J.

Urol. Nephrol., 1995, suppl., vol. 173, p. 71–76.

17. George P.L.C., Messerli F.H., Genest J. Diurnal variation of plasma vasopressin in man. J. Clin. Endocrinol. Metab, 1975, vol 41, p.

18. Hunsballe J.M., Hansen T.K., Rittig S., Norgaard J.P. et al.

Polyuric and non-polyuric bedwetting – pathogenic differences in nocturnal enuresis. Scand. J. Urol. Nephrol, 1995, vol. 173, suppl., p. 77–79.

19. Norgaard J.P., Jonler M., Rittig S., Djurhuus J.C. A pharmacodynamic study of desmopressin in patients with noctural enuresis. J. Urol., 1995, vol. 153, p. 1984–1986.

20. Krieger J. Hormonal control of sodium and water excretion in vasopressin and oxytocin-immunoreactive neurons in the paraventricular and supraoptic nucleus of the hypothalamus following urinary retention.

J. Kyoto Pref. Univ. Med., 1995, vol. 104, p. 393–403.

21. Rittig S., Knudsen U.B., Norgaard J.P. et al. The diurnal rhythm of plasma atrial natriuretic peptide in children with nocturnal enuresis.

Scand. J. Clin. Lab. Invest., 1991, vol. 51, p. 209.

22. Essen J., Peckham C. Nocturnal enuresis in childhood. Dev. Child.

Neurol., 1976, vol. 18, p. 577–589.

23. Gillberg C. Enuresis: psychological and psychiatric aspects. Scand.

J. Urol. Nephrol., 1995, suppl., vol. 173, p. 113–118.

24. Schaffer D. Enuresis. In: “Child and adolescent psychiatry: modern approaches” (Rutter M., Hershov L., Taylor E., eds.). 1994, Oxford: Blackwell Science, 1994, p. 465–481.

25. Devlin J.B. Prevalence and risk factors for childhood nocturnal enuresis.

Irish Med. J., 1991, vol. 84, p. 118–120.

26. Korovina N.A., Gavryushova A.P., Zakharova I.N. Protocol for the diagnosis and treatment of enuresis in children. M., 2000, 24 p.

27. Badalyan L.O., Zavadenko N.N. Enuresis in children. Review of Psychiatry and Medical Psychology named after. V.M. Bekhtereva, 1991, No. 3, p. 51–60.

28. Tsirkin S.Yu. (ed.). Handbook of psychology and psychiatry of childhood and adolescence. St. Petersburg: Peter, 1999.

29. Studenikin M.Ya., Peterkova V.A., Fofanova O.V. and others. The effectiveness of desmopressin in the treatment of children with primary nocturnal enuresis. Pediatrics, 1997, No. 4, p. 140–143.

30. Modern approaches to the treatment of nocturnal enuresis with the drug “Adiuretin”. Ed. M.Ya.Studenikina. M., 2000, 16 p.

31. Register of Medicines of Russia “Encyclopedia of Medicines” (Chief editor: Yu.F. Krylov) – 8th edition, revised. and additional M., RLS-2001, 2000, 1504 p.

32. Vidal reference book. Medicines in Russia: Directory. M., AstraPharmServis, 2001, 1536 p.

All parents are faced with the problem of bedwetting in children, but not everyone knows that you really need to start worrying when it happens after 5 years. The disease means the bladder is unable to hold its contents. When a person sleeps, the muscles relax, so involuntary urination occurs.

If “trouble” happened to a small child, then there is nothing to worry about. Parents of those children who have crossed the five-year mark and continue to wet the bed should sound the alarm

Factors contributing to the occurrence of the disease

Until a certain age, urination in babies is not regulated due to the fact that from the moment of birth they adapt to new conditions, form all life processes and skills to meet their physiological needs. If by the age of 4 these processes have not returned to normal, then parents need to ask themselves the question of the causes of the pathology.

According to the famous pediatrician Komarovsky E.O., enuresis does not mean the presence of serious pathologies in the body, so its treatment can quickly help get rid of involuntary urination during sleep, if it is properly organized. The main thing is that parents must remember the need for a gentle attitude towards the child, even if the treatment is delayed. The activity of all organs in the body is carried out through the brain, which is connected to them by nerves through the central nervous system, so the problem of urinary incontinence at night is not only physiological and medical in nature, but also psychological.

Anything can become an irritating factor: quarrels, parental divorce, the appearance of a small child in the family who receives more attention, fear, relationships in the classroom. Along with sessions with a psychologist, parents need to create a favorable environment in the family that minimizes stress: no punishment, ridicule, or publicizing the problem.

About the causes of the disease

In newborn children, the nervous system is not yet sufficiently developed, so urination occurs uncontrollably - up to 20 times a day (we recommend reading:). As the baby grows, nerve endings develop, children begin to control urges and learn to go to the toilet.

Full formation of the reflex should occur on average by 4 years, but depending on the individual characteristics of the body, it can happen a year earlier or upon reaching 5 years. The alarm should be sounded if, at the age of 6, 7, 8, 10, 11 years, involuntary urination in a child occurs during daytime and night sleep. Causes of enuresis:

• complications during pregnancy or childbirth, as a result of which the child was found to have perinatal hypoxic damage to the nervous system;
• hereditary predisposition - this means that a gene is passed from the parents to the child, which helps to increase the level of substances that reduce the response of bladder cells to antidiuretic hormone in the blood;
• presence of infection in the urinary tract or urological disease;
• stressful situations, unfavorable environment, psychological trauma;
• insufficient bladder capacity - this symptom must be taken into account if the child has previously had pyelonephritis (see also:);
• congenital or acquired diseases of the brain or spinal cord;
• diabetes mellitus (we recommend reading:);
• allergic reaction.

The cause of urinary incontinence can be psychological trauma received by the child. The nervous system of children is unstable, so even a quarrel in the family sometimes turns into health problems.

Enuresis in children can occur as a result of the action of several factors simultaneously; one cause can give rise to another. A very simple reason for involuntary urination at night can be, in the absence of pathologies, a sound sleep or an excessive amount of liquid, fruit, cold foods taken immediately before bed, or hypothermia of the body. Do not discount the psychological factors that contribute to the development of urinary incontinence: quarrels, night terrors, jealousy, etc.

Which specialist should I contact?

The doctor who deals with the primary diagnosis and treatment of all childhood diseases is a pediatrician. Despite the fact that the disease is associated with the urinary organs, it is worth starting with a visit to this particular specialist. A qualified doctor must identify the specialist who will be needed for a more accurate diagnosis and refer the parents and child for a full examination.

Considering that enuresis is a disease that can be caused by a number of different factors, it is appropriate to undergo examination by several specialists:

• the neurologist prescribes electroencephalography, which should reveal the state of the nervous system;
• the psychologist finds out whether there have been stressful situations, how the child is developing, uses special techniques to identify the emotional background in the family, and gives recommendations to parents;
• The urologist prescribes a bladder test, a urine test, and then drug treatment.

Each specialist works in turn, looking for the causes of the disease in their area.

If there is any doubt about determining the cause, the council may refer the baby for examination to other specialists - a nephrologist, an endocrinologist. A core range of specialists is usually enough to confidently make a diagnosis and prescribe treatment that will help relieve the child of involuntary urination at night.

How to treat enuresis?

There is no single prescription for the treatment of bedwetting in children, since the prescription depends on the causes of its occurrence. Each specific case requires an individual approach. Methods of drug treatment are prescribed based on the results of diagnosing the condition of the bladder muscles, the content of the hormone vasopressin, which regulates fluid levels, as well as the condition of its receptors:

1. Minirin - produced on the basis of vasopressin in the form of nasal drops, instilled before bedtime;
2. Driptan – with increased bladder tone;
3. Minirin in combination with Proserin - for hypotension of the bladder in the form of injections;
4. Nootropil, Persen in tablet form, B vitamins - treat nocturnal enuresis of neurotic origin.

All medications are used only after examination, identification of the causes and prescription by a specialist with strict adherence to the rules of administration and dosage. Alternatively, patients may be referred to a homeopathic physician who will prescribe alternative remedies:

1. Pulsatilla – in the presence of infectious diseases of the urinary tract, also for emotionally excitable children;
2. Gelsemium – for symptoms of relaxation of the bladder muscles as a result of stressful situations;
3. preparations containing Phosphorus are prescribed to children who drink a lot of cold water;
4. Sepia – for urinary incontinence when coughing, laughing at any time, also in the first 3 hours after falling asleep.

Modern homeopathic medicines can guarantee a cure for enuresis, provided that the diagnosis is correct. Alternative methods may be prescribed if medications do not have the desired effect and bedwetting in children cannot be cured.

Diseases of nervous origin are often treated using traditional medicine. Persen is considered one of the safest sedatives

About non-drug methods

Medications will not have the necessary effect on curing enuresis if the cause of its occurrence is psychological. Other factors that help normalize the urination process:

• Organization of the daily routine. Correct regulation of all processes during the day will accustom the body to internal discipline (eating at strictly defined hours, walks, daytime rest, sleep, entertainment) and will gradually eliminate enuresis in children. It is necessary to teach your child to stop eating 3 hours before bedtime. To fulfill this difficult condition, the best example should be the parents themselves.
• Bladder training exercises. It is necessary to teach how to control the process of urination. To do this, you need to learn to briefly delay the desire to go to the toilet.
• Creating a motive. Motivational therapy is a powerful psychotherapeutic tool that is used for children suffering from enuresis. It is used exclusively in cases where the cause of the disease is psychological factors. The motive should be to reward the child for “dry” nights (we recommend reading:). What will be the subject of reward and for how many successful nights is an individual decision, but the technique works in 70% of cases.
• Physiotherapeutic treatment. Physiotherapy in the form of electrophoresis, acupuncture, magnetic therapy, electrosleep, circular shower, and therapeutic exercises is designed to improve the functioning of the brain and nerve endings.
• Psychotherapeutic assistance. Using special techniques, the specialist teaches the child methods of self-hypnosis. As a result, the reflex connection between the central nervous system and the bladder muscles should be restored. If the neurotic nature of bedwetting is pronounced, then psychologists use their tools to shift depressive states. The main role in psychotherapy should be played by creating a favorable positive atmosphere in the family.

In some cases, the child may benefit from therapeutic exercises, which stimulate nerve endings and strengthen the nervous system.

Traditional medicine in the fight against disease

Traditional medicine is a storehouse of healing methods for all kinds of diseases, so you should not neglect effective home recipes that came from time immemorial. They have been tested in practice by many generations of people and contain only natural ingredients:

• For children under 10 years old, brew a tablespoon of dill in a glass of boiling water and leave for an hour. Drink half a glass in the morning on an empty stomach.
• Cook lingonberry compote with the addition of 2 tablespoons of rosehip, let it sit. The infusion can be drunk several times a day; it has a calming effect on the nervous system.
• Pour 2 tablespoons of rose hips into one liter of boiling water and leave. Instead of tea, drink throughout the day. Rosehip strengthens nerve cells well.
• Bring lingonberry berries and leaves, St. John's wort in an arbitrary small amount to a boil in ½ liter of water. Leave for 30 minutes, strain, cool and take throughout the day.
• Brew 30 g of crushed plantain leaf in 350 ml of hot water, let it brew, take 10 g 4 times a day.
• Chop the herbs of mint, St. John's wort, birch leaves, chamomile flowers in equal parts and mix. Pour 50g of the mixture into 1 liter of hot water in a thermos and leave for 8 hours. Take 100 g half an hour before meals. To ensure that your child drinks the infusion with pleasure, you can add honey to it. After 3 months you need to take a break for 2 weeks, then continue taking the drug.
• A collection of knotweed, yarrow, St. John's wort, and blackberry leaves will relieve the symptoms of enuresis. All ingredients must be crushed and mixed in equal parts. Pour 300 ml of boiling water over the finished 10g mixture and leave in a thermos for 2 hours. The infusion should be taken 5 times a day before meals.

Folk remedies will have the desired effect if taken under the supervision of a physician. Herbal remedies are an addition to the main treatment and should not be a complete replacement for it. In addition, herbal remedies can have a good effect in preventing enuresis.

– disorder of voluntary urination, the child’s inability to control the act of urination. Urinary incontinence in children is characterized by the inability to accumulate and retain urine, which is accompanied by involuntary urination during sleep or wakefulness. To find out the reasons, children undergo urological (ultrasound of the urinary system, cystoscopy, radiography of the kidneys and bladder, electromyography, uroflowmetry) and neurological (EEG, EchoEG, REG) examination. Treatment of urinary incontinence is carried out taking into account the causes and may include drug therapy, physical therapy, psychotherapy, etc.

General information

Urinary incontinence in children is persistently repeated involuntary (unconscious) urination during the day or at night. Urinary incontinence affects 8 to 12% of children, with the most common form of pathology in childhood being enuresis. The polyetiological nature of urinary incontinence in children makes this problem relevant for a number of pediatric disciplines: child neurology, pediatric urology, child psychiatry.

In children under the age of 1.5-2 years, urinary incontinence is considered a physiological phenomenon associated with the immaturity of somatovegetative regulatory mechanisms. Normally, a child develops the skills of holding urination when the bladder is full by the age of 3-4 years. However, if urinary control skills have not been established by this period, one should look for the reasons causing urinary incontinence in the child. Urinary incontinence in children is a social and hygienic problem, often leading to the development of psychopathological disorders that require long-term treatment.

Causes of urinary incontinence in children

Urinary incontinence in children can be caused by a violation of the nervous regulation of the function of the pelvic organs due to organic lesions of the brain and spinal cord: injuries (craniocerebral, spinal cord), tumors, infections (arachnoiditis, myelitis, etc.), cerebral palsy. Children with various mental illnesses (mental retardation, autism, schizophrenia, epilepsy) often suffer from urinary incontinence.

Urinary incontinence may be caused by anatomical disorders in the development of the child’s genitourinary system. Thus, the organic basis of urinary incontinence can be represented by cleft urachus, ectopia of the ureteric orifice, exstrophy of the bladder, hypospadias, epispadias, infravesicular obstruction, etc.

In some cases, urinary incontinence in children occurs due to sleep apnea syndrome, endocrine diseases (diabetes mellitus, diabetes insipidus, hypothyroidism, hyperthyroidism), and taking medications (anticonvulsants and tranquilizers).

In some cases, bedwetting is explained by a disturbance in the rhythm of secretion of the antidiuretic hormone (vasopressin). Due to insufficient concentration of vasopressin in plasma at night, the kidneys secrete a large volume of urine, which overwhelms the bladder and leads to involuntary urination.

Urinary incontinence can be accompanied by urogenital diseases (pyelonephritis, cystitis, urethritis, vulvovaginitis in girls, balanoposthitis in boys, vesicoureteral reflux, nephroptosis, pyelectasia), helminthic infestation. Allergic diseases can contribute to increased excitability of the bladder and urinary incontinence in children: urticaria, atopic dermatitis, bronchial asthma, allergic rhinitis.

In children, especially preschoolers, urinary incontinence can be of a stressful nature. Quite often, a psychologically traumatic situation is the divorce of parents, the death of a loved one, conflicts in the family, ridicule of peers, transfer to another school or kindergarten, change of place of residence, the birth of another child in the family. Recently, among the reasons contributing to urinary incontinence, pediatricians have cited the widespread use of disposable diapers, which delay the formation of a conditioned reflex to urinate in a child.

In most cases, urinary incontinence in children is caused by a combination of these factors.

Classification

In the event that involuntary leakage of urine occurs through the urethra, they speak of vesical incontinence; if urine is released through other unnatural channels (for example, genitourinary and ureterintestinal fistulas), this condition is regarded as extravesical urinary incontinence. In the future, only forms of vesical urinary incontinence in children will be considered.

In pediatric urology, it is customary to distinguish between incontinence and urinary incontinence: in the first case, the child feels the urge to urinate, but cannot hold urine; in the second, the child does not control urination because he does not feel the urge. In the event that urinary incontinence occurs during sleep (in children over 3.5-4 years old at least 2 times a month) in the absence of mental illness and anatomical and physiological defects of the urogenital area, they speak of enuresis (night or daytime).

Urinary incontinence in children can be primary or secondary. By primary (persistent) we mean a delay in the formation of the physiological reflex of the formation and control of urination. This usually occurs against the background of neuropsychic disorders or organic disorders of the urinary system. Cases of secondary (acquired) urinary incontinence include situations when the skill of inhibiting urination is lost after a period of urinary control for more than 6 months. Secondary urinary incontinence in children can have a psychogenic, traumatic or other origin.

According to the mechanisms of development, urinary incontinence can be imperative, reflex, stress, from bladder overflow, or combined.

With imperative (imperative) urinary incontinence, the child is unable to control urination at the height of the urge. This option, as a rule, occurs in children with a hyperreflex form of neurogenic bladder.

Stress urinary incontinence in children develops in connection with efforts accompanied by a sharp increase in intra-abdominal pressure (coughing, laughing, sneezing, lifting heavy objects, etc.). This type is most often caused by functional weakness of the pelvic floor muscles and urethral sphincter.

Reflex urinary incontinence in children is caused by the disconnection of the cortical and spinal centers that regulate the function of the pelvic organs, including voluntary urination. In these cases, there is an involuntary leakage of urine drop by drop or in small portions.

Paradoxical ischuria, or urinary incontinence associated with bladder overflow, can be small - up to 150 ml; medium -150-300 ml and large volume - more than 300 ml. This disorder is characterized by involuntary loss of urine due to overfilling and overdistension of the bladder in children with a hyporeflex neurogenic bladder and bladder outlet obstruction.

Symptoms of urinary incontinence

Urinary incontinence is not an independent disease, but a disorder that occurs in various nosological forms. Urinary incontinence in a child may be constant or intermittent; be noted only in a dream or also in a waking state (usually while laughing, running); have the character of a slight leakage of urine or complete spontaneous emptying of the bladder.

Children with urinary incontinence often have comorbidities such as recurrent urinary tract infections, constipation, or encopresis. Due to constant contact of the skin with urine, dermatitis and pustular lesions often occur.

Children with enuresis are characterized by emotional lability, isolation, vulnerability or irascibility, irritability, and behavioral abnormalities. Such children may suffer from stuttering, bruxism, sleep disorders, sleepwalking, and sleep-talking. Autonomic symptoms are typical: tachycardia or bradycardia, sweating, cyanosis and coldness of the extremities.

Diagnostics

A specialized examination of children with urinary incontinence is aimed, first of all, at identifying the causes of this condition. Therefore, a team of pediatric specialists, including a pediatrician, pediatric urologist or pediatric nephrologist, and child psychiatrist, can participate in the diagnostic search. A study of somatic status involves collecting a detailed history, assessing the general condition, examining the lumbar region, perineum, and external genitalia.

At the stage of uronephrological examination, the daily rhythm of urination is assessed, laboratory tests are carried out (general urine analysis, bacteriological urine culture, Zimnitsky's test, Nechiporenko, etc.), uroflowmetry, electroneuromyography.

Treatment of urinary incontinence in children

Depending on the identified etiological factors, treatment is carried out differentiated. For congenital malformations of the urinary tract, surgical correction is performed (urethroplasty, sphincteroplasty, suturing of a bladder fistula, etc.). If inflammatory diseases are detected, courses of conservative treatment of urethritis, cystitis, and pyelonephritis are prescribed. Treatment of children with mental disorders and psychogenic urinary incontinence is carried out by child psychiatrists and psychologists using drug therapy and psychotherapy. If the cause of urinary incontinence in a child is insufficient maturity of the nervous system, courses of nootropic drugs are indicated.

Regular aspects play an important role in the treatment of any type of incontinence: eliminating stressful situations, creating a friendly atmosphere, limiting fluid intake at night, forcing the child to wake up and sit on the potty at night, etc.

Physiotherapeutic methods are effective in the treatment of various forms of urinary incontinence in children: darsonvalization, diathermy, electrophoresis, electrosleep, magnetic therapy, IRT, electrical stimulation of the bladder, transcranial electrical stimulation.

Prevention

The diversity of preventive measures aimed at preventing urinary incontinence in children is due to the polyetiology of the disorder. General recommendations include maintaining a sleep-wake schedule, timely potty training, sanitary and hygienic education of children, and normalization of the psychological climate. Timely treatment of urinary tract infections, anomalies of the genitourinary system and other concomitant diseases is necessary. A favorable course of pregnancy plays an important role.

Children should never be scolded for urinary incontinence - this can increase the child's feelings of shame and inferiority.

Kovbas Oksana Anatolyevna

Deputy Chief Physician

Leading doctor

Pulmonologist

Enuresis- This is urinary incontinence. Most people understand enuresis as uncontrolled urination at night in children, but from a medical point of view, enuresis is any uncontrolled urination - in both children and adults.

Nocturnal enuresis in children attracts special attention. What parent doesn’t want to see their child healthy and developing normally, and a wet bed doesn’t really fit into this picture...

Meanwhile, enuresis occurs quite often. At the age of 5, enuresis occurs in approximately every 5th child. Until the age of 5, night urination cannot be considered a pathology at all: the brain structures responsible for waking up a child at night when the bladder is full mature only by the age of 4-5. But sometimes this process is delayed. In older groups of children, the percentage of children with identified enuresis is lower. At 6 years of age, enuresis is diagnosed in 12% of children. At 12 years old – 3%. However, the problem persists even into adolescence: enuresis is observed in 1% of children aged 15-16 years. Enuresis is more common in boys. In girls it is three times less common.

There are primary and secondary enuresis. If a child, having already left infancy, still continues to wet the bed, this is primary enuresis. If cases of night urination appeared after the child learned to get up to go to the toilet, then doctors talk about secondary enuresis.

Causes of enuresis

In each specific case, nocturnal enuresis in a child is explained, as a rule, not by one reason, but by a complex of factors. This is, first of all:

• delayed development of brain structures that control urination;
• lack of antidiuretic hormone (ADH). Under the influence of this hormone, the kidneys reduce the water content in urine at night, resulting in less urine being produced at night. If the hormone is not produced enough, the child experiences bladder overflow at night;
• . If a child sleeps too deeply, he simply cannot wake up when he needs to go to the toilet. It is difficult to wake up such a child; at the moment of sudden awakening, he may experience unreasonable fear, disorientation in space, and motor overexcitation. Enuresis is often accompanied by sleep talking or sleep walking;
• diseases of the urinary system and genital organs (cystitis, etc.). A symptom of such diseases is more frequent urge to go to the toilet. In general, children suffering from enuresis are characterized by a decrease in the critical volume of urine: they are able to hold less urine without urinating than their peers;
• . Pinworms can crawl into the urethra (in girls), irritating the mucous membrane and causing urination;
• neurological disorders and stress. Nervous tension experienced by a child can cause uncontrollable urination at night. Children often react this way to conflicts in the family, divorce of parents, loss of loved ones, problems at school. In some cases, enuresis is one of the manifestations of increased excitability of the nervous system, which, in turn, may be a consequence of birth trauma;
• endocrine disorders. In this case, in addition to enuresis, the child may experience sweating, swelling, and a tendency to allergies;
• (proliferation of the nasopharyngeal tonsil). With adenoids, the brain center responsible for urination does not receive the required amount of oxygen, which causes its disorder.

Methods for diagnosing enuresis

First of all, it is necessary to establish the reasons that caused enuresis. For this purpose, the child must be examined by specialist doctors, and it is also necessary to undergo tests and instrumental examinations.

Specialist consultation

First of all, a child suffering from enuresis should be shown and. You may also need to consult such specialists as (he can be replaced by a child clinical psychologist or) and (you need to make sure that the child’s nocturnal enuresis is not associated with).

Instrumental studies

Treatment methods for enuresis

Treatment of enuresis is necessary if involuntary night urination is observed in children over 5 years of age and if we are talking about repeated episodes of enuresis over several months (an isolated case is not yet a disease).

Although bedwetting treatment takes time and patience, it achieves its goal in the vast majority of cases.

Drug treatment of enuresis is carried out

• in case of deficiency of antidiuretic hormone (its synthetic analogues are prescribed);
• with increased or decreased tone of the bladder.

The correct attitude of parents to the problem is of enormous importance. The child needs to be provided with psychological comfort. If enuresis is caused by stress, this stressful state must be relieved.

What should parents do if their child has nocturnal enuresis?

It is very important to properly respond to wet bed incidents. You cannot scold a child for this. If a child feels that their parents are angry or annoyed, they may develop a guilt complex, which will only make the problem worse. If the child is big enough, he will worry anyway. The child needs to be instilled with confidence that nothing fatal has happened, that the problem is temporary, and after some time everything will be fine. Under no circumstances should you discuss the “embarrassment” that happened in front of strangers, especially in front of children your own age.