Enuresis is a condition in which the ability to control the emptying of the bladder is not formed or is lost, resulting in episodes of involuntary urination. Bedwetting or uncontrolled emptying of the bladder during wakefulness may form.

A delicate illness, which is not customary to spread, is a huge problem both psychologically, socially and hygienically. Urinary incontinence ( incontinence ) occurs in both children and adults.

Physiology of urination, norm

It is legitimate to make this diagnosis to a patient over 4-5 years old. The lower age limit, according to some authors, is somewhat different. But in the medical community, it is accepted that the disease has clinical significance at the age of about 5 years and older.

The ability to retain urine in newborn babies and toddlers in the first years of life is absent. This skill begins to form closer to three years old, and ends closer to four. At this age, urination is already controlled by the child: he is able to delay the act of urination, if necessary, to regulate the outflow of urine.

The following mechanisms help keep urine normal:

• Elasticity and normal tone of the organs of the genitourinary system.
• Controlling influence of the central nervous system and PNS.
• Sufficient development and activity of smooth and striated muscles of the urethra and the adjacent zone.
• Normal anatomical development and position of the bladder and urethra.

However, as a result of some reasons, organic or functional, there is a violation of the processes of control over urination, and enuresis develops in adults or children.

Classification

There are several classifications of this pathology.

Due to the appearance:

• Primary. This is an independent nosological disease. Arises from childhood. With this form, there are no manifestations of organic damage or psychoemotional nature. Most often it is nocturnal enuresis . 
• Secondary. It arises as a symptom in kidney pathology, against the background of neurological, endocrinological, urological diseases. Its symptoms occur both during the day and at night. 

Primary enuresis of inorganic nature in children occurs in 80-90% of cases; with age, the incidence of secondary pathology arising against the background of previous somatic diseases increases.

By the time of onset of symptoms:

• Night. Symptoms come on at night. This is the most common form; of all cases, nocturnal enuresis accounts for up to 85%. 
• Day. In 5% of cases, clinical symptoms occur during the day. 
• Mixed. In about 10% of patients, incontinence can occur both during the day and at night. 

By the presence / absence of complications:

• Uncomplicated. The form in which the patient has no abnormalities in laboratory tests of urinalysis during examination, and there are no changes in the somatic, neurological status, no psychological disorders are found. 
• Complicated. If, during examination, a patient reveals somatic diseases, anatomical and physiological abnormalities in the structure of the genitourinary system or neurological disorders, this form of enuresis is considered complicated. 

By the frequency of manifestations:

• Frequent. Urination occurs involuntarily every night or daily. 
• Moderate. Nocturnal enuresis occurs several times a week (2-3). 
• Rare. Episodes of incontinence are possible 2-3 times a month. 

Special forms of enuresis should be noted :

• Neurotic enuresis . This pathology is more common in shy, fearful children, with superficial sleep and its disturbances. Such children are extremely acutely and painfully experiencing the presence of their disease. It occurs secondarily against the background of the transferred psychotrauma or lability of the nervous system: visiting a kindergarten, doctor, school, divorce of parents or other changes negatively affecting the child’s psyche. 
• Urgent. It is characterized by a strong, intolerable urge to urinate, which a person cannot contain. This form is found in spinal cord injuries, brain injuries, infectious processes of the urinary system. 
• Neurosis-like enuresis . May be of primary or secondary origin. If it occurs in childhood, then a feature of this form is that small patients before adolescence, in contrast to neurotic enuresis in children, are relatively indifferent to episodes of incontinence. Later, there is criticism and increased feelings about this. Often found with nervous tics, stuttering, phobias.  
• Neurogenic. A form of incontinence that occurs secondarily with a neurogenic bladder. 

Causes of occurrence

The causes of bedwetting are multifaceted. And today this problem continues to be studied and researched.

Development theories

There are several theories of the onset of pathology:

1. Delay in the maturation of the nervous system. It can be caused by both organic and functional (psychogenic) disorders.
2. Unfavorable heredity. The risk of this pathology in children is several times higher if their parents had this disease.
3. Violation of the rhythm of vasopressin secretion. The hormone vasopressin helps to reduce urine output. Normally, it is produced to a greater extent at night, so a healthy person has less urine at night. If the secretion of vasopressin is pathologically reduced in the dark, nocturnal enuresis occurs .
4. Exposure to stress and psychological factors. The causes of bedwetting in childhood often arise due to the strong influence of stressful situations: nervous situation in the family, severe fright, constant psycho-emotional stress.

Several theories are sometimes intertwined in one patient. The disease is considered polietiologic .

The provoking factors that can lead to the disease are:

• Elderly age. With age, muscle tone decreases, the walls of the bladder become sluggish and flabby, and changes in the work of the brain develop.
• Weakening of the muscles of the perineum, pelvic floor (typical for women after childbirth).
• Nutrition and diet. Consumption of citrus fruits, coffee, chocolate, alcohol can affect the increased urge to empty the bladder.
• Increased physical activity. Excessive exercise leads to increased pressure on the walls of the urinary tract.
• Various diseases. Strokes, spinal cord injuries, neurogenic disorders, multiple sclerosis, Alzheimer’s, Parkinson’s, urinary tract infections, kidney disease, diabetes mellitus are pathologies that are risk factors for the development of enuresis .

Clinical picture

Symptoms of bedwetting can occur in patients of any age: in children over 4-5 years of age, in adolescence, in young people or the elderly. The main symptom of the disease is urinary incontinence. Wet bed during sleep, urine leakage during the day – patients (their parents) can contact a doctor with such complaints.

Involuntary urination can occur unnoticed for the patient: if the process is typical for the night, then awakening during emptying of the bladder may not occur, and in the morning wet sheets become an unpleasant “surprise”. Sometimes awakening occurs from the first drops of urine, before emptying at night, patients behave restlessly, superficial sleep is characteristic.

Some people have complaints of frequent, urgent urge to urinate, sometimes they are painful (more typical for the infectious nature of diseases of the genitourinary organs).

The inability to hold urine negatively affects the psychological state of patients: they become notorious, withdrawn, or, on the contrary, overly aggressive, emotionally unbalanced.

This pathological condition requires the intervention of specialists and the provision of medical care.

Treatment methods

Treatment of enuresis primarily requires clarification of the root cause of the disease and its elimination. Currently, they use an integrated approach in therapy: they use medications, psychological correction of behavior, physiotherapy , adherence to the regimen.  

Comprehensive treatment of the underlying disease

If enuresis is of secondary origin and is a symptom of the underlying disease, the chances of success in incontinence therapy are high: with adequate treatment of the root cause and elimination of the disease, the patient will forget about a delicate problem:

• If enuresis occurs against the background of infectious processes in the urinary tract, courses of antibacterial or antiviral therapy should be carried out, depending on the causative agent that caused the infection.
• The hormonal background should be normalized in case of endocrine pathologies, which can also provoke involuntary urination.
• Neurological correction with nootropic drugs, agents that improve metabolic processes in cells, is required if neurotic enuresis occurs .

With the timely identification of the cause that led to the onset of the pathology, and its elimination, there are great chances of success. The situation with the primary forms of the disease is more complicated.

Correction of behavior and regime

It is very important, especially in childhood, to correctly approach the treatment of enuresis , especially if it was provoked by nervous disorders and psychotrauma . A trusting, warm relationship should be established between the child and the parents. In no case should you punish, ridicule or humiliate a little patient for wet sheets. It is necessary to explain in an accessible form the essence of the problem, talk about ways to deal with it.

It is useful to keep a diary at home, noting “dry nights” in it, praise and reward your child for them. The child should be woken up several times a night to urinate.

At any age, with this problem, psychological comfort, minimization of stress, a positive attitude towards success in therapy are important. One of the components of treatment, especially in neurosis-like forms, are classes with a psychotherapist.

It is necessary to correct the diet, excluding coffee, alcohol from drinking, do not drink liquids before going to bed and in the evening, limit the use of table salt, chocolate, tea.

Pharmacotherapy

The following medications are used for enuresis :

• Medicines that reduce urine production: Desmopressin ( Adiuretin ).
• Means that increase the capacity of the bladder: Oxybutynin .
• Tricyclic antidepressants: Imipramine .

There is no universal cure for bedwetting in children or adults. The selection of medicines, their dose and scheme are prescribed by the doctor in each case individually.

Physiotherapy

It has a positive effect as one of the methods of complex therapy in conjunction with other methods.

According to the doctor’s recommendations, it is possible to use

• Darsonvalization on the projection of the bladder.
• Electrophoresis with substances that reduce the tone of smooth muscles: atropine, euphyllin.
• Healing mud for the lumbar region and lower abdomen.
• Paraffin therapy.
• Ion galvanization with atropine sulfate solution.
• Nitrogen, hydrogen sulfide baths, circular showers.
• Acupuncture.

Physiotherapy procedures are usually prescribed for 10-14 days, after a break and good tolerance, it is possible to repeat the course of treatment.

Urinary incontinence or bedwetting is quite common in the population. This pathology affects from 5 to 30% of children aged 5 to 15 years (moreover, boys are subject to the disease 2-3 times more often than girls), enuresis in adults occurs with a frequency of 1.5-2%. Treatment of pathology is complex, long-term, requires an individual approach to the patient.