1. Nocturnal enuresis in children Dr. Smita Brahmachari, M.D. (Repertory) from N.I.H., Kolkata. S.M.O., Dept. of AYUSH, Govt. of NCT Delhi.

2. Nocturnal enuresis (bedwetting) Involuntary discharge of urine at night by children old enough to be expected to have bladder control – Persists beyond the age of 5 years – Total bladder control never achieved or relapsed – Incidence of more than twice weekly – Continent during the day – Types of nocturnal enuresis (NE) PNE (primary) when bladder control has never been attained SNE (secondary) previously dry for a at least six months. Adapted from Canadian Paediatric Society. Management of primary nocturnal enuresis. Paediatrics & Child Health 2005;10(10): 611-4.

3. NE: It’s NOT the Child’s Fault Bedwetting is a medical condition, a behavioural and psychological disorder in children. It is mostly caused by the lack of naturally occurring messenger that reduces urine production to a non-bedwetter’s volume at night – Leads to an overproduction of urine, often more than a child’s small bladder can hold As the children grow, most will eventually stop wetting the bed.

4. classification Primary (PNE): bedwetting persisting from early age due to delayed maturation of voiding mechanism. Secondary (SNE): wets bed after remaining dry for variable period with a underlying cause……UTI; DM; Renal abnormality and failure must be ruled out.

5. Incidence Most of the children start having bladder control after the age of 4 yrs. About 15 – 20% of children wet bed after the age of 5 years and about 5% of 10-year old children continue bedwetting. Occurs more commonly in boys aged 4 – 11 years than girls.

6. Patients’ Perspective A survey reported that 68% of parents said that their child’s paediatrician had never addressed bedwetting during a routine visit, regardless of the child’s age 1 Most parents believe that NE is not a physical condition and are uncomfortable initiating a dialogue with physicians 1 Most parents (80%) believe that children wet the bed because they are stressed or worried, or in some cases simply out of laziness. Inadequate treatment of NE has psychological ramifications including impaired personal, social and emotional behaviour 2,3 Adapted from : Dunlop et al.,Clinical Paediatrics 2005;44:297-303 1. Fergusson et al. Pediatrics 1986; 78: 884 2 Butler et al. BJU intern 2002; Vol 89; issue 3;295-7 3

7. ETIOLOGY Familial predisposition is commonly seen. Emotional and psycho-social factors: stressful home life…conflict between parents, starting school, a new sibling, or moving to a new home; habitually ignoring the urge to urinate and poor daytime toilet habits. Emotional and behavioural issues are not causative, but influence treatment outcome. Physical causes are rare, but may include: UTI, Seizure disorder, Diabetes Insipidus, Diabetes Mellitus, ADHD, Down’s syndrome, Chronic renal disease, Chronic constipation…full bowels put pressure on the bladder; deep sleep and arousal disorder, lower spinal cord lesions and congenital malformations of genitourinary tract. Diminished functional bladder capacity. Slow development of bladder control.

8. ESOTERIC VIEW The bladder is the reservoir in which all the substances excreted by the kidneys as urine await their opportunity to leave the body. The pressure caused by the sheer bulk of urine eventually forces us to release it, and this leads to a feeling of relief. The urge to urinate is also linked conspicuously to certain types of situation in which we are being put under psychological pressure…..whether they be examinations, therapy or whatever….involving anticipatory fears or stress – related conditions. The pressure which is initially experienced psychologically is shifted down into the bladder and here experienced in the form of actual physical pressure. Pressure always demands of us that we let go and relax. If this fails to occur a the psychological level, we are obliged to allow it to happen physically via bladder. If a child spends all day under strong pressures (whether from parents or from school) that it can neither let go nor express its own needs, nocturnal bed wetting solves several problems at once: it provides the chance to let go in response to the pressures being experienced, and at the same time it offers the child the opportunity to condemn its all-powerful parents to utter helplessness. By way of this particular symptom, in fact, the child is able to return in safely disguised form all the pressure that it is put under during the day. Adapted from: Dethlefson and Dahlke. The Healing Power of Illness. Ist ed. Reprinted. Brisbane: Element Books Limited, 1994.

9. Impact of Enuresis on Children Psycho-social impact – Low self-esteem – Shame, embarrassment – Guilt Parents become intolerant of the bedwetting Interferes with age appropriate peer activities

10. Management chart Child with complaints of ---involuntary urination usually at night, after the age of 5 years, --- occurring at least twice per month for more than 3 months Investigate to assess the cause: - Stool test; urine routine, microscopic and culture; blood sugar; assess any physical; emotional factor or habit causing bedwetting and treat to eliminate the cause if any. Probable causes: Pinworm; UTI; DM TREAT according to the cause elicited…Homoeopathic treatment + general management. Probable cause: nocturnal enuresis/bedwetting

11. Signs and symptoms The history should address the following: Hydration history Daytime voiding pattern Number and timing of episodes of bedwetting Sleep history (should include the times the child goes to bed, falls asleep, and awakens in the morning. Parents should be asked to make a subjective assessment of the child’s depth of sleep. The presence of restless sleep, snoring, and the type and frequency of nocturnal arousals (e.g., nightmares, sleep terrors, or sleepwalking) should be determined. Whether the child has experienced periods of dryness and the circumstances of these episodes should also be determined.) Nutrition history (Many children with enuresis do not drink appreciable amounts of liquids during the school day, arrive home from school thirsty, and drink most of their daily fluids in the 4 or 5 hours before bedtime, a pattern that favors nocturnal production of urine.) Behavior, personality and emotional status of the child (Basic and revealing information includes whether the child has experienced teasing by family or friends or has self-restricted participation in school, sleepovers, or trips.). If the history is not clear, request that the family record fluid intake, daytime voiding, and episodes of bedwetting for at least a 2-week period.

12. Treatment schedule Follow up: long term treatment is usually required. Assess after every 10- 15 days to evaluate the improvement. Symptoms better (episodes of bedwetting decrease in frequency and dry nights)….stop treatment and follow for few days. Symptoms worsening….episodes of bedwetting become more frequent. Needs referral.

13. REFERRAL Symptoms worsening: – Episodes of bedwetting become more frequent. – Rashes on the bottom and genital area. – Burning sensation or pain when urinating. – Disturbed sleep. Reassess the case and manage under the pediatrician/ psychiatrist.

14. General management Advice to the parents Remove guilt feeling in the child. Support and reassure the child. Do not punish or blame the child. Reduce child’s evening fluid intake especially before sleep. Child should pass urine before bedtime. Set a goal for the child of getting up at night to use the toilet. Reward child for dry nights. Advice daytime rehearsal aimed at increasing the holding time of bladder. When the child feels the urge to urinate, he or she should go to bed and pretend he or she is sleeping. He or she should then wait a few minutes and get out of bed to use the toilet. Conditioning devices, which cause an alarm to sound as soon as the voided urine touches the bed sheet. It is important to check the child’s hearing before starting treatment. The alarm causes inhibition of further micturition and the child awakens. If properly used, it is an effective method of therapy.

15. HOMOEOPATHIC APPROACH Through out the whole urinary tract, we find the latent symptoms of all the miasms. Psora and sycosis take an active part in the production of disease in these organ. It is the tubercular state which causes nocturnal enuresis in children, as soon as they fall asleep. Urine is copious, they wet everything. These cases can only be cured by getting at the pseudo-psoric diathesis and by selecting medicine which covers the pseudo-psoric base, like Calcarea carb., Calcarea phos., Lycopodium, Sarsaparilla etc. In tubercular diathesis, especially in the nervous or neurotic patients, urine is pale, colorless and copious with little solid deposit. The urine of this type of patients is often offensive and easily decomposed, the odor is musty, like old hay, or it is foul smelling, even carrion like.

16. HOMOEOPATHIC MEDICINES SYMPTOMSINDICATED MEDICINES Awakens with urging; chronic; at night, during 1 st sleep, child is roused with difficulty KREOSOTE After bladder seemed to be emptiedHELONIAS At night, in children, in latter part of night, even if they have urinated during night and drank no water CHLORALUM At night floods the bed 5-6 timesFERRUM and PHOSPHORIC ACID Before midnightBRYONIA and PULSATILLA After midnightPULSATILLA and RUTA From midnight till morningPLANTAGO First sleepCAUSTICUM and SEPIA

17. HOMOEOPATHIC MEDICINES SYMPTOMSINDICATED MEDICINES In obstinate cases, during full moon, with H/O of eczema PSORINUM From wormsURANIUM NITRICUM With strong smelling urineMEDORRHINUM A stout light – haired boyARG NIT In boys of light complexionSEPIA In boysRHUS TOX AND SILICEA AdolescenceLAC CAN In fat children, red face, sweats easily, catches cold easily CALCAREA CARB Pale, lean children with large abdomen, who love sugar and highly seasoned food and abhor to be washed SULPHUR

18. HOMOEOPATHIC MEDICINES SYMPTOMSINDICATED MEDICINES In children with acidity of stomachNATRUM PHOS With general debilityCALC PHOS In children who grow too rapidlyPHOSPHORUS In anaemic childrenFERRUM IOD In weakly childrenCHINA In nervous childrenGELSEMIUM In little girlsPULSATILLA From infancy to a girl at the age of 16NUX VOM In children where urine is scanty, acrid, loaded with uric acid and its deposits PLANTAGO After being accused of theftHYOSCYAMUS When there is no tangible cause except a habitEQUISETUM HYMENALE After frightSTRAMONIUM After injuries of headSILICEA

19. HOMOEOPATHIC MEDICINES The above medicines are listed in Synthesis Repertory and Repertory of Hering’s Guiding symptoms of our Materia Medica under the Rubric Bladder – Urination – Involuntary.

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