Bed­wet­ting in chil­dren

Most chil­dren can con­trol void­ing by the age of five years. How­ever, in­con­ti­nence can oc­cur in about 1% of those aged 18 years.

The Star Malaysia - Star2 - - HEALTH - By Dr MIL­TON LUM

THE kid­neys pro­duce urine, which passes through the ureters to en­ter the blad­der, a hol­low and dis­ten­si­ble or­gan that sits on the pelvic floor. The stored urine ex­its the body through the ure­thra, which is a tubu­lar struc­ture. This act (void­ing) in­volves mus­cles, nerves, the spinal cord and the brain.

The blad­der has two types of mus­cles. The de­tru­sor mus­cle stores urine and con­tracts when emp­ty­ing the blad­der. The blad­der sphinc­ter is a cir­cu­lar group of mus­cles found at the bot­tom of the blad­der. It au­to­mat­i­cally con­tracts to re­tain urine in the blad­der and re­laxes when the de­tru­sor mus­cle con­tracts (when the urine gets into the ure­thra).

When the pelvic floor mus­cles con­tract, urine is held back in the blad­der.

The new­born’s blad­der fills up to a cer­tain set level at which the blad­der mus­cle con­tracts au­to­mat­i­cally, lead­ing to void­ing. As the new­born grows, his or her ner­vous sys­tem ma­tures. The brain starts re­ceiv­ing mes­sages from the fill­ing blad­der through the spinal cord and also sends mes­sages to the blad­der.

Even­tu­ally, the child is able to stop the blad­der from void­ing au­to­mat­i­cally un­til the child de­cides when and where to void.

When the con­trol mech­a­nisms are im­ma­ture or fails, it re­sults in bed­wet­ting (in­con­ti­nence). Most chil­dren are able to con­trol void­ing by the age of five years. How­ever, in­con­ti­nence can oc­cur in about 1% of those aged 18 years. In­con­ti­nence is twice as com­mon in males as com­pared to fe­males.

There are cer­tain med­i­cal terms used to de­scribe in­con­ti­nence in chil­dren:

> Pri­mary enure­sis is in­con­ti­nence in some­one who has never been dry for at least six months

> Sec­ondary enure­sis is in­con­ti­nence that be­gins af­ter at least six months of dry­ness

> Noc­tur­nal enure­sis is in­con­ti­nence which oc­curs dur­ing sleep. It is also called night time in­con­ti­nence

> Di­ur­nal enure­sis is in­con­ti­nence which oc­curs when awake. It is also called day­time in­con­ti­nence

There are sev­eral causes of bed­wet­ting in chil­dren and they vary from the sim­ple to the com­plex.

Causes

Noc­tur­nal enure­sis is more com­mon than di­ur­nal enure­sis af­ter the age of five years. The causes of noc­tur­nal enure­sis are not well clar­i­fied yet. Most cases re­sult from a va­ri­ety of causes that in­clude slower phys- ical devel­op­ment, an in­creased pro­duc­tion of urine at night, a lack of abil­ity to recog­nise blad­der fill­ing when asleep, and, oc­ca­sion­ally, anx­i­ety.

Noc­tur­nal enure­sis be­tween the ages of five and 10 years due to a smaller blad­der ca­pac­ity usu­ally dis­ap­pears grad­u­ally as the blad­der ca­pac­ity in­creases.

The body pro­duces a hor­mone called an­tid­i­uretic hor­mone (ADH) which re­duces the pro­duc­tion of urine. As less ADH is pro­duced at night, the need to void is less. Some­times the body does not pro­duce suf­fi­cient ADH at night, lead­ing to the pro­duc­tion of more urine. If a child does not sense the in­creased vol­ume of urine in the blad­der and awak­ens to void, bed wet­ting will re­sult.

Anx­i­ety has been sug­gested as a cause of bed­wet­ting in chil­dren be­tween two and four years of age when they have yet to achieve to­tal con­trol of their blad­ders. Anx­i­ety af­ter the age of four years can also lead to noc­tur­nal enure­sis af­ter the child has been dry for six months or more. The anx­i­ety-caus­ing events in­clude an­gry par­ents or relatives, birth of a sib­ling, and un­fa­mil­iar so­cial sit­u­a­tions.

In­con­ti­nence it­self can cause anx­i­ety. Di­ur­nal enure­sis can cause anx­i­ety that leads to noc­tur­nal enure­sis.

A strong fam­ily his­tory of bed­wet­ting is sug­ges­tive of ge­netic causes. Stud­ies have re­ported that a child has an 80% chance of bed­wet­ting if both par­ents had been bed wet­ters.

There is a small group of chil­dren who have phys­i­cal ab­nor­mal­i­ties in their uri­nary tract which lead to in­con­ti­nence, e.g. a blocked blad­der or ure­thra, and nerve dam­age as­so­ci­ated with spina bi­fida, which is a birth de­fect of the spinal cord.

Di­ur­nal enure­sis is less com­mon than noc­tur­nal enure­sis and usu­ally dis­ap­pears ear­lier than noc­tur­nal enure­sis.

An over­ac­tive blad­der is one of the causes of di­ur­nal enure­sis. When the de­tru­sor mus­cle of the blad­der con­tracts strongly, the blad­der sphinc­ter may be un­able to pre­vent void­ing. This oc­curs fre­quently when there is a uri­nary tract in­fec­tion (UTI), which is more com­mon in girls be­cause of their short ure­thras.

Many chil­dren who have di­ur­nal enure­sis have ab­nor­mal habits, the most com­mon be­ing in­fre­quent void­ing. They ig­nore the feel­ing of a full blad­der and do not void for long pe­ri­ods for var­i­ous rea­sons, e.g. not want­ing to use the toi­lets at school. As the blad­der is over­filled, the urine leaks. Such chil­dren are prone to UTIs, which in turn leads to an over­ac­tive blad­der.

The causes of noc­tur­nal enure­sis may in­ter­act with in­fre­quent void­ing to lead to di­ur­nal enure­sis. These small blad­der ca­pac­ity,

ab­nor­mal­i­ties of Pres­sure from a dis­tended when a child has con­sti­pa­tion, caf­feine-con­tain­ing in­crease urine out­put,

causes.

Man­age­ment

There are var­i­ous avail­able. They in­clude train­ing, medicines, and mois­ture Most cases of bed­wet­ting re­solve spon­ta­neously

as the child es­ti­mated that the wet­ting re­duces by age of five years.

The body’s changes time in­clude an in­crease

res­o­lu­tion of an nor­mal pro­duc­tion of anx­i­ety pro­vok­ing learn­ing to re­spond time to void.

Blad­der train­ing help to strengthen blad­der’s mus­cles. an­tic­i­pate the need one­self when there

The meth­ods used enure­sis in­clude de­ter­min­ing

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