Enuresis Nocturna

ENURESIS NOCTURNA (from Greek enureo- I urinate), a disease characterized by the involuntary discharge of large amounts of urine, predominantly during nighttime or daytime sleep and only in exceptional cases also during wakefulness. This form does not include cases of urinary incontinence resulting from anatomical defects of congenital or inflammatory nature in the urinary apparatus and nervous system. In normal development, a child ceases to urinate involuntarily during the daytime by the end of the first year (depending on upbringing, sometimes by 6 months), and at night by approximately 2 years, but in many children, the act of urination during sleep continues for much longer, and the normal reaction of the neuromuscular apparatus to the urge to urinate is established slowly, remaining in such an unstable state until the period of puberty. Sometimes the habit of waking up at the proper time is established, then lost, and involuntary urination resumes. This occurs not only in children but has also been observed, for example, among soldiers as a mass phenomenon during wartime. In childhood, this disease is not uncommon. Its frequency ranges from 6% to 18% (in dormitories and closed institutions), with boys suffering twice as often as girls. The age at which most patients seek medical attention for E. n. is from 7 to 12 years. According to data from the polyclinic of the People's Commissariat of Health (Moscow, 1922-24), the percentage of patients seeking help is distributed as follows: 6 years 7 years 8 years 9 years 12 years 15 years 5.4 7.2 25.8 18.5 10.4 2.2 By the time the body is fully formed, E. n. usually ceases, but there are cases where it persists in women until their first childbirth or remains for a lifetime. A child who appears healthy urinates involuntarily every night or periodically, waking up during or after the act of urination or sometimes after a long time; in this case, a complete act of urination occurs, not the dripping of urine as in urinary incontinence due to weakness of the bladder sphincter. Almost always, such a child exhibits a number of phenomena indicating incomplete function of the nervous system, neurovascular apparatus, various deviations in the psychological sphere, as well as more or less pronounced neuropathy in the child's family. The etiology of the disease remains unclear to this day, although a very large number of theories (often contradictory to each other) have been proposed to explain the causes and genesis of E. n. If we disregard already rejected theories linking this condition to organic defects 1) in the nervous system - myelodysplasia, spina bifida occulta (Fuchs), neuritis of the pudendal nerve (Ztilzer), and 2) in the genitalia - phimosis, weakness of the sphincter, stones in the bladder or urethra, etc., other theories concern functional disorders of the local apparatus or general changes related to metabolism, the autonomic nervous system, degeneration. Changes in the urine are of little importance, especially since authors who propose them to explain the origin of E. n. give contradictory indications: either lack of acids or increased acidity. Theories of reflex irritation coming from the autonomic sphere, from the presence of worms (Henoch), chronic catarrh of the intestines, tuberculosis (Kovats, Langer), adenoid growths, etc., certainly do not explain the essence of the condition and are not applicable to all cases of E. n., and the sometimes successful results of treatment directed at these organs probably concern mainly improvement of the general condition. A number of authors view E. n. as an anomaly of the psychological sphere (Schwarz, Hintze) - 'psychic infantilism'), as a sexual neurosis closely related to masturbation (Freud and his school), as improper upbringing (Homburger). Pfister considered enuresis nocturna as a manifestation of epilepsy, while Cramer, Laveran and others considered it as monosymptomatic hysteria. The depth of sleep in enuretics is no greater than in other children (Courtin), and dreams about urination are not the cause but the consequence of the act that has occurred. A number of authors consider E. n. as a vasomotor reaction, as a symptom of vagotonia, as an autonomic neurosis, also noting that at night there is more urine than during the day, especially after fatigue. In general, at present it can be definitely stated that E. n. is purely a functional disorder in the area of innervation of the act of urination, not associated with organic changes. It is based on the congenital inadequacy of this function, sometimes combined with other temporary or permanent functional defects of the nervous system. Due to such a constitutional predisposition, some children (always with a neuropathic tendency) poorly develop the necessary reflex for bladder control, especially during sleep, and easily lose it under various circumstances that disrupt the functioning of the nervous system (fatigue, psychological trauma, environmental influence, infections). Thus E. n. is an independent nosological unit, not a symptom of many diseases which are not the primary cause but only a contributing factor to E. n. Thus E. n. can be placed on the same level as stuttering, for example. The prognosis, despite the fact that most enuretics recover spontaneously by the time of physical development, must still be made with caution. Pototzky divides enuretics into 3 groups: 1) with increased nervous excitability (children with signs of general neuropathy, vasomotor lability, etc.), 2) with psychopathy, with impairment of volitional functions, suppressed, indifferent to everything, or distracted, and 3) with mental retardation. The prognosis is worst in the last group. In view of the widespread and persistent nature of the disease in many cases, as well as the violation of hygiene of life for both the patients and their surroundings, given the existing views on this disease as shameful, it undoubtedly has greater social significance than has been considered so far. Therefore, many have proposed to establish special shelters, departments in shelters and colonies, boarding schools for enuretics (Zappert, During, Lazar), especially for schoolchildren and adolescents who are not accepted anywhere because of their unfortunate illness. Such institutions already exist in Austria. A number of other authors, on the contrary, recommend transferring treatment to the family, of course, provided that the nature of the disease is explained and those around are instructed. Even more than theories of etiology and pathogenesis, methods for treating E. n. have been proposed; it is impossible to list all that has been and is being proposed by various authors to get rid of this disease - ranging from the most indifferent internal remedies to risky surgical measures (epidural injections). Any medications of directly opposite action, any physio-mechanical procedures, diet therapy and psychotherapy and pedagogy - find application in the treatment of E. n. Proceeding from the view that E. n. is a functional disease in a neuropathic child, therapy should be directed at correcting this function, guided by the clinical picture and study of the patient, but in any case, all kinds of psychotherapy and strengthening of the body in general are in the forefront. Other physical therapy and medicinal effects, if they are not harmful, also act mainly by suggestion. It is necessary to improve the patient's condition, arouse confidence in recovery, and attract the patient himself to fight this defect (reward for dry nights or independent awakening, keeping records by older patients). Treatment by hypnosis is also very suitable (Speransky, Homburger, Strohmayer, Mosse, Lange). Punishment, humiliation, and painful procedures are unacceptable, as with any nervous patient. Changing the environment sometimes has a good effect, but not sufficiently durable if it is not supported by appropriate suggestion. Physical exercise, reasonable entertainment, moderate hydrotherapy, reduction of fluid intake to the point of thirst, elimination of large amounts of vegetables from the diet, especially potatoes, training in regular bladder emptying, and attention to both the sensation of the urge to urinate and the results of treatment are appropriate.