Nocturnal enuresis and its homoeopathic management

Dr Roshni Ravi Kunder

ABSTRACT
Nocturnal enuresis is defined as intermittent incontinence during sleep in a child aged 5 years or more in absence of congenital anomalies of the urinary tract or congenital or acquired defects of the central nervous system.[1] Enuresis is often highly distressing for children and parents and in many cases, the quality of family life is affected. Loss of self esteem, social isolation, poor school performances and psychological impairment.[1] 

INTRODUCTION
Enuresis is defined as the voluntary or involuntary wetting of clothes or bedding with urine for a period of at least 3 consecutive months in children older than 5 years of age. The generally accepted definition, suggested by the American Pediatric Academy, is the involuntary wetting of clothes or bedding by urine during the daytime or nighttime.[2]

Enuresis may be primary or secondary. Primary Nocturnal Enuresis occurs in

children without a period of 6 consecutive months of nighttime urinary control.

 Secondary Nocturnal Enuresis occurs in children with a period of 6 consecutive months of nighttime urinary control before incontinence. Enuresis in this group is associated with organic or psychological causes.

EPIDEMIOLOGY
The prevalence in India is 7.61%–16.3%. The prevalence is highest in children aged 5–8 years (and 6–8 years) and lowest in children aged 11–12 years (8–10 years).[3] The worldwide prevalence of enuresis among children aged 6–12 years is 1.4%–28%.  In general, prevalence of nocturnal enuresis is higher among male children than female children. [3]

AETIOLOGY[4]

  • Delayed maturation of the cortical mechanism that allow voluntary control of micturation reflex
  • Defective sleep arousal
  • Reduced anti-diuretic hormone production at night, resulting in an increased urine output (nocturnal polyuria)
  • Genetic factors with chromosome 12 and 13q the likely sites of the gene for enuresis
  • Bladder factor (lack of inhibition, reduced capacity, overactive)
  • Constipation
  • Organic factors, such as urinary tract infection or obstructive uropathy 
  • Sleep disorder
  • Sleep disordered breathing secondary to enlarged adenoids 
  • Psychological factors more often implicate secondary enuresis.

PATHOGENESIS
Due to the discordance between nocturnal urine production and bladder capacity, the bladder may easily fill at night, leading to the awakening of the child for urination or in children with trouble awakening, incontinence [5]

Enuresis may be more correctly analyzed as a problem with awakening from sleep. This problem with awakening has been a focus point in enuresis. In normal children, when the bladder reaches maximum capacity, there is a sudden urge for urination that does not occur correctly in enuretic children. The exact cause behind this mechanism is not known, although some researchers suggest that chronic over-stimulation leads to down regulation of the voiding center [6].

Additionally, inadequate secretion of the anti-diuretic hormone (ADH), which also leads to the production of more urine, has been seen in these children. The frequency of this is thought to be around 2 out of 3 children [7].

DIAGNOSTIC CRITERIA:[8]

The Diagnostic and Statistical Manual of Mental Disorders 5 criteria for diagnosis of enuresis are as follows.

  • Repeated voiding of urine into bed or clothes, where involuntary or intentional.
  • The behaviour either (a)occurs twice a week for at least 3 consecutive months (b)result in clinically significant distress or social , functional or academic impairment.
  • The behaviour occurs in child who is at least 5 year old or has reached the equivalent developmental level.
  • The development cannot be attributed to the physiologic effect of a substance or other medical condition

APPROACH TO TREATMENT OF A CHILD WITH NOCTURNAL ENURESIS

Reassure the child and parents that the condition is self limiting and to avoid punitive measures that can affect the child’s psycho-logic development adversely.[4]

First-line treatment involves simple behavioral changes such as carrying the child to the toilet at night or awakening him or her for urination, along with daily motivation and exercises aimed at increasing bladder capacity. In children, non-surgical and non-pharmacological methods that correct voiding habits [9]

Fluid intake should be restricted to 2 oz after 6 or 7PM [4]

Similarly, avoidance of drinks with a diuretic effect (such as those containing caffeine) is advised, although the effect of this has also not been investigated [10].

Conditioning therapy involves use of a loud auditory or vibratory alarm attached to a moist sensor in the underwear. The alarm sounds when voiding occurs and is intended to awaken the children and alert them to void.  [4]

INDICATIONS OF SOME HOMOEOPATHIC MEDICINES

Kreosotum

  • Frequent urging with copious pale discharge; at night cannot get out of bed quick enough.[11]
  • Wets bed at night, wakes with urging, but cannot retain urine or dreams he is urinating in decent manner.
  • Urine flows during deep, first sleep, from which the child is roused with difficulty.[12]

Equisetum Hyemale

  • Incontinence in children, with dreams or night-mares when passing urine[13] boericke
  • Wets bed at night; when he dreams he always sees a crowd of people.
  • Enuresis, nocturnal and diurnal. [11]

Squilla Maritima

  • Continuous, painful pressure on bladder.
  • Tenesmus of bladder after micturition.Frequent calls to urinate, especially at night, with scanty or profuse discharge of pale urine.Involuntary micturition, especially when coughing. Inability to retain urine. Enuresis nocturna.[12]

Calcarea Carbonica

  • Too frequent emission of urine, even in the night.Wetting the bed
  • Craving for eggs; for indigestible things, chalk, coal
  • Faty children rather bloated than solid, pale but flushing easily, the head sweats profusely,[11]

Cina

  • Nocturnal enuresis; urine white, turbid, at times fetid.
  • In children there is extreme ill-humour and naughtiness
  • Frequent want to make water, with profuse discharge. Wetting the bed. Urine soon becomes turbid.
  • Involuntary emission of urine (at night)[11]

Natrum Muriaticum

  • Frequent and urgent want to urinate, day and night, sometimes every hour, with copious emission. Involuntary emission of urine, sometimes on coughing, walking, laughing, or sneezing. Nocturnal emission of urine. Clear urine, with red sediment, resembling brick-dust[11]
  • Incontinence of urine : whenever he sat down urine came away, day and night, necessitating very frequent change of clothing and bedclothes ; continual craving for salt.[12]

Pulsatilla

  • Children are peevish, changeable, pale and chilly
  • Involuntary micturition : urine dribbles while sitting or walking ; while coughing or passing wind ; at night in bed, especially in little girls.
    Enuresis nocturna for two years, in a girl. Mild disposition, fair complexion, frequently changing color, delicate frame ; the complaint has been preceded by an acute exanthema, probably measles.[12]

Belladonna

  • Enuresis nocturna of children.
    Enuresis, with profuse perspiration.
    Wets bed ; restless, starts in sleep. [12]

Sepia

  • Involuntary urination, during first sleep.[13]
  • Emission of urine at night (has to rise frequently).Involuntary discharge of urine at night, esp. in first sleep.[11]

Causticum

  • Enuresis, especially during first sleep; < winter, > in summer. Tendency to escape during the day, from any extra exertion, laughing, walking.[11]
  • Involuntary during first sleep at night; also from slightest excitement.[13]

Studies were done in homoeopathy
A prospective, single arm, non randomised, open-label, observational trial conducted on 34 individuals of 5 to 18 years of age presenting with nocturnal enuresis at OPD of Calcutta homoeopathic medical college and Hospital,  was found that totally  13 different homoeopathic medicines used. Kreosotum was the most frequently used medicine (26.5%), followed by Calcarea phosphoricum (17.6%),Calcarea carbonica(11.7%).[14]

A study conducted on 30  enuretic children at SKH hospital postgraduate research centre,Beed, shows that  Calcarea carb, Sulphur, Puls are the most frequently used constitutional medicine.Sep,Silicea,Merc, Thuja,Arg-Nit, Benz Acid, Ars Alb,Lyco and Kali Bich are further used or miasmatic constitutional treatment which shows improvement in 56.66% cases while 5 cases(6.66%) showed that no relapse of the symptoms within 5 to 6 months , 8cases (26.66%) showed very minute or minimal improvement in bed wetting.It was found during the treatment that with constitutional remedy , patient adopts behavioral changes and learns to exercise normal habits.[15]

MURPH’S REPERTORY:[16]

Bladder, bed wetting, enuresis  APIS, ARGN, ARN, ARS, BELL, BENZ AC, CAUST, EQUIS, FERR, GRAPH, KREOS, LAC C, LYC, MAG P, NAT M , NIT AC, PU;S, RHUS T, SEP, SIL, SULPH, THY

Bladder, bed wetting, enuresis children in   Bell, Caust, Cina, Kreos, Lyco, EQUIS

Bladder bed wetting, enuresis, dreams of urinating while Kreos, Seneg, Sep

Bladder bed wetting, enuresis, first sleep – CAUST, SEP, Kreos, Phos

THE ESSENTIAL SYNTHESIS [17]

Bladder, urination, involuntary night – APIS, ARGN, ARN, ARS, BELL, BENZ AC, CAUST, EQUIS, FERR, GRAPH, KALI N, KREOS, LAC C, MAG P, NAT M, PULS, RHUST, SEP, SIL, SULPH

Bladder urination children in – Carb v

CONCLUSION
Nocturnal enuresis is highly prevalent in India and has a deep impact on the emotional and psychological aspect which can intern affect the quality of life. Research shows homoeopathy has a significant role in treatment of nocturnal enuresis.

REFERENCES

  1. Kuwertz-Bröking E, von Gontard A. Clinical management of nocturnal enuresis. Pediatric Nephrology. 2018 Jul 1;33(7):1145-54. accessed on 18-2-2020, available from https://link.springer.com/article/10.1007/s00467-017-3778-1
  2. Neveus T, von Gontard A, Hoebeke P, Hjalmas K, Bauer S, Bower W, et al. The standardization of terminology of lower urinary tract function in children and adolescents: report from the Standardisation Committee of the International Children’s Continence Society. J Urol. 2006;176(1):314–24. doi: 10.1016/S0022-5347(06)00305-3.
  3. Reddy NM, Malve H, Nerli R, Venkatesh P, Agarwal I, Rege V. Nocturnal enuresis in india: Are we diagnosing and managing correctly. Indian journal of nephrology. 2017 Nov;27(6):417. accessed on 20-2-2020, available from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5704404/
  4. Kliegman, M. Robert, Stanton, F. Bonita. Geme, St.  Schor; Nelson Textbook of  Paediatrics; 20th edition; ELSEVIER; Philadelphia; 2016
  5.  Neveus T, Lackgren G, Tuvemo T, Jerker H, Hjalmas K, Stenberg A. Enuresis-background and treatment. S J Urol Nephro. 2000;34(206):1–44. [PubMed] [Google Scholar]
  6. Yeung CK, Diao M, Sreedhar B. Cortical arousal in children with severe enuresis. N Engl J Med. 2008;358(22):2414–5. doi: 10.1056/NEJMc0706528.
  7. 7) Rittig S, Knudsen UB, Norgaard JP, Pedersen EB, Djurhuus JC. Abnormal diurnal rhythm of plasma vasopressin and urinary output in patients with enuresis. Am J Physiol. 1989;256(4 Pt 2):F664–71. [PubMed] [Google Scholar]
  8. Diagnostic and Statistical Manual of Mental Disorders. 5th ed.Arlington: American Psychiatric Association; 2013:355-357.
  9. Austin PF, Bauer SB, Bower W, Chase J, Franco I, Hoebeke P, et al. The standardization of terminology of lower urinary tract function in children and adolescents: Update report from the standardization committee of the international children’s continence society. J Urol. 2014;191(6):1863–5.
  10. Blum NJ. Nocturnal enuresis: behavioral treatments. Urol Clin North Am. 2004;31(3):499–507. doi: 10.1016/j.ucl.2004.04.003. ix. [PubMed] [CrossRef] [Google Scholar]
  11. Clarke J. A dictionary of practical materia medica 1st/e, vol 2, New Delhi, Jain Publishers Pvt Ltd; 2012, 1226-27
  12. C Hering, MD. The guiding symptom of our materia medica,  vol 6, New Delhi, Jain Publishers Pvt Ltd; 1986
  13. Boericke W. Pocket manual of Homoeopathic Materia Medica and Repertory. 9th ed. New Delhi: B Jain Publishers Pvt Ltd; 2012
  14. Saha S, Tamkeen R, Saha S. An open observational trial evaluating the role of individualised homoeopathic medicines in the management of nocturnal enuresis. IJRH. 2019;12(3):149-156.Accessed on 16-2-2020, available from http://aohindia.in/xmlui/bitstream/handle/123456789/1850/Original%20Article%205.pdf?sequence=1&isAllowed=y
  15. Choudhary A. Nocturnal enuresis in children and its homoeopathic management. NJIRM. 2017;8(2):177-182. 
  16. Murphy R. Homoeopathic medical repertory A modern alphabetical and practical repertory. 3rd ed. New Delhi: B Jain PublishersPvt Ltd; 2009:328.
  17. Schroyens F. The Essential Synthesis. New Delhi:B Jain Publishers Pvt Ltd; 2012:964.

Dr Roshni Ravi Kunder
PG Scholar, Department of Paediatrics
Government Homoeopathic Medical College & Hospital, Bangalore.
Dr. Siddhaiah Puranik Road, Basaveshwar Nagar, Bengaluru, 560079
Under the Guidance of Dr. MUDASSIR M MULLA
Associate professor and PG Guide Department of Paediatrics.