Enuresis (Bedwetting) is involuntary urination during asleep, though generally a normal part of child’s development before the age of 5 years.
• Enuresis is a child’s problem of bed wetting during the night after having learned to control bladder.
Types of Nocturnal Enuresis
Nocturnal Enuresis is a condition in which a small child pass urine during night on a bed after the age of 5 years for at least twice (2) a week for three (3) months.
a) Primary Enuresis – A child always wet the bed and has never had bladder control at night.
b) Secondary Enuresis – A child did have bladder control at night for a period of at least 6 months, but lost it and now wets the bed again.
Renal Disorders
1) Acute Glomerulonephritis
Its a condition resulting from glomerular injury and inflammation as a result of an immune response (usually to a streptococcal Infection).
Causes of Acute Glomerulonephritis
• Follows an immunologic injury (such as deposition of antigen anti-body complexes from the bloodstream in the glomeruli)
• Presene of conditions such as Hematuria, Edema (Dropsy), Hypertension, Proteinuria.
• Characterized by diffuse inflammatory changes in the glomeruli and clinically by the abrupt onset of Hematuria with RBC casts and mild Proteinuria 1–2 weeks after a streptococcal Infection
• Range of latent period (from onset of Infection to onset of nephritis) is 7–21 days
Risk Factors
• More common in children (peak ages 2–6 years)
• Most common in children is recent Group A beta hemolytic streptococcal Infection (such as Pharyngitis or Impetigo – only a few Strains cause this kidney problem [type 12 and type 49])
Prevention
• Early and aggressive treatment of streptococcal Infections.
2) Renal Insufficiency & Failure
Its a condition resulting from compromised renal function shown by a decrease in glomerular filtration rate (GFR) and characterized by elevated BUN and creatinine, and greatly diminished capacity for dealing with Water solute Fluctuations.
Chronic renal insufficiency occurs when serum creatinine is between 1.5–3.0 mg/dL, while chronic renal failure occurs when serum creatinine is greater than 3.0 mg/dL.
Causes of Renal Insufficiency and Failure
• Diabetes, Hypertension, glomerulonephritis, polycystic renal disease, obstructive uropathy, amyloidosis.
• Congenital anomalies, Infection, Collagen vascular disease, nephrotoxins, ischemia, acute renal failure.
• Deterioration may continue after initial insult resolves
Symptoms of Renal Insufficiency and Failure
• First sign is often simply an abnormal urinalysis (Proteinuria, Hematuria, pyuria, casts).
• Patient may be asymptomatic, but may have extra-renal symptoms of Edema (Dropsy), Hypertension, or signs of uremia
Risk Factors
• Poorly controlled chronic conditions mentioned above, especially Hypertension, Diabetes
• Chronic NSAID use, especially in patients with Hypertension
• Aging
Prevention
• Early treatment of above-mentioned conditions.
• ACE inhibitors decrease progression to renal failure in both diabetic and non-diabetic patients.
• Protein restriction may reduce progression of chronic renal disease.
• Blood pressure control in crucial.
Urological Disorders
1) Asymptomatic Bacteriuria
Significant bacterial counts in urine of a patient who has no other symptoms.
Its more common with female gender, aging, perimenopausal status, Pregnancy, structural abnormalities in tract, prostatic hypertrophy, asymptomatic calculi, indwelling urinary catheter.
Causes of Asymptomatic Bacteriuria
• Most commonly caused by Gram-negative bacteria such as E. coli
Risk Factors
• Indwelling catheters
• Pregnancy
• Diabetes Mellitus
• Spinal cord injury
Prevention
• Screen, culture, and treat asymptomatic bacteriuria in pregnant women, before TURP and other urologic procedures with mucosal bleeding, and to improve urinary incontinence in the Elderly
• Increase fluids to Flush Urinary Tract System
• Empty bladder fully and frequently to avoid stasis
2) Hematuria
The presence of red blood cells (RBCs) in the urine in microscopic (>3 RBCs/high-power field) or gross (visible to naked Eye) form.
Causes of Hematuria
• Infection: Proximal (renal) or distal (urethral) in location.
• Renal calculi, tumors, Trauma, polycystic renal disease, neoplasms in persons over 50, hydroNephrosis, renal vascular diseases.
• Most commonly seen in inflammation or Infection of Prostate or bladder, stones, and in older patients with malignancy or benign prostatic hypertrophy (BPH).
• Medications (anticoagulants-heparin, warfarin, aspirin).
• Benign prostatic hypertrophy, Prostatitis, epididymitis
• Coagulopathies, sickle cell disease
• Strenuous exercise
• Vascular glomerular abnormalities, familial nephritis (Alport syndrome)
• Granulomatous diseases (Tuberculosis)
• Connective tissue diseases (Lupus)
• Trauma
Risk Factors
• UTIs
• Renal calculi
• Environmental exposure to elements that can cause bladder Cancer
3) Urinary Tract System Infection (UTI, Cystitis)
UTI is Infection of one or more of the Urinary Tract System structures but most commonly is used to refer to Cystitis (inflammation or Infection of the bladder). If acute, usually one organism is identified; if chronic, two or more organisms may be found.
Causes of Urinary Tract System Infection
• Most commonly caused by E. coli (80%–90%), other Gram-negative bacteria from gastro-intestinal tract (E. coli, Proteus mirabilis, Klebsiella pneumoniae, Enterobacter sp.).
• A Gram-positive organism (Staphylococcus saprophyticus) is common in sexually active young women but an uncommon cause of Infection in men. If found in men it is truly a urinary pathogen.
• Symptomatic women with pyuria but without significant bacteriuria (sterile pyuria) may have Infection with Chlamydia trachomatis.
• Viruses may be associated with hemorrhagic Cystitis.
• Most UTIs (>95%) are caused by ascending Infections from urethra.
Risk Factors
• Female; sexual activity; history of prior UTI; Diabetes Mellitus or other immuno-compromised state; Pregnancy; use of spermicides, diaphragm, or oral Contraceptives
• Structural Urinary Tract System abnormalities (strictures, stones, tumors, neuropathic bladder)
• Procedures such as catheterization or recent surgery
• Aging issues: Relaxation of pelvic supporting structures, BPH or Prostatitis, incontinence of urine/stool, cognitively impaired
• Dysfunctional voiding pattern or infrequent voiding
• Chronic Constipation in children
Prevention
• In women who experience three or more UTIs, voiding immediately after intercourse and avoiding use of a diaphragm may be helpful
• Drinking Cranberry juice or taking Cranberry pills to reduce pyuria and bacteriuria
• Education of parents and children regarding hygiene, tips on toilet training; education of adolescents regarding sexual intercourse
• Low-dose oral antimicrobial prophylaxis can be considered for recurrent Infections
• Post-coital treatment with a single-dose antibiotic is an option
• In post-menopausal women, systemic or topical estrogen therapy markedly reduces the incidence of recurrent UTI
4) Acute Pyelonephritis
Acute bacterial Infection of soft tissue of the renal parenchyma and pelvis, or other portion of upper Urinary Tract System, typically producing signs and symptoms of systemic toxicity.
Causes of Acute Pyelonephritis
• E. coli organism (75%)
• Other Gram-negatives (10%–15%, P. mirabilis, K. pneumoniae, Enterobacter)
• S. aureus or saprophyticus (10%–15%)
• Most common route of Infection is ascension from bladder
Risk Factors
• Urinary Tract System abnormalities or instrumentation, stones, catheters, Diabetes or other immuno-compromised states, recent pyelonephritis, BPH, Pregnancy, fecal incontinence.
• Recent lower UTI
Prevention
• Hygiene, hydration, voiding after coitus
• Prophylactic antibiotics if infected recurrently or frequently
• Screening pregnant women for asymptomatic bacteriuria
5) Urinary Incontinence (UI)
Its a general term used to describe the involuntary loss of urine based upon Infections or other diseases (5%) or fecal incontinence (10–25%)
Causes of Urinary Incontinence (UI)
• Urge incontinence – Involuntary loss of large amount urine preceded by strong, unexpected urge may be due to aging, Parkinson’s, Stroke
• Stress incontinence – Involuntary loss of small amounts of urine associated with activities that increase intra-abdominal pressure (including Coughing, sneezing, lifting, and certain exercises), may be due to aging, pelvic floor muscle weakness (e.g., cystocele, rectocele), perineal Trauma, Prostatitis/pelvic surgery, and estrogen deficiency in women
• Overflow incontinence from chronic urine retention resulting from the chronically distended bladder receiving an additional increment of urine to exceed intravesical pressure and release small amount of urine, may be due to prostatic enlargement, anti-Cholinergics, tricyclic anti-depressants, diabetic neuropathy, outflow obstruction, Multiple Sclerosis
• Functional incontinence – Physical or cognitive disability, sedating medications that make it difficult to use the bathroom.
• Total incontinence – Loss of urine at all times in all positions, due to sphincteric inefficiency from surgery, nerve damage, tumor infiltration, or Fistula formation.
• Transient incontinence may be due to delirium, Infection, atrophic vaginitis, urethritis, or drugs (Sedatives, Hypnotics, Diuretics, opioids, Calcium channel blockers, anti-Cholinergics, anti-depressants, anti-histamines, decongestants, and other less common causes including Diabetes Mellitus or insipidus, restricted mobility, stool impaction, Depression.
Risk Factors
• Elderly, estrogen deficiency, prostatic hypertrophy, multiparity, Dementia, Diabetes, Parkinson’s, myelodysplasia, Multiple Sclerosis (MS), Spinal cord injury or lesion, Stroke, immobility, Pregnancy, use of Diuretics
Prevention
• Kegel exercises, regular pelvic examination to detect pathology early
• Avoid Constipation
• Regular rectal exam for detection of BPH and initiation of therapy before symptom presents
6) Enuresis
Persistent involuntary loss of urine in girls (older than 5) and boys (older than 6 years) most commonly occuring during sleep.
• Primary Enuresis occurs in a child who has never achieved night-time continence.
• Secondary Enuresis occurs as a return of involuntary urination after night-time continence has been achieved.
Causes of Enuresis
• Usually multifactorial appears to run in families. Has been linked to specific genetic markers (e.g., chromosome 8, 12, 13, 22, and ENUR 1 gene on chromosome 13). 77% risk if both parents had Enuresis, 44% for one parent, and 15% if neither.
• Children with night-time incontinence also have daytime problems (20%).
• Primary Enuresis may be due to food Allergies, disorders of the urinary or Nervous Systems, psychological factors, reduced bladder capacity, lack of normal increase in nocturnal antiDiuretic Hormone (ADH) secretion.
• Primary nocturnal Enuresis (PNE) is primarily an arousal disorder with failure of the CNS to recognize bladder fullness or contraction and/or failure to inhibit bladder contraction or sphincter relaxation, detrussor instability.
• Secondary Enuresis may be due to bacteriuria, UTI, inability to concentrate urine secondary to insufficient ADH or a renal tubular defect, a pelvic mass or Spinal cord malformation, meatal stenosis, ectopic ureter, glycosuria as in Diabetes Mellitus or Diabetes insipidus, possible sleep disorder.
Risk Factors
• Males > females; First born
• Family history in at least one parent
7) Urolithiasis/Nephrolithiasis
Urolithiasis are stones that occur within the Urinary Tract System, while nephrolithiasis are stones that occur within the kidney
Stones are initially formed in the proximal Urinary Tract System and then pass distally, usually arrested in the ureter and cause pain, Infection, and obstruction
Stones are mostly composed of Calcium (80%), uric acid (5%), cystine (2%), or struvite.
Causes of Urolithiasis/Nephrolithiasis
• Supersaturation of urine with stone-forming salts
• In many instances, may be a manifestation of systemic disease (e.g., Bone diseases, immobilization, Hyperthyroidism, primary hyperparaThyroidism, hypervitaminosis D, renal tubular acidosis, mild-alkali syndrome, Gout, others), but idiopathic hypercalciuria responsible for about 50% in adults.
• Up to 98% of stones <0.5 cm in diameter will pass spontaneously, especially in the distal ureter
• Calcium stones are the most common. When they cause obstruction it tends to be acute and intermittent, producing no long-term effects on renal function
• Cystine and struvite stones are more likely to be associated with renal damage
• Struvite stones form in alkaline urine; may be seen with chronic proteus species Infections
Risk Factors
• Cystinuria, genetic defects, renal tubular acidosis, low Water intake, high-Protein diet, excessive oxalate intake, sedentary lifestyle
• Middle age, Whites, family history, Obesity, Diabetes Mellitus, chronic Diarrhea, malabsorption, history of bowel or barriatric surgery, pathologic skeletal fractures, Gout, Paget’s
• Certain medications: Vitamins A, C, D, loop Diuretics, ammonium Chloride, acetazolamide, alkali, antacids
Prevention
• Adequate fluid intake
• If prone to Calcium stones, restrict Protein, Sodium, Dairy products and other oxalate rich foods
• If prone to uric acid stones, alkalinization of urine may prevent formation
Working Mechanism of Urinary System
• Urine forms when the kidneys clean the blood and passes it on the Urinary Tract System (the organs in the body that make, store and remove urine).
• The kidneys normally make about 1.5-2 quarts of urine each day in an adult, but less in children.
• Urine travels from the kidneys to the bladder through the ureters (the tubes that join them).
• The bladder has the job of storing and releasing urine.
• The muscular neck of the bladder stays closed in order to store urine.
• The urethra is the tube that carries urine (from the bladder) out of the body, kept closed with sphincter muscles.• The brain works with the bladder to control when to release urine, where the brain sends a signal to the bladder (when ready to release urine) causing the bladder muscles to contract, pushing urine out of the bladder, through the urethra.
• The sphincter muscles open, and urine is released out of the body.At First, Infants release urine in an uncontrolled way by a simple reflex, but as they grow, several things develop to allow them to gain control over the way their bladder empties:
• The bladder grows to hold more urine volume with age.
• The child gains control over the sphincter and pelvic floor muscles by the age 2-3 years. When they squeeze these muscles, children can hold the flow of urine until they reach to a toilet.
• The brain matures with age to allow children to relax or squeeze these muscles at all times, thus become toilet trained.
• 90% of children can control their bladder both day and night by age 7. If they have to use the bathroom at night, they will wake up and go.
Causes of Primary Enuresis (Bedwetting)
• Inability to hold urine for the entire night.
• Deep sleep (Difficulties waking up from sleep).
• Excessive production of urine during the evening and night hours.
• The child has poor daytime toilet habits.
• Urinary Tract System Infection – Bladder irritation can cause lower abdominal pain or irritation with urination (Dysuria), a stronger urge to urinate (urgency), and frequent urination (frequency).
• Diabetes – The body increases urine output as a consequence of excessive blood glucose levels. Having to urinate frequently is a common symptom of Diabetes.
• Structural or anatomical abnormality – An abnormality in the organs, muscles, or nerves involved in urination can cause incontinence or other urinary problems that could show up as bedwetting.
• Neurological problems – Abnormalities in the Nervous System, or injury or disease of the Nervous System, can upset the delicate neurological balance that controls urination.
• Emotional problems – A stressful life and major changes (such as starting school, a new baby, or moving to a new home) or children who are being physically or sexually abused sometimes begin bedwetting.
• Sleep patterns – Obstructive sleep apnea (characterized by excessively loud Snoring and/or choking while asleep) can be associated with Enuresis.
• Pinworm Infection – Characterized by intense itching of the anal and/or genital area.
• Excessive fluid intake.
• Psycholigical adjustment
• Emotional insecurity
• Bladder Infection
• Taking too much liquid before going to bed
Causes of Enuresis (Bedwetting) (in general)
• Bladder has less space in the bladder at night.
• Kidney produces more urine at night.
• Brain is unable to wake up during sleep.
• Urinary bladder has not enough strength to hold urine for whole night.
• Delayed bladder maturation.
• Lack of co-ordination between bladder and brain.
• Excessive intake of fluids during evening or night.
• Psychological factors/problems (such as Stress, Anxiety) and other emotional problems.
• Chronic Constipation.
• Intestinal worm infestation.
• Excessive sleep (sleep apnea).
• Some diseases (such as Diabetes or Urinary Tract System Infection).
• Genetic factors.
• Deep sleep (Difficulties waking up from sleep).
• Slower than normal development of the central Nervous System.
• Urinary Tract System Infections.
• Abnormalities in the Spinal cord.
• A small bladder.
• Hormonal imbalance (Anti-Diuretic Hormone [ADH] prevents the body from creating excess urine at night).
• Medical conditions (such as abnormal anatomy or function of the kidneys, bladder, or neurologic system).
• Sexual abuse.
Complications of Enuresis (Bedwetting)
• Guilt and embarrassment which can lead to self esteem
• Loss of opportunities for social activities
• Rashes on child’s bottom
Diet Rules for Enuresis (Bedwetting)
• Reduce evening beverages (restrict to daytime hours).
• Program the child to take bathroom breaks before going to sleep.
• Ensure the child is getting enough fibre and Water in their diet.
• Eliminate bladder Irritants (include caffeine, citrus juices, artificial flavourings, food dyes, and sweeteners).
• Remove the most common sources of food reactions to see if the symptoms improve. Re-introduce one food at a time, and watch if the bedwetting worsens.
• Provide Cranberry juice (eradicate bacteria in the bladder or Urinary Tract System that could be a contributing factor to the bed wetting issue).
Home Remedies for Enuresis (Bedwetting) in Children
• Massage – Massaging the lower abdomen with Olive Oil might prevent involuntary flexing of the pelvic muscles that result in bedwetting.
• Bladder Exercises – A few exercises might help in strengthening the muscles of the Urinary Tract System and stretch them to prevent bladder contraction.
• Cinnamon – If the bedwetting is caused by bacterial Infection (or Diabetes), a dose of Cinnamon every day might help, since it has anti-oxidant properties.
• Cranberry Juice – It might be useful to treat Urinary Tract System Infections, thus might be beneficial to the treatment of bedwetting.
• Walnuts & Raisins – It might help in reducing the symptoms of bedwetting. Give three (3) Almonds and two (2) Raisins before the one goes to bed repeatedly every day for a few months until there is significant progress.
• Mustard Seeds – Its recommended to help children with a Urinary Tract System Infection (UTI), which can cause bedwetting in young children.
Food Remedies for Enuresis (Bedwetting)
• Anise (Aniseed) – Anise (Aniseed) may help with urination as Anise (Aniseed) oil has an Anti-Diuretic effect through a similar mechanism in the kidney. Urinating helps the body get rid of many toxins and waste products.
Herbal Remedies for Enuresis (Bedwetting)
Ashwagandha
Bistort
Corn Silk
Damiana
Hemp Nettle
Horsetail
Hyssop
Mastic Tree
Notopterygium Root
Pipsissewa
Stink Weed
Sweet Violet
Yarrow
• Ashwagandha – Its used mostly for bed wetting resulting from psychological reasons (such as Stress, weakness, fatigue).
• Bistort – Bistort is very helpful in treating bedwetting, being a potent Astringent.
• Corn Silk – Corn Silk tea is a very effective solution for bed-wetting given to children as a method of treating Enuresis (bed wetting). Regular drinking a cup of Corn Silk tea before going to bed gradually solves the problem.
• Damiana – Its leaves and roots tea is a good treatment for patients who have bedwetting issues largely due to Stress.
• Hemp Nettle – Hemp Nettle may also be primarily useful for Stress incontinence and bedwetting, due to the Astringent actions of the Tannins in Toning the tissues of the Urinary Tract System.
• Horsetail – Horsetail is beneficial to the health of the Urinary Tract System and is a nourishing Diuretic. Its Toning and Astringent actions make it invaluable in the treatment of incontinence and bed-wetting in children.
• Hyssop – It has positive effect on Nervous System that promotes the coordination between Nervous System components that increase brain functioning, decrease Stress and helps to increase mental capacity.
• Mastic Tree – Mastic Tree Gum (with Gum acacia) is beneficial for children suffering with bed-wetting (or Enuresis).
• Notopterygium Root – Notopterygium Root is relatively warm, with a spicy and bitter taste, thus offering certain therapeutic effect on the pathological changes of the bladder and kidney meridians. Its helpful in the treatment of Enuresis, frequent urination, knee cold and pain, Asthma caused by kidney deficiency.
• Pipsissewa – Pipsissewa extract (when combined with Mullein) can be used to relieve bedwetting in children. Pipsissewa infusion has Astringent, tonic and Diuretic effect, thus mainly used to provide relief and support for the urinary system (such as helping those suffering from Cystitis or chronic Urinary Tract System Infections and to draw excess Water off of the body).
• Stink Weed – Boiled liquid of the pods may be administered during the day to avoid bed-wetting at night.
• Sweet Violet – Sweet Violet seeds of possess Diuretic and purgative properties which have been used therapeutically to treat problems related to the Urinary Tract System (especially gravels). Sweet Violet is a Diuretic plant which favours the elimination of body Fluids or accumulation of Water in the body, due to cases of Obesity, Edema (Dropsy) and heart diseases.
• Yarrow – Yarrow sitz baths is successful against bedwetting (in children and older people). Two (2) cups of its tea should be drunk daily as well (in these cases ).
