Indian J. Pedlar. 34 : 419, 1967

F o r G e n e r a l l ' r a e t i t i o n e r s :

ENURESIS

Bed-wetting after the age of 3-4 years or after once having attained bladder control, is abnormal and constitutes enuresis. It is usually nocturnal but may be diurnal.

Causes

The etiology of enuresis is ill-under- stood and may be multifactorial. It constitutes a distressing behaviour disorder of childhood.

(i) Enviromnental factors. Unhealthy parent-child relationship and sibling- rivalry are the chief causes. The onset of bed-wetting may be traced to the loss of an affectionate parent or grandparent, arrival of a new sibling or other similar psychic trauma. Overstrictness, rejection, excessively zealous attempts at 'potting' in early infancy and inconsistent discipline are important predisposing causes. Occa- sionally, lack of reasonable toilet facilities in extremely squalid home conditions may make the child reluct- ant to get out of bed.

(ii) Emotional factors. These include guilt feelings about masturbation, ambivalent feelings towards parents and hostility against siblings or com- panions. They give rise to internal conflicts which may manifest itself as psychosomatic symptoms, such as enuresis.

(iii) Intelligence. All behaviour disorders are more often associated with mental subnormality. Neverthe- less, a high intelligence quotient may coexist with severe personality defects and maladjustment.

(iv) Hereditary and constitutional 3actors. There is no direct inheritance but a predisposition to neurosis may be passed down to children. Sometimes there is a history of one parent, usually the father, having been similarly affected. Constitutional predisposition is rather ill-defined. It is nevertheless true that no individual child is exactly like another.

(v) Organic and physical factors. Pyelonephritis, cystitis, diabetes melli- tus and insipidus, and hyperthyroidism may have enuresis as the most promin- ent initial symptom. Epileptic children may wet their bed during an undetected seizure in the night. Physical handicaps, especially defective sight and hearing, lead to scholastic backwardness and consequent feelings of inferiority and inadequacy. Adolescence, especially the onset of menstruation, brings a large number of problems which if inadequately handled by teachers and parents, may precipitate enuresis in a predisposed child. Some workers have suggested a delayed maturation of neurogenic mechanisms of the bladder but there is little proof of it.

420 INDIAN JOURNAL OF PEDIATRICS V(')L. 34 NO. 238

Management

Treating an enuretic child is an exercise in patient counselling. The parents should be told that the disorder is harmless and emotional in basis. They must be discouraged to punish the child for the act. Physical punishments and demoralizing indigni- ties hurled on them should be stopped forthwith. The child should be encouraged to have dry nights and understanding sympathy should be shown after wet ones.

Fluid restriction after sunset helps and diuretic drinks like tea and coffee are best avoided at all hours. The child should be awakened again at the parents' bed time and made to evacuate the bladder completely. Training during the day-time in prolonging the inter- vals between each voiding may prevent nocturnal enuresis.

The place of drugs is difficult to assess. They are to be tried wh.en

other measures fail. Belladonna tincture is a time old medicine. Starting with an initial dose of I0 drops every night, the quantity is increased by one drop each night, till relief or toxicity occurs. When the child has very deep sleep, amphe- tamine sulphate (5-10 rag. at bedtime) may be tried. Pituitary snuff has been used in an attempt to reduce the urinary volume at night. Others have used anticholinergic drugs, and various forms of stimulants and tranquillisers with variable S u c c e s s .

Mechanical devices may be tried, provided there is no severe disturbance of lhe psyche. A 'buzzer' which goes off by completion of an electrical circuit by the first few drops of urine, awakens the child and produces a conditioned reflex. Formal psycho- therapy may be needed in a few chil- dren who show gross anxiety symptoms or depressive illness.