The paediatric urology division has remained at the forefront of urological care by performing extensive endourology and also reconstructive surgery, especially with children born with extrophy of the bladder. Short hospital stay, good post-operative analgesia and care, and excellent results have made our hospital one of the institutions of choice for this speciality.
Sleep Enuresis (Bed-Wetting) in Children: The most common urological problem seen in children is bed-wetting during sleep (medically referred to as sleep enuresis or nocturnal enuresis). About 10-20% of children between the ages of 5 to 6 years are known to wet their bed. It is estimated that there are around 80-110 million enuretic children in the world. Enuresis is more common in first-born children, more prevalent in boys than in girls, and is much more common if the parents have also had a similar problem or if there is a family history of the condition.
If one parent has had a similar problem, there is a 44% chance of his or her child, or children, having this problem. If both parents have had this problem, then there is a 77% chance of their child, or children, having a similar problem.
Enuresis is considered a disorder only if the child is at least 5 years of age and the problem continues more or less continuously for approximately one year. It is primary enuresis if it has been present since birth and considered to be secondary enuresis if it starts between the ages of 5 and 8, that is, after the child has been toilet trained.
Apart from the commonly faced problem of changing the sheets, bed-wetting needs to be handled sympathetically because it affects the self-esteem of the child. A positive change occurs in children who are successfully treated. Therefore, treatment is definitely worthwhile.
Enuretics who wet only at night and have no other abnormalities in their urological history, are termed to be monosymptomatic and have monosymptomatic nocturnal enuresis (MNE). They must be distinguished from children who have both night-time incontinence and daytime symptoms such as urgency, frequency or incontinence
Approximately 25% of children who attain initial night-time dryness by the age of 12 years, relapse and wet for a period averaging 2.5 years, relapse and wet for a period averaging 2.5 years.
Nocturnal enuresis has a spontaneous resolution rate of 15% per year so that, by the age of 15, it persists in only 1% of the population.
MNE is a symptom rather than a disease. A number of theories have been proposed which include behavioural, genetic, developmental, neurologic, psychological, urodynamic and organic causes. There is no single explanation for this symptom and an individual factor, or multiple factors, may be operating.
Clearly, the vast majority of children with MNE do not suffer from psychiatric, neurologic or urological disturbances and therefore investigation and treatment along these lines is both inappropriate and unrewarding.
There could be several causes for MNE in children:
- Urodynamic Findings: Bladder instability does not occur in children with MNE at a higher rate than in normal subjects, and in most enuretics, unstable contractions are not the cause for bed-wetting. Consequently, therapy for eliminating uninhabited contractions is generally ineffective. However, the single most important observation in MNE is a reduced bladder capacity. This reduction is functional and not anatomic. It is not the cause for enuresis, although it often increases coincidentally with cure. Those children who have diurnal symptoms of frequency, urgency or even incontinence, will have bladder instability.
- Sleep Factors: Sleep patterns of enuretics are not different from those of normal children. Most enuretics neither have a disorder of arousal nor wet as a consequence of sleeping too deeply. Instead, findings support the concept that enuresis is related to a delay in CNS development, or more accurately, a dual delay in the development of perception and inhibition of filling and contraction of the bladder by the CNF.
- Alteration in Vasopressin Secretions: About 50% less urine is normally excreted during the night than during the day. In many children with enuresis, the circadian rhythm of plasma vasopressin secretion is altered, with no decrease in AVP during the night. This causes them to produce larger amounts of dilute urine at night. Administration of vasopressin will be helpful only in those children in whom this increased nocturnal urine output has been documented. Studies indicate that the circadian rhythm of AVP matures over time, and it indicates that enuresis associated with AVP-induced nocturnal polyuria may simply represent another manifestation of developmental delay.
- Developmental Delay: All the seemingly unrelated alterations in urodynamic function, sleep, AVP secretion, etc., that have been mentioned above, all occur normally in infants and young children and actually represent a varied expression of neurophysiological immaturity. In most children, MNE represents a delay in development, and each of these physiological alterations tends to improve with time, and to resolve spontaneously.
- Organic Urinary Tract Disease: Most children with MNE do not have an organic urinary tract cause for their wetting. The incidence of an organic urinary tract cause is less than 0.4%. MNE should be distinguished from enuresis associated with daytime symptoms. Such children, especially boys, should undergo urinary tract imaging with an ultrasound to search for signs of possible obstruction.
A detailed history, physical examination and a urine analysis are sufficient for most children with primary MNE. The goal is to identify those children who require further study. History of urinary tract infection, diurnal symptoms, obstructive symptoms or certain signs of neuropathy must be pursued. In their absence, there is generally no indication for radiographic study or cystoscopy.
- Vesicoureteral Reflux (VUR) in Children: About 1% of children in the world have VUR. It results when the connection between the bladder and the ureter is not normal. The lower part of the ureter tunnels through the muscle of the bladder (valve mechanism). If this tunnel is too short, VUR occurs. Behaviors such as infrequent or incomplete urination and related constipation are also associated with VUR.
Urine is made in the kidneys. Normally, it only flows one way – down the ureters and into the bladder. VUR occurs when urine flows back to a kidney from the bladder, through the ureters. This can happen on either or both sides.
Your doctor can tell you how serious your child’s VUR is, with a grading scale obtained by conducting an MCU. This scale ranges from Grade 1 (mild) to Grade 5 (severe). Most of the time, mild VUR will go away by itself. However, the more severe the VUR, the less likely is the possibility that it will go away on its own. VUR can have serious consequences. Kidney infections can occur when infected urine flows back into the kidneys. The risk of kidney damage is greatest during the first 6 years of life. The goal is to find VUR early and prevent infection that could result in kidney damage. VUR tends to run in families. As many as one-third of siblings will have VUR. If a parent has VUR, about half of his or her children will also have it.
Urinary Tract Infection in Children
Urinary tract infection is quite common in children. Surprisingly, it is as commonly, not diagnosed. Infection of the urinary tract occurs both in normal children and in those with some urinary tract abnormality.
The reason why so much of importance is placed upon the diagnosis and management of this problem is because, firstly, unlike other diseases, infants who have urinary tract infection may not have any symptoms pertaining to the urinary tract at all. The common belief that most parents have is that an infant with urinary tract infection should have symptoms such as a burning sensation while urinating, blood in the urine, difficulty in passing urine and so on.
This belief is incorrect. Infants who are less than one year of age may only not feed well and may have fever, loose stools, vomiting, etc. Unless one has a high degree of suspicion about the presence of a urinary tract infection, it can be missed.
The second reason is, if urinary tract infection is missed, it can cause disastrous results. If the kidneys are affected because of urinary tract infection, it can result in irreversible kidney damage and have negative long-term consequences. These are renal scarring, blood pressure, protein in the urine or ultimately, chronic renal failure. When these have set in, no matter what is done at a later stage, the problems cannot be set right.
Infection commonly occurs as a result of bacteria ascending from the genital area. Girls have a higher incidence in their early years because of their short urethra. There may be numerous other causes contributing to the incidence of infection, in which either the urine flowing down from the kidney may be blocked at different levels, or the normal flow of urine out of the bladder is disturbed, with urine flowing backwards into the kidney. Kidney scarring, the most serious long-term result, occurs due to the urine flowing backwards into the kidney, or because pressure in the kidney is increased by the block and there is added infection. This, in turn, leads to decreased kidney function and even blood pressure. Those who had infection very early in their life and who had severe scars in the kidney are more prone to hypertension and nephropathy.
Diagnosis & Tests
- For Sleep Enuresis
While bed-wetting can be caused by a variety of urological problems, it is very uncommon for a child with bed-wetting to have any major urinary problem. In our general clinic, we find that only 1-4% have any urinary abnormality. While bed-wetting can cause a psychological problem in children, all enuretic children are psychologically normal. A psychopathology is not a causal problem for primary enuresis, and therefore treatment for a psychopathology is ineffective in reducing bed-wetting.
There are numerous theories that have been put forth about the causation of enuresis. It is generally considered a disorder of delayed maturation.
One contributory cause may be due to a deficiency of a hormone. This deficiency permits large volumes of urine to be formed during the night, which the bladder cannot hold and therefore empties.
Some of these children are thought to have a respiratory block, either due to adenoids or tonsils, and therefore have enuresis. Removal of these tonsils has sometimes been found to lead to an improvement in their bedwetting. Foods that have been prepared using milk as an ingredient, drinks containing caffeine and a large fluid intake also contribute to bedwetting. Some allergies such as fever, eczema, rashes, food and drug allergies are also thought to contribute to this condition.
Since only a very small percentage of these children have an organic urinary abnormality, evaluation of these children is very basic, which includes the following procedures:
- Physical Examination
- Urine Microscopy
- Ultrasound Evaluation
If all these are normal, pharmacological, psychological and behavioural treatment can be administered – quite often success is achieved with a combination of all three.
Signs of urinary tract infections include:
- Foul-smelling or cloudy urine
- Pain in the side
- Burning or pain when urinating
- Frequent and urgent urination
Infants with infection may not show these signs. Instead, they may have diarrhoea, poor feeding, fever and increased irritability. If there is any question, consult your doctor and have your child’s urine checked. Children can quickly become very sick.
Any child who has had a urinary tract infection with fever should be considered for testing to VUR. Children with frequent urinary tract infections should also be considered for testing. The following test will indicate whether or not your child has VUR:
Micturating Cystourethrogram (MCU): A test using x-rays and a special dye will determine whether or not if your child has VUR. Kidney infections may cause damage or scarring in the kidneys. This can result in poor kidney function and high blood pressure. Scarring and functions of the kidneys need to be documented by a nuclear isotope renogram (DMSA).
If you had VUR as a child, there is a chance that your children will also have VUR. Also, if one of your children has VUR, his or her brothers and sisters may also have it. For these reasons, it is important to discuss testing options with your child’s doctor.
For Urinary Tract Infection
The diagnosis and tests for urinary tract infection are as follows:
- Urine Test: Those children, who have a fever that has an unknown cause, must have a urine test performed. It hardly costs Rs.15, even in a private clinic, and will provide a very good indication if urinary tract infection is present. Once urinary tract infection has been detected, all children under the age of 5 years must undergo further tests such as :
- A Urine Culture
- Ultrasound Evaluation or an X-Ray: to find out both the degree and cause of infection, and decide on the treatment required. All boys above the age of 5 years and those girls with recurrent infection or infection with high fever will undergo similar evaluation. The goal of current practice is the early detection of urinary tract abnormalities and prevention of renal infection by either medical or surgical means. Long-term studies have shown a 10% incidence of renal failure, a 13% incidence of blood pressure, and another 13% incidence of toxemia during pregnancy. When one considers that renal scarring is the fourth leading cause for renal transplantation in children, the need for prevention becomes obvious.
For Sleep Enuresis
A number of treatment modalities have been used to treat nocturnal enuresis. However, their effectiveness, even in control studies, has been difficult to assess because of the high spontaneous resolution rate and the extremely high placebo improvement effect, which can exceed 65%.
Therapy generally follows two lines – drug therapy and behavioral modification.
Parents have different attitudes and expectations about bed-wetting and its cure. Treatment for MNE should generally be discouraged before the age of 7 years, because even the success rates for treatment before this age are very poor.
The following are the various types of treatments:
- Anticholinergic Therapy: has had an effectiveness ranging from 5% to 40%. Although these ranges increase the functional capacity of the bladder, the relapse rate is also high. The usual recommended dose of Imipramine is 25 mg for children between 5 and 8 years of age and 50 mg for older children (0.8 to 1.6 mg/kg per day), which should be given as a single dose shortly before bedtime.
- DDAVP: This drug, administered in the form of a nasal spray, has been effective in about 25% of cases. It works by reducing the urine output at night. The usual clinical dose is between 10 and 20 mcg per night for the nasal spray and 200 to 400 mcg per night for the tablets. The therapeutic effect of DDAVP is temporary. Once the treatment is stopped, 50 to 90% of children relapse and resume their original pattern of wetting.
Behavioral Modification: Behavioural modification should be considered as the first line of management in enuresis. Bladder training, responsibility reinforcement, conditioning therapy using the urinary alarm, are all a part of this management – the last being considered the most effective approach available for nocturnal enuresis.
The following are the recommendations for the most effective evaluation and treatment plan:
- Screening for Urinary Abnormalities: The doctor should screen for any possible urinary abnormalities. If something is found, a referral can be made to the urologist.
- Reduction in Liquid Intake: All children should decrease their liquid intake by one-half of normal levels starting from evening onwards.
- Avoidance of Caffeine: Most children should avoid caffeine.
- Adequate Sleep: Children should get adequate time in bed. The average 8-year-old needs about 10 hours of sleep per night.
- Use of an Alarm at Night: An alarm should be used to wake up the child so that he or she can pass urine at night. Due positive reinforcement should be provided to the child for dry nights. Parents should not punish children for this problem.
- Changing of Bed Linen: To help them have a positive outlook, children may be made to change their bed linen when wet. Do not use diapers for children with this conditions.
- Progress Chart: A progress chart will be a good record for these children.
- Urination Before Going to Bed: Children should urinate just before going to bed.
Treatment of VUR is important to protect the kidneys, by preventing possible infections and kidney damage.
There are 3 options for managing or treating VUR:
- Antibiotics: may be used to prevent infections until VUR goes away by itself. Children must take the medications every day, and be re-tested for VUR on a regular basis.
- Surgery: can fix the ureters to stop VUR. This type of treatment cures most children. Surgery may be favoured if VUR is severe or if there are other related medical conditions.
- Endoscopic treatment: In endoscopic treatment, a substance is injected where the ureter joins the bladder.
Treatment VUR is important to protect the kidneys, by preventing possible infections and kidney damage. There are 3 options for managing or treating VUR. Regular follow-up visits according to protocol are mandatory. This should be discussed with your doctor.
Some families find it hard to ensure that the child has his or her routine x-ray test performed,and takes the daily medications required for antibiotic treatment. Your concerns or beliefs matter. It is therefore important to discuss them with your doctor.
Please make sure that you understand the risks and benefits of each treatment, as well as the follow-up required for each treatment.
For Urinary Tract Infection
Treatment of VUR is important to protect the kidneys, by preventing possible infections and kidney damage. There are 3 options for managing or treating VUR:
- Medical Treatment: Antibiotics are prescribed and are administered either orally or through injection, depending upon the condition of the child. If the child is very ill, the antibiotics are administered through injections. Otherwise, the medicine is orally administered.