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‘The unconscious or involuntary passage of urine.’ (Blacks, 1992. p199)
‘Enuresis is a term which is reserved for incontinence in children. It is the involuntary passing of urine at night when asleep. The existence of incontinence during the day suggests a kidney or bladder condition. It is mainly a disorder found in boys and affects 10% of boys aged 4-11 years. There are estimated to be 500,000 cases in Britain between the age of 6 and 16. As a group they also have signs of decreased muscle tone, co-ordination problems and EEG abnormalities. It is considered to be a sleep disorder and so is treated by the antidepressant imipramine. This is an attempt to alter depth of sleep and has little effect. There is the added danger of poisoning by overdose.
‘Less harmful are behavioural methods such as an alarm bell. This is connected to a mat under the sheet so that the bell sounds if the child wets the bed. Intranasal desmopressin, antidiuretic hormone, is used in some cases although the manipulation of pituitary hormones to treat bed-wetting seems excessive. Enuresis is notoriously difficult to treat and is frequently related to psychological factors. It may be necessary to address the family as a whole as well as the individual child.’ (Gascoigne, 1995. p179)
Nocturnal Enuresis
‘The involuntary passage of urine during sleep. It is a condition predominantly of childhood. In a small minority of cases it is due to some organic cause such as infection of the genito-urinary tract, but in the vast majority of cases it is due to inadequate or improper training of the child or psychological ill-health. Traditionally it is said to be associated with threadworms, but there is little, if any, evidence to support this tradition.
‘Before deciding that a child is suffering from nocturnal enuresis, it is necessary to remember that the age at which a child achieves full control of bladder function varies considerably. Such control is usually achieved in the second year, but more commonly in the third year of life, and there are some children who do not normally achieve such control until the fourth, or even fifth, year.
‘It is a difficult condition to cure in the absence of an organic cause. If there should be an organic cause, treatment consists of its eradication. In the absence of such a cause, treatment consists essentially of reassurance and firm but kindly and understanding training. In quite a number of cases the use of a buzzer alarm which wakens the child should he start passing water is helpful provided that it is backed up by psychological support from the parents and the family doctor.’ (Blacks, 1992. p412)
‘Nocturnal enuresis is a normal occurrence in young children but persists in as many as 5% by 10 years of age. In the absence of urinary-tract infection simple measures such as bladder training or the use of an alarm system may be successful. Drug therapy is not appropriate for children under 7 years of age and should be reserved for when alternative measures have failed preferably on a short-term basis to cover periods away from home. The possible side-effects and the toxicity of these drugs if taken in overdose should be borne in mind when they are prescribed.
‘Desmopressin, an analogue of vasopressin [antidiuretic hormone, ADH], is used for nocturnal enuresis; particular care is needed to avoid fluid overload and treatment should not be continued for longer than 3 months without stopping for a week for full re-assessment.
‘Tricyclics such as amitriptyline, imipramine, and less often nortriptyline are also used but behaviour disturbances may occur and relapse is common after withdrawal. Treatment should not normally exceed 3 months unless a full physical examination (including ECG) is given and the child is fully re-assessed.’ (British National Formulary, no 33 (March 1997) p351)
Organic Causes of Bladder Dysfunction
Urinary incontinence is often a symptom resulting from confusion and immobility experienced in acute illness.
Other chronic causes may relate to damage to the cerebral cortex (cerebrovascular disease, Alzheimer’s, Parkinson’s), spinal cord damage (MS, trauma or tumour), or damage to afferent parasympathetic fibres (diabetic autonomic neuropathy). Local causes include pressure on the bladder from fæcal impaction, stress incontinence due to pelvic floor weakness in women, prostatic obstruction, and post-menopausal atrophic changes in the vagina, urethral and trigonal mucosa. Other causes include drugs such as diuretics, poor mobility, anxiety or attention-seeking behaviour.
Important considerations are duration and timing of incontinence, associated urinary symptoms and drug treatment. Examination of abdomen, central nervous system, rectum, perineum, vulva and vagina are necessary to determine existence of any organic cause. Urine cultures are taken. Pelvic ultrasound may identify chronic urinary retention; catheterisation and cystometrography provides information about dynamic filling pressures within the bladder. Cystoscopy and cinefluoroscopy may be used where the diagnosis is otherwise unclear.
Patterns of Neurogenic Bladder Dysfunction
- Atonic bladder
- Cause: Damage to sacral segments of conus medullaris
- Damage to sacral roots/nerves and pelvic nerves
- Results: Loss of detrusor contraction
- Difficulty initiating micturation
- Distension of bladder, overflow incontinence
- Hypertonic bladder
- Cause: Spinal cord damage involving pyramidal tracts above conus medullaris
- Frontal lobe lesions
- Results: Urgency and urge incontinence
- Bladder/sphincter incoordination
- Incomplete bladder emptying
- Cortical lesions
- Post-central — loss of awareness of bladder fullness, incontinence
- Pre-central — difficulty initiating micturation
- Frontal — inappropriate micturation, loss of social control (Edwards et al, 1995. p1030)
Treatment of Urinary Incontinence
‘The mainstay of treatment is toilet training in which patients are encouraged to anticipate episodes of incontinence by regular emptying of their bladder. Practical measures such as modifying the dose of a diuretic or facilitating access to the lavatory may also be effective.’ (Edwards et al, 1995. p1121) Physical obstructive causes (fæcal impaction, prostatitis) are generally treated by removal of the obstruction. Bladder relaxants such as oxybutinin are used in cases featuring hypertonic bladder. Oestrogen creams are used in atrophic vaginitis. Exercises and possibly reconstructive surgery are the treatments for pelvic floor weakness. If all preventative and management treatment fails, catheters and incontinence pads are used. (See also extract from BNF under Nocturnal Enuresis above.)
Bell & Pad Training
‘This is used in the treatment of enuresis. A special pad is placed under the patient’s bed-sheet. It contains an electric circuit which is completed when wetted by urine, thereby sounding an alarm bell which wakes the patient. Micturation is interrupted and the patient gets up to complete emptying his or her bladder. After repeated training the patient learns to respond to sensations of bladder distension and wakens before micturation occurs.’ (Edwards et al, 1995. p984)
Esoteric View
In an attempt to understand the ‘meaning’ of nocturnal enuresis from a more esoteric point of view, I looked at several publications which are usually quite helpful in coming to an understanding of the dynamics involved.
Few of them dealt with the problem directly. Dethlefson does so, but perhaps reveals more about himself than the condition in the process. ‘Illness and death are regularly used to submit the world to extortion … it is quite easy to detect the theme of ‘symptoms as expressions of power’ in the particular case of bed-wetting. If a child spends all day under such strong pressures (whether from parents of from school) that it can neither let go nor express its own needs, nocturnal bed-wetting solves several problems at once: it provides the chance to let go in response to the pressures being experienced, and at the same time it offers the child the opportunity to condemn its otherwise all-powerful parents to utter helplessness. By way of this particular symptom, in fact, the child is able to return in safely disguised form all the pressure that it is put under during the day. At the same time we should not overlook the link between bed-wetting and crying. Both of them serve to unload and release inner pressures by way of ‘letting go’. We could thus describe bed-wetting as a kind of ‘lower level crying’. (Dethlefson & Dahlke, 1990. p180-181) I find, as with many other areas he covers, that while there appears to be some element of truth in his analysis, its judgmental tones are obstructive and it does not seem to reflect the whole picture.
Page does not mention the problem specifically, but deals with the diathesis in her chapter on base chakra imbalances: the polarity between control and insecurity manifested by individuals who have not fully inhabited their bodies or committed themselves to life on earth. The lack of sufficient soul pressure in the area of the base chakra leads to problems — ‘Whether the insecurity is consciously revealed or not, when there is poor control on matter by spirit, diseases emerge which relate to undisciplined energy in the base chakra. These include panic attacks with palpitations, hyperventilation, frequency of micturation (passing water), regular trips to the toilet to open the bowels and muscle spasms. The physical body is out of control.’ (Page, 1994. p119-120)
The anthroposophists have a similar slant though from a different model. The kidney is regarded as the organ which impregnates food substances absorbed by the body with astral forces, connecting with the astral body and its supporting element, air. Urine secretion varies with atmospheric (air) pressure and also in response to stress, bodily reactions of which are moderated through the function of the adrenal glands — flight or fright responses effect urine release.
Remedies
The following are remedies listed in the Complete Repertory under Bladder, Urination, involuntary, together with Bladder, Urination, involuntary, night, incontinence in bed, plus remedies listed in various materia medica and articles (in red font) associated with enuresis. Where these latter remedies do not appear in the Complete in the rubrics above, the publications containing the reference(s) to the remedies are listed (see Bibliography).
