Urinary incontinence according to microbiology 10. Enuresis - description, causes, diagnosis, treatment. Symptoms of stress urinary incontinence

Urinary incontinence- involuntary flow of urine through the external opening of the urethra. The frequency is more than 30% of women over 60 years old.

Code for the international classification of diseases ICD-10:

• N39.3
• N39.4
• N39.9

Classification, pathogenesis. Stressful - sudden urination with increased intra-abdominal pressure (coughing, laughing, lifting weights, etc.). Links of pathogenesis: .. Weakening of the tone of the muscles of the pelvic floor .. Violation of the anatomical and topographic relationships between the neck of the bladder and the pubic articulation and the vagina .. Protrusion of the neck of the bladder and urethra as a hernia .. Increased abdominal pressure leads to increased pressure in the bladder .. The pressure in the bladder is not balanced by the equal pressure transmitted to the urethra .. The excretion of urine. Total (general) - an absolute inability to keep urine in the bladder. Urine is excreted in drops, constantly - associated with dysfunction of the urethra for the same reasons as stress incontinence. Forced - a sudden imperative urge to urinate, accompanied by the release of urine in a volume of several milliliters to the volume of a full bladder .. Urinary tract infection .. Multiple sclerosis.

Causes

Risk factors... Birth trauma to the perineum in primiparous, with a fetus weighing more than 4 kg, a narrow pelvis, rapid labor. Prolonged hard physical labor. Prolonged cough. Elderly age. Operations on the genitals and pelvic organs.
Clinical picture... Physical examination .. The presence of postoperative scars .. Assessment of the motor and sensory innervation of the lower parts of the trunk and perineum .. Inspection of the external opening of the urethra - it is possible to detect its gaping .. Inspection of the perineum: cystocele, rectocele, enterocele.

Diagnostics

Research methods... Urethrometry - shortening of the urethra. Ureteroscopy, cystoscopy. Cystometry. OAM (true bacteriuria and leukocyturia with secondary infection).
Differential diagnosis... Genitourinary fistulas. Neurogenic bladder.

TREATMENT E
Exercise therapy. Exercises for the muscles of the pelvis. Exercises for the bladder.
Drug therapy. With stress incontinence - sympathomimetics (ephedrine 0.025 g 3 r / day) or  - adrenomimetics for 1.5 months. For involuntary incontinence - imipramine 50 mg 4 r / day or oxybutynin 5 mg 3 r / day.
Surgery. Narrowing of the anterior vagina. Abdominal retropubic urethropexy .. According to Marshall-Margetti-Krantz .. According to Burkh .. Paravaginal plastics. Transvaginal suturing .. According to Pereira .. According to Stamey .. According to Gittes. Lobkovo is a vaginal loop. Artificial urinary sphincter. Collagen urethral implant.
Complications. Urinary tract infection. Depressive - anxiety states.

Course and prognosis... With surgical treatment, cure occurs in 84% of cases, improvement - in 4%. When carrying out exercise therapy - 12% and 75%, respectively. With drug treatment - 14% and 60%, respectively.
Synonym. Anishuria

ICD-10. N39.3 Involuntary urination N39.4 Other specified types of urinary incontinence N39.9 Disorder of the urinary system, unspecified R32 Urinary incontinence, unspecified

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Neurotechno.ru

Enuresis in children - disease diagnosis and treatment

World pediatrics has long been dealing with the problem of childhood urinary incontinence. At the end of the last century, the ICCS society was created, the purpose of which is to study the causes and methods of treating enuresis.

The prevalence of the disorder is very high - about 20% of children and 1% of adolescents suffer from impaired control of urination. Of these, 60% are boys.

The disease is dangerous not so much with medical manifestations as with a complication in psychological and social adaptation. The child is exposed to censure of adults, ridicule of peers. Psychoemotional trauma leads to the appearance of complexes that manifest themselves negatively in the later life of a person.

A child can control daytime urination by age four, and symptoms of night-time incontinence should disappear by age six. If it doesn't, doctors diagnose bedwetting.

According to the international classification of diseases ICD-10, enuresis in children is designated by the codes F98.0 and R32. Usually, this diagnosis means a violation of control of urination at night.

Causes of urinary incontinence

The main factors, as a result of which the child does not wake up with the urge to urinate:

The causes of bedwetting in children are not fully understood. Urinary incontinence in children is a symptom, not an independent disease. The formation of a conditioned reflex, which is responsible for the activity of the urinary tract, is impaired. Uncontrolled urination occurs due to:

1. Genetic predisposition. It has been noticed that one of the parents, who suffered from bedwetting in childhood, endows the offspring with a similar disorder with a 40% probability. If a father and mother had a similar disorder at the same time, the child will inherit it in 80% of cases.
2. Brain damage due to injuries, infections, pathologies of pregnancy and childbirth, which led to a delay in the formation of the central nervous system, a violation of the synthesis of the diuretic hormone vasopressin. A large amount of urine is produced at night, the result is an uncontrolled release of urine.
3. Sleep disorders - profundosomnia, apnea, nightmares. Excessive evening activity, violent entertainment, computer games excite the nervous system and impede proper rest. Episodes of bedwetting often occur in unfamiliar surroundings - in another house, transport, or guests.
4. Urological diseases, diabetes mellitus and diabetes insipidus, allergies, thyroid diseases, helminthic invasion.

In 0.1% of cases, enuresis is caused by anomalies of the genitourinary system - splitting or displacement of the urethra, non-closure of the urachus, defects of the bladder and the orifice of the ureter, detrusor of the bladder.

Enuresis is diagnosed in children with developmental delay, cerebral palsy, epilepsy, autism, oligophrenia, schizophrenia. Taking tranquilizers and anticonvulsants can provoke uncontrolled nighttime urine output.

Important. Enuresis often occurs against the background of a stressful situation - the loss of loved ones, the divorce of parents, and troubles at school. Susceptible and unbalanced children are more likely to suffer from urinary incontinence.

Diagnosis of bedwetting

The first stage of diagnosis includes measures aimed at establishing the cause of the violation, its severity. A pediatrician, pediatric urologist or nephrologist examines complaints, collects a patient's anamnesis with information about birth trauma, family conditions, sleep patterns, incontinence rates. A physical examination is performed for defects in the genitourinary system.

The neurological examination includes:

• determination of skin sensitivity;
• assessment of the reflexes of the lower extremities;
• study of the sphincter response.

Laboratory tests of blood and urine, ultrasound diagnostics of the genitourinary system are carried out.

If no serious pathologies are found in children, treatment of enuresis is prescribed. In complicated cases and in the absence of the effect of therapy, a detailed examination should be carried out:

1. descending cystourethrography;
2. urodynamic complex study;
3. Spine CT or MRI.

The consultations of pediatric doctors - gynecologist, neurologist, endocrinologist, psychologist are shown.

Treatment of infantile enuresis with non-drug methods

Bedwetting in 80% of children goes away with time. This is due to the maturation of the central nervous system, the improvement of the reactions of the nerve endings of the organs of the urinary system, the brain.

The main starting point in the treatment of enuresis in children, according to many pediatricians and the authoritative doctor in our country, Dr. Komarovsky, should be motivation for "dry nights".

Since incontinence therapy is started at a conscious age - over 7 years old, you need to create a strong desire to get out of bed dry in the morning. The effectiveness of the method is reinforced with praise and encouragement. You cannot be scolded and punished for unintentional mistakes. This will aggravate the course of the disease. The child should feel confident, know that everything will work out for him.

The second, no less important, point in the treatment of infantile enuresis is careful adherence to the daily regimen and drinking schedule. All active noisy games are transferred to the first half of the day so that the child's nervous system calms down before bedtime. After 17 hours, the liquid can only be consumed with strong thirst.

Before going to bed, ventilate the bedroom and humidify the air. Do not wrap the child too much - this will cause increased sweating and a desire to drink.

One of the most effective remedies in the treatment of nocturnal enuresis in both boys and girls is the so-called urinary alarm clock. The essence of the method is to develop a reflex to a sound or vibration signal of an alarm device, which is triggered when drops of liquid hit the sensor. The child who wakes up goes to the toilet and finishes urinating.

After 8-12 weeks, the reflex becomes stable. Alarm therapy relieves bedwetting in up to 80% of patients.

An alternative option is to wake up the usual alarm clock during the night. The technique involves a gradual increase in the interval and movement of urination in the morning.

Treatment of bedwetting with medicines

If the efforts did not bring the expected effect, there is no dynamics for a long time, drug therapy is started. The main groups of drugs used:

• M-anticholinergics. They relieve tone, relax muscles. It is prescribed for the treatment of enuresis in adolescents and children from 5 years of age, in courses of 1-3 months. The safest in terms of side effects are Spazmex and Detrusitol.
• Alpha-one-blockers. They act on the bladder, increase its capacity, and improve its functions. Duration of admission is 3-12 months. They have contraindications.
• Tranquilizers. Prescribed to hyperactive patients with neurotic disorders.
• Nootropic drugs. They stimulate the higher mental reactions of the brain, accelerate the maturation of the nervous system.
• Synthetic hormone vasopressin. Taking the drug leads to a decrease in the amount of urine produced by the body at night. Prescribed to children from 5 years old, a course of 3 months.

For the treatment of enuresis tablets in children, physiotherapeutic methods are additionally used:

1. darsonvalization;
2. magnetotherapy;
3. electrosleep;
4. diathermy;
5. electrophoresis.

Bifidback therapy, acupuncture, acupressure are effective.

If enuresis is caused by defects in the organs of the urinary system, surgical treatment is performed.

Important. Therapy for urinary incontinence is a long, painstaking work of the parents and the child himself. You need to provide him with constant psychological support, not pay attention to mistakes.

The family should have a calm, friendly atmosphere.

It is advisable to consult a child psychologist to understand and help your child cope with the disorder. The reasons may be lack of communication and closeness, tension between family members, insincerity. Urinary incontinence is a kind of subconscious release from daytime experiences, a protest against the unfriendliness of others.

Sometimes desperate parents turn to traditional healers who, with conspiracies and prayers, save children from enuresis.

In some cases, there is indeed a cure. The phenomenon can be explained by a strong suggestion, a vivid experience of the rite, or a coincidence. It is known that bedwetting is a temporary factor. It goes away on its own, you just need to be patient and wait.

procistit.ru

Stress urinary incontinence> Clinical protocols of the Ministry of Health of the Republic of Kazakhstan

II. METHODS, APPROACHES AND PROCEDURES OF DIAGNOSTICS AND TREATMENT

The list of basic and additional diagnostic measures (list separately: basic (mandatory) and additional examinations)

Basic (required):

General blood analysis

Biochemical blood test (total protein, creatinine, alanine aminotransferase, aspartate aminotransferase, urea, bilirubin)

Coagulogram

Blood type and Rh factor

Hepatitis C

Hepatitis B

Clinical analysis of urine

Ultrasound of the pelvic organs

Consultation with a therapist

Gynecological examination

Conducting a cough test

Study of the volume of residual urine

Filling out the urination diary (Appendix No. 4)

Filling out questionnaires on the quality of life (Appendix No. 3)

Bladder ultrasound

Bacteriological examination of urine

Examination of smears to detect specific and nonspecific infection

Oncocytology smear

Additional examinations (in case of recurrence of incontinence after surgical treatment with a synthetic loop)

Cystoscopy

Ureteroscopy

Ultrasound examination of the urethra

Kidney ultrasound

Computed tomography of the pelvic organs

Measuring urine flow rate (uroflowmetry)

Cystometry

Intraurethral pressure profilometry

Diagnostic criteria

Complaints: urine leakage during exercise

Physical examination: gynecological examination of the vagina in the mirrors to exclude urinary-genital fistula, positive cough test, stress type of urinary incontinence according to urination diaries.

Laboratory tests: clinical urinalysis to exclude chronic inflammation of the bladder.

Instrumental studies: ultrasound of the bladder to determine the vesicourethral angle and hypermobility of the urethrovesical segment, to determine the volume of residual urine to exclude obstruction of the urethra in the postoperative period.

Indications for consultation with specialists: a therapist in order to prepare for surgical treatment, anesthesiologist.

diseases.medelement.com

Enuresis is the involuntary urination during sleep. In medical practice, the term "enuresis" usually means involuntary urination during sleep more often than 1 r / month in girls over 5 years old and in boys over 6 years old. Frequency- 40% of children at the age of 3, 10% at the age of 6, 3% at the age of 12 and 1% at the age of 18.

Code for the international classification of diseases ICD-10:

Causes

Etiology... Primary enuresis. In healthy children, by the age of 1.5-2 years, a conditioned reflex connection is formed: the urge to urinate leads to awakening. If the formation of this connection is delayed, one speaks of primary enuresis. It is assumed that enuresis is associated with a violation of the cycle of ADH secretion; in children with enuresis, the morning vasopressin content is reduced. One of the possible causes is sleep disturbance. Secondary enuresis. Secondary enuresis is caused by a violation of an already formed conditioned reflex .. Somatic diseases: diabetes, urinary tract infections .. Stressful situation .. Organic and functional diseases of the urinary system: obstructive or neurogenic dysfunction of the urinary bladder, pseudoenuresis - paradoxical ischuria during sleep.

Genetic aspects... Enuresis is familial and is often associated with mental disorders. Nocturnal enuresis, type 1 (* 600631, 13q13-q14.3, gene ENUR1, Â), nocturnal enuresis, type 2 (* 600808, 12q13-q21, gene ENUR2, Â).

Risk factors... Heredity .. If one of the parents suffered from enuresis, the incidence of the disease in the child is 44%. If both parents suffered from enuresis, the incidence is 77%. Children suffer from the first birth more often.

Diagnostics

Laboratory research OAM: with primary enuresis, changes are absent or minimal; in patients with secondary enuresis, when a secondary infection is attached, characteristic changes appear.

Instrumental research... Determination of the size of the bladder: the child retains urine until a constant urge to urinate appears, then the volume of excreted urine is measured. Uroflowmetry. Ultrasound of the kidneys and urinary tract before and after urination. Cystoscopy - according to indications. Excretory urography - according to indications. Spine X-ray - if indicated for differential diagnosis. Retrograde cystometry in urethroprofilometry - according to indications for differential diagnosis.

Differential diagnosis... Malformations of the urinary organs (for example, bladder outlet obstruction - valve of the posterior urethra), caudal spine (spinal hernia, myelodysplasia - neurogenic bladder dysfunction). Injuries and diseases of the urinary tract or spinal cord. Malformations or tumors of the lumbosacral spinal cord. Tumors of the pelvic organs. Diabetes insipidus. SD. Tubulopathy. Sickle cell anemia. Chronic constipation.

Treatment

Treatment... Motivational treatment .. It is desirable to reward for "dry" nights .. Do not punish the child for "wet" nights .. Stop drinking fluids 2 hours before bedtime. Use of specialized alarm clocks. Complete cure occurs in 70% of cases. The alarm clock beeps when the first drops of urine are released - a conditioned reflex connection is formed, the child begins to wake up with the urge to urinate. To fix the reflex, the alarm clock must be used for another 3 weeks after the last episode of enuresis. Drug therapy. In most children without treatment, enuresis disappears by 6-10 years, therefore it is recommended to avoid the use of drugs if possible in order to avoid unwanted side effects .. Imipramine 1-2 mg / kg (up to 50 mg) one hour before bedtime, amitriptyline 50 mg at night. The drugs are effective, but 60% of patients relapse after discontinuation of the drug. Desmopressin is an analogue of vasopressin; it is prescribed to children over 6 years of age at an initial dose of 20 mcg (up to 40 mcg) intranasally at night. The drug is effective, but relapses are possible after discontinuation.

Complications... Urinary tract infections (mainly with secondary enuresis). Neurotic disorders.

Synonyms... Bed-wetting. Nocturnal enuresis

ICD-10. F98.0 Inorganic enuresis. R32 Unspecified urinary incontinence

Enuresis is urinary incontinence.

Separately, nighttime and daytime urinary incontinence are distinguished.

By ICD - 10 enuresis encrypted with the psychiatrist code F 98.0; neurologists are forced to code as G 93.8 - other specified disorders of the nervous system.

Frequency of bedwetting

Among children, about 10-15% suffer from enuresis. The younger the child, the higher the frequency, due to age-related immaturity in the regulation of the function of the pelvic organs.

In children over 12 years old - 4.5% suffer from enuresis.

In adults - 1% of the population over 18 years old; but the frequency increases after 60 years.

In general, about 0.5% of the world's population suffers from enuresis .

Enuresis in boys occurs more often than girls in a ratio of 3: 2; this preponderance remains at all ages.

Should enuresis be treated?

Suffering from bedwetting reduces the quality of life of patients and their loved ones; promotes conflicts; leads to disharmonious relationships with the opposite sex in the future; most hide and are ashamed of illness; it is difficult to change bedding and sleepwear frequently. In 30% of cases, parents, in order to help, scold, shame and punish for the fact that baby peeing in bed at night ... But such measures only intensify neurosis and enuresis. It should be clarified that incontinence during sleep is an uncontrolled, involuntary loss of urine. Treatment of bedwetting is necessary.

Which doctor should I go to for the treatment of bedwetting?

In our country see a neurologist , urologist, gynecologist. Baby pees in bed- one of the most common childhood problems, therefore, you need to see a good pediatrician or family doctor.

History of the doctrine of enuresis

First described the disease Ibn Sina (Avicenna) in 1023 in the famous book The Canon of Medicine. He believed that urination occurs during deep sleep, gave advice for healing. His conclusions have been used by doctors for centuries.

Ibn Sina (Avicenna) "Canon of Medicine"

Term Enuresis means to urinate , derived from the Greek word "enourein".

The problem of enuresis has an ancient history.

One of the old medical books, Enuresis nocturna, describes a study carried out in the army in connection with the increasing incidence of enuresis.

It is interesting that in the 18th century, patients with enuresis were called "mochuns". In the old terminology, simulation was called "feigned illness." The mochuns were considered unfit for service, so some irresponsible young people feigned.

But in what ways they helped to get rid of enuresis on warships before the revolution. Mochun was placed on the second floor of bunk beds. After a wet night in response to unauthorized urination followed by a trial and the help of an aggressive neighbor downstairs.

1837 - the beginning of an in-depth study of the topic of enuresis .

• Installed connection between enuresis and adenoid vegetations .

In up to 80% of cases, after nasal breathing was restored, incontinence problems disappeared. Adenoids cause oxygen deficiency, chronic hypoxia of the brain, which delays the maturation of its connections that regulate voluntary urination. Although not all children with adenoids suffer from enuresis.

• Various remedies have been used in the treatment with good results in practice.

1. In 1841 the book “Benefit injections of lukewarm water with involuntary urination. "

2. In 1845, the publication of "The use of saltpeter and benzoic acid against bedwetting «.

• In the early 19th century, doctors studied the causes of bedwetting , conducted numerous studies.

In 1909 at the International Congress in Budapest scientists Futch and Mattuschek reported that the cause of enuresis is often the result of underdevelopment of the lower part of the spinal cord.

Excessive hair growth in the sacrum, syndactyly, spina bifida (non-closure of the vertebral arches), clubfoot were considered markers of immaturity, in addition to enuresis.

• Patients with enuresis were divided into groups based on etiology.

Classification of the scientist A.A. Pevnitsky:

1. Patients with a lack of intelligence (oligophrenics)

2.With organic spinal cord diseases and bladder disorders

3. Patients with myelodysplasia

4. Patients with diabetes

5.With inflammatory diseases in the bladder and urethra

6. Enuresis, developed on the basis of nervous and muscle exhaustion, due to severe infectious diseases

7. Others.

• The actual cause of enuresis in the early 19th century was “ hereditary syphilis “When the fetus has been infected in utero from a mother with active syphilis.
• The analysis did not reveal a relationship between the occurrence of enuresis with the age of the parents and the number of births in the mother. It should be noted that the number of births in women in the 19th century was up to 14 and more, on average 4-10 births for each woman ... These statistics have changed dramatically these days.

Psychologists about enuresis

Marked Sigmund Freud further studied in the works J. Sadger urethral issue or urinary erotica, her connection with character formation, had many supporters.

• Freud noted enuresis patients as a special type of people with typical character traits: accuracy, thrift, stubbornness, meticulousness.

In some, during infancy, it manifests itself by arbitrary delays in the act of defecation in order to experience a special sense of pleasure .

• Sadger identified in a separate category children with immaturity by 3 years of regulation of urinary retention. Their process of urination is accompanied by a special erogenous pleasure, pleasure and relief.

How different theories of the origin of enuresis differ!

Presently psychotherapeutic assistance is relevant in most patients with enuresis.

According to the classification, primary and secondary enuresis are divided.

Primary enuresis occurs independently, in the absence of another reason, when urinary incontinence occurs when the bladder is full, there is no signal to wake up during sleep, the regulation of the function of the pelvic organs is impaired or immature.
Secondary enuresis is the result of several congenital and acquired diseases.
Separately known and mixed enuresis, when a combination of immaturity of the regulation of the function of the pelvic organs, a possible hereditary predisposition, the presence of current aggravating diseases, drug effects (for example, drugs that deepen sleep) have been identified.
Primary enuresis - in which a child over 4-5 years old continues to wet the bed, in the absence of neurological, urological diseases or developmental anomalies.

More often, by the age of 1.5-2 years, the function of regulation of the pelvic organs matures, when children begin to ask for a potty. This happens if they were taught the skills of neatness.

How to potty train a child

Potty training begins at 6-8 months of age when the child is able to sit. Plant it on a pot for a short time: for 1-5 minutes... Better to plant on a pot after and before bedtime, 20 minutes after eating, before swimming, before and after a walk.

Such landings are accompanied by encouraging, inviting voice intonations and idiomatic expressions "writing-writing" and "a-a", this contributes to the formation of a conditioned reflex skill. And then the children themselves use these sound symbols, asking for a potty.

In successful cases of urination, praise should be given to the pot. Do not scold children under 1.5-2 years old for wet pants or bedding. But we must gently make it clear that it is good and time to ask for a potty after 2-4 years.

Period from 2 years to 4-5 years, if the regulation of the function of the pelvic organs is completely or partially not yet formed, it is considered borderline state between norm and pathology that does not require treatment. We are waiting for ripening.

Secondary enuresis occurs after a period of normal urination regulation, when more than 6 months have been dry.

The causes of bedwetting in children and adults are:

1. Immaturity of regulation from the central nervous system and urinary tract.

The biological chain is not active, not ready for work. They have not yet formed their function of transmitting the awakening signal for emptying the already filled bladder from the receptors, along the pathways to the spinal cord and then to the brain.

2. Enuresis against the background of various neuropsychiatric disorders such as tic disorder, obsessive-compulsive disorder, attention deficit hyperactivity disorder, behavioral disturbances, hysterical reactions, stuttering, sleep disturbances and fears.

3. Delayed maturation of the nervous system ... The lag in the development of the central nervous system can be of a functional and organic nature.

• In functional disorders, enuresis is combined with a temporal delay in the development of speech and motor development (2-4 age periods later they start talking and walking), exhaustion, sleep disturbances, attention deficit hyperactivity disorder, motor awkwardness, and autonomic disorders.
• With a more severe delay in the maturation of the nervous system against the background of organic pathology, for example, infantile cerebral palsy; malformations of the brain; chromosomal pathology; severe consequences of infections, injuries, intoxication transferred during pregnancy and childbirth.

Such children begin to walk and talk much later and with impairments.

4. Psycho-traumatic reasons , acute or chronic stress (divorce of parents, conflicts in the family and school, moving to a new place of residence). In patients with enuresis, special character traits are formed, such as sensitivity, resentment, secrecy, susceptibility to events taking place in life.

Psychosocial factors, such as belonging to low-income families, the stay of children in specialized institutions, also contribute to the occurrence of enuresis. It has been found that as a result of such psychosocial deprivation, levels of growth hormone and vasopressin are reduced. Vasopressin, in turn, leads to overproduction of urine at night, promoting enuresis.

5. Hereditary burden enuresis can often be detected in most male (or female) relatives. Moreover, often from the anamnesis, spontaneous cessation of enuresis by a certain age is revealed, usually by 12 or 18 years. Therefore, such a variant of the development of symptoms of the disease can be assumed in a child.

The risk of bedwetting in a child is 3 times higher, in comparison with the general population, if one of the parents suffered, or at least one relative with enuresis is known.
If both parents have a history of bedwetting, the child's risk of bedwetting increases 5 times.
Children with hereditary burden of bedwetting may not have concomitant pathology from the nervous or urinary system; develop according to age norms; they have no other risk factors; not excitable; more often their attitude to enuresis is calm.

6. Violation of the rhythm of secretion of antidiuretic hormone (ADH).

• ADH regulates the volume of urine secretion: the less hormone in the blood, the more urine is produced.
• At night, the amount of urine physiologically decreases, for this the amount of ADH is higher.
• With enuresis, which has arisen due to insufficient nighttime production of antidiuretic hormone, the amount of urine at night increases significantly.

Parents talk about 2-4 times involuntary urination per night, forcing them to change bed linen several times per night. They assure that they do not give the child so much to drink, wondering where so much urine comes from.

7. Congenital and acquired diseases of the genitourinary system ... The options are: a small bladder capacity, a narrow urethra in girls, a narrow opening of the foreskin in boys, narrowing of the ureters, congenital malformations of the kidneys.

8. Urinary tract infections (for example, cystitis). Newly emerged enuresis, although the function of regulation of the pelvic organs had already been formed earlier. Associated with cooling, more often against the background of acute respiratory infections. Manifested by others dysuric disorders : increased urge to urinate, soreness in the pelvic floor, anxiety, may be hyperthermia, inflammatory changes in urine tests.

9. Urinary incontinence can be a manifestation of epilepsy in children and adults. Moreover, urinary incontinence can be part of the structure of an epileptic seizure. Or there may be a loss of urine and a bowel movement at the end of an epileptic seizure, as a result of the relaxation of the sphincters. In such cases, on a wet night, one can judge about the occurrence of a nocturnal epileptic seizure. This loss of urine during or after an epileptic seizure is not actually referred to as enuresis.

Often, for a long time, this passing urine as a manifestation of epilepsy may be misinterpreted as enuresis. The courses of treatment of enuresis as a primary neurosis are followed, which do not lead to improvement. epileptiform activity is revealed, changing the diagnosis to a specific and subsequent appointment of antiepileptic therapy. When interviewing, it is important to identify in detail the symptoms of the disease, to collect anamnesis, to clarify the hereditary burden of epilepsy.

Such loss of urine during epileptic seizures does not require any other methods of treatment, except for the appointment of antiepileptic drugs.

It should be noted that the course of epilepsy does not exclude concomitant pathology, such as enuresis. Rare but cases of simultaneous course of epilepsy and enuresis are possible .

For the diagnosis of epilepsy or enuresis, it is not replaceable during sleep

In patients with epilepsy, after clarification of the nature of urinary incontinence, detection of concomitant enuresis, therapy should be prescribed in combination with anticonvulsants. In case of epilepsy, some methods of treatment are contraindicated, such as physiotherapy (electrotherapy, acupuncture). Some treatments for bedwetting can. An individual approach to treatment is important.

Among the rare causes of enuresis are:

10. Enuresis as a symptom of sleep apnea and partial obstruction of the upper airways. Typical for adults, more often overweight men.

10. Manifestation of some endocrine diseases: diabetes mellitus and diabetes insipidus, hypothyroidism and hyperthyroidism.

11. How manifestations side effects of certain medications sleep-promoting agents such as valproate and sonapax (thioridazine).

Resolution of the Government of the Russian Federation of July 4, 2013 No. 565
"On the approval of the Regulations on the military medical examination" in the "Schedule of diseases" Article No. 87 "Enuresis".
According to this article: “Examination and treatment of citizens during the initial registration and conscription for military service, as well as military personnel, suffering from nocturnal urinary incontinence, is carried out in a stationary environment with the participation of a urologist, a neurologist, a dermatovenerologist and, if necessary, a psychiatrist «.

A pediatric neurologist of the polyclinic level should be referred to a neurological or urological hospital for all boys with enuresis periodically, once every 1-3 years during childhood, from the age of 5 to 18 years.

Purpose of hospitalization for enuresis in boys - registration of the enuresis itself and its frequency in the hospital, and not only from the words of the parents and the patient; clarifying the nature of the disease, identifying the causes, conducting additional examination methods, conducting complex treatment and subsequent recommendations for rehabilitation.

Diagnosis of bedwetting
Anamnesis

During the conversation, we find out:

1. Whether the child has developed neatness skills, and by what age.

2. The frequency of bedwetting.

3. Type of flow (remitting, undulating, constant).

4. The nature of urination (the force of the stream, as frequent urge to urinate, soreness).

5. Were there any urinary tract infections or other infections (ARVI), at what time.

6. The presence of gynecological diseases in women, erectile dysfunction and andrological diseases in men.

7. The presence of encopresis.

8. The presence of constipation.

9. Whether heredity is aggravated (the presence of relatives with enuresis, to what age it persisted, how was it treated).

10. How urine flows out during incontinence (drop by drop, in portions).

11. Whether there is an urgent urge to urinate.

12. Whether there is airway obstruction, attacks of sleep apnea.

13. The presence of epileptic seizures or other paroxysms during sleep or wakefulness.

14. Allergic history.

15. Does the patient take any drugs constantly or in courses (special attention to drugs that depress the nervous system - valproate, sonapax, carbamazepine and others).

16. Whether heredity is aggravated by diabetes mellitus or diabetes insipidus.

17. Neuropsychic development: at what age he began to walk, phrasal speech appeared. School performance.

18. The presence of an acute or chronic stressful situation in the family, child care or at work (for adults).

19. Indications of chromosomal pathology, congenital malformations, trauma, operations, acute and chronic infectious, somatic diseases.

20. Clarify what the patient himself associates with the presence of enuresis.

Evaluation of patients with enuresis

Grade somatic status includes examination of the abdominal organs, endocrine and genitourinary systems, determination of height and weight indicators.

The presence of stigma of dysembryogenesis, congenital malformations.

Neurological examination : Particular attention to the presence of movement and sensory disorders, including sensitivity in the perineum and anus (rarely performed in the practice of a doctor).

Revealing personality traits , sleep disorders (sleepwalking, dreaming, bruxism, nocturnal snoring), obsessive actions and tics, other paroxysmal and neurosis-like symptoms. The level of intellectual activity.

Additional examination methods for enuresis

General urine analysis.

If there are violations in the general analysis of urine, the examination should be continued: urine analysis according to Nechiporenko and Zimnitsky, urine culture tank, ultrasound of the kidneys and bladder or internal organs.

Zimnitsky test - urine analysis to determine the excretory and concentration ability of the kidneys. In 1900, the Russian therapist Semyon Semyonovich Zimnitsky first suggested the test.

How to test Zimnitsky

It is necessary to collect 8 portions of urine per day every 3 hours... At home, use 3-liter cans, store in a cold place (refrigerator). The next morning, all the collected urine in 8 banks is handed over to the laboratory for analysis.

Evaluation of the results of urine analysis according to Zimnitsky

Urine analysis according to Nechiporenko was proposed by the Soviet scientist and physician Alexander Zakharovich Nechiporenko in the middle of the 20th century.
An analysis is needed to confirm an infectious (inflammatory) nature. Urinary tract infection is determined by an increase in the number of leukocytes, erythrocytes, cylinders in 1 ml of urine.
Normal indicators in urine analysis according to Nechiporenko : leukocytes - up to 2,000 in men and up to 4,000 in women; Erythrocytes - up to 1,000; cylinders up to 20.

How to conduct a urine sample according to Nechiporenko

After thorough washing of the external genitalia with running water, you should collect an average portion of 50-100 ml of urine in a dry clean jar and submit it to the laboratory for analysis.

How is urine analysis performed according to Nechiporenko in the laboratory

After stirring, 5-10 ml of urine in a test tube is centrifuged for 3 minutes at 3500 rpm. 1 ml of urine with sediment from the bottom of the test tube is placed in the Goryaev chamber. The number of leukocytes, erythrocytes and cylinders in 1 cubic mm is counted over the entire grid in the urine sediment separately. Calculate using the formula.

Additional research for enuresis carried out according to indications.

• With inflammatory changes in the urinary tract and bladder, the following may be indicated: cystoscopy, cystourethrography, excretory urography.
• To confirm abnormalities in the development of the urinary tract and bladder, it is possible to carry out: computed or magnetic resonance imaging (CT or MRI ).
• To determine neuronal regulation, neuroelectromyography (NEMG) of the bladder and pelvic floor muscles is possible, but it is not prescribed in practice.
• To exclude the allergic nature of the disease - taking anamnesis, allergist consultation , allergy tests.
• To exclude endocrine pathology - endocrinologist consultation , blood test for hormones.

Treatment of bedwetting in children and adults

Treatment depends on the identified cause of bedwetting.

Treatment methods are divided into medication and non-medication (regime; psychotherapeutic, physiotherapeutic and others).

Medical treatment of bedwetting

It is known that doctors of different specialties treat enuresis in different ways, based on the etiology.

How to treat bedwetting with a neurologist

So, now I will tell you in detail about the various methods. As a pediatric neurologist, I treating enuresis more than 20 years.

Remember that self-medication is undesirable, you need to see a doctor!

In the therapy of a neurologist, an individual comprehensive approach is important:

1. Usage tranquilizers :

1.1. Hydroxyzine ( Atarax), tablets 0.01 and 0.025 g, syrup (5 ml contains 0.01 g).

According to the instructions, it is possible to prescribe to children from 30 months (from 2.5 years) at a dose of 1 mg / kg body weight / day in 2-3 doses.

• A child aged 5-6 years, weighing 20 kg - receives an average of 1 ml of atarax syrup 2 times a day, more often it is prescribed in the evening and at night, the duration of treatment is 1-2 months.

Currently, drugs are rarely used:

1.2. Medazepam (Rudotel) - 0.01 g tablets and 0.005 and 0.001 g capsules: a daily dose of 2 mg / kg of body weight in 2 divided doses.

1.3. Trimethosin (Trioxazine) - 0.3 g tablets: a daily dose of 0.6 g in 2 divided doses (from 6 years old), for 7-12-year-olds - about 1.2 g in 2 doses,

1.4. Meprobamate (0.2 g tablets) 0.1-0.2 g in 2 divided doses: 1/3 dose in the morning, 2/3 dose in the evening for 1 month.

2. To accelerate the maturation of the nervous system, taking into account the severity of manifestations of neurotization, are now widely used nootropic drugs:

Commonly used nootropics in children and adults

2.1. Hopantenic acid (calcium hopantenate, pantogam, pantocalcin, hopanten, hopantenic acid calcium salt), tablets 0.25; 0.5, 10% syrup. Inside, 15-30 minutes after eating. In medium doses for children: 0.25 - 0.5 * 2 times a day; dose for adults 1.5 - 3 g in 2 divided doses, course for 1-6 months (on average 2 months). After 3-6 months, a repetition of the course of treatment is possible.

2.2. Glycine(Glycine, Glycine forte canon) is a metabolic agent. With a slight sedative effect. Sublingual tablets 0.1. Taking 1-2 tablets sublingually or buccally (or in powder form after crushing the tablet), 2-3 times a day for 14-30 days.

2.3. Piracetam(Piracetam) is a nootropic. Stimulates metabolic processes and blood circulation in the brain. Increases glucose utilization, improves metabolic processes and microcirculation. It has a protective effect (neuroprotector) in case of brain damage caused by hypoxia, intoxication. Improves integrative brain activity. It does not have a sedative and psychostimulating effect.

Piracetam () is available in the form of: granules for preparing syrup for children, capsules, solution for intravenous and intramuscular administration, solution for infusion, solution for oral administration, syrup, coated tablets.

Piracetam analogs - nootropil; lucetam; noocetam; noobil; memotropil; oikamide; pirabene; pyramids; piratropil; cerebryl; stats; ceretran; dinangen; merapiran; brainox; piracetam MS; piracetam Obolenskoye piracetam - AKOS; piracetam - Darina; piracetam N.S.; piracetam - Ratiopharm; piracetam - Ferein; piracetam - Richter; piracetam - Rusfar; piracetam 0.4 capsules; piracetam, coated tablets 0.2; piracetam - Avexim; piracetam - Bufus; piracetam - Vial; piracetam - C3; piracetam - Eskom; piracetam, solution for injection 20%, escotropil.

Release form of piracetam:
0.4 g capsules; tablets of 0.2 g; 0.8; 1.2;

Solution for oral administration nootropil 20% (200 mg in 1 ml)

Solution for injection 20% solution in ampoules of 5 ml (1 g in 1 ampoule);

Solution for intravenous administration 20% (in 1 ml 200 mg of piracetam, in 1 bottle of 15 ml - 12 g of piracetam).

• Oral solution: daily dose - 1.2 - 2.4 - 4.8 g / day.
• On average, the dose of piracetam to a child at the age of 5-6 is 3.3 g (5 ml of a 20% solution) 2-3 times a day, before breakfast, lunch and dinner.
• Can be added to liquids (fruit juice).

2.4. Phenibut(gamma-amino-beta-phenylbutyric acid hydrochloride) - nootropic, anxiolytic. It has a tranquilizing, psychostimulating, antiplatelet and antioxidant effect.

Improves the functional state of the brain by normalizing metabolism and improving blood circulation (increases the volumetric and linear velocity of cerebral blood flow, reduces the tone of cerebral vessels, improves microcirculation, has an antiplatelet effect). Helps reduce anxiety, tension, anxiety and fear; has a mild anticonvulsant effect.

Increases physical and mental performance, reduces vaso-vegetative symptoms (headache, sleep disturbances, irritability, emotional lability).

Improves psychological indicators: attention, memory, speed and accuracy of reactions. Low toxicity.

The average dose of phenibut for children 5-6 years old is 1 tablet (250 mg) 2 times a day, with the selection of doses, the course is within 2 months.

• Dose, frequency of administration and duration of treatment depend on indications, age, tolerance.
• The drug should be selected individually, within 7 days, increasing the dose by ¼ part in 2-3 days, until effective and safe.
• This is followed by a course of treatment for 1-2 months, followed by gradual withdrawal in 1-2 weeks, with a decrease in ¼ of the dose in 2-3 days (in order to avoid withdrawal syndrome).
• If necessary, after 5-6 months, the course of Phenibut can be repeated.
• Children tolerate the drug better than adults. In adults, asthenic syndrome is more pronounced, which can cause some lethargy when taking high doses of Phenibut.
• Inside, regardless of food intake.
• Phenibut's analogs : capsules Anvifen, Noofen.
• Phenibut tablets are produced in Latvia, Belarus and Russia, and Anvifen only in Russia.
• According to medical practitioners, the effectiveness of Phenibut varies from manufacturer to manufacturer.
• Phenibut is available in dosages of 100 and 250 mg. Anvifen is available in tablets of 250 mg, 125 mg, 50 mg, 25 mg, which makes it easier to choose the dose of Anvifen.

2.5. Picamilon(INN - Nicotinoyl gamma-aminobutyric acid).

Nootropic. Expands the vessels of the brain. It has a tranquilizing, psychostimulating, antiplatelet and antioxidant effect.

Improves the functional state of the brain by normalizing tissue metabolism and improving cerebral circulation (increases the volumetric and linear velocity of cerebral blood flow, reduces the resistance of cerebral vessels, suppresses platelet aggregation, improves microcirculation).

Picamilon has earned its popularity due to its mild, lightweight action for children and adults. It is well tolerated and inexpensive. It is often used in combination with other nootropics.

Increases physical and mental performance, reduces headache, improves memory, normalizes sleep; helps to reduce or disappear feelings of anxiety, tension, fear; improves the condition of patients with motor and speech disorders.

Picamilon has earned its popularity due to its mild, lightweight, economical, well-tolerated action for children and adults.

Form of release of picamilon - solution for intravenous and intramuscular administration, tablets

It is prescribed in / in, in / m, inside, regardless of food intake.
In a dose of 20-50 mg orally 2-3 times a day, a course for 1-2 months. A second course is possible in 5-6 months.

Intravenous drip or jet (slow), intramuscular. Before dropping, the contents of the ampoule are dissolved in 200 ml of 0.9% NaCl solution. Injected intravenously or intramuscularly, 100-200 mg, 1-2 times a day, in a daily dose of 20-40 mg. The course is up to 10-30 days.
In / m, in a daily dose of 20-40 mg (2-4 ml of a 10% solution), for 10-30 days.

Picamilon analogs - picogam, pikanoyl, amilonosar, sodium salt of N-nicotinoyl-gamma-aminobutyric acid.

Picamilon release form: Tablets of 0.02 g (20 mg) and 0.05 g (50 mg). Solution for injection in sealed ampoules - 50 mg / ml (5%) and 100 mg / ml (10%).

Producer of Picamilon: Chemical-Pharmaceutical Plant JSC Akrikhin (Russia); NPK Echo CJSC (Russia).

2.6. Encephabol(pyritinol dihydrochloride monohydrate) - Nootropic drug.

Encephabol suspension for taking 2% fl 200ml, Encephabol tablets 100 mg 50 pcs. dragee.

Encephabol analogs - pyriditol, cereton, enerbol, pyritinol (Pyritinol)
Increases metabolism in the brain by increasing glucose, nucleic acids and acetylcholine in synapses, improving cholinergic transmission. Pyritinol stabilizes the cell membranes of neurons and their functions by inhibiting lysosomal enzymes, thereby preventing the formation of free radicals. Improves the rheological properties of blood, increases the plasticity of erythrocytes by increasing the content of ATP in their membrane, which leads to a decrease in blood viscosity and an improvement in blood flow. As a result, memory performance improves and metabolic processes are restored.

Children Encephabol : up to 3 years - from 0.05 to 0.1 g; 4-10 years - 0.15 g; 11 - 14 years - up to 0.3 g. Inside, 15-30 minutes after meals, 2-3 times a day, the last intake no later than 17 hours, a course of up to 2 months. If necessary, after 3 months, the course can be repeated.

• The use of encephabol is possible from the third day of life.
• In the first month - 1 ml of suspension per day.
• At 2 months - 2 ml of the medicine.
• Then 1 ml is added every week, bringing the daily dose to 5 ml.
• Children 1-7 years old - 2.5-5 ml 2-3 times a day, taking into account the severity of the disease.
• Children over 7 years old - a daily dose of 2.5 - 10 ml, 1-3 times a day. The use of tablets is possible. A single dosage in this case is 1-2 tablets.

Encephabol suspension is taken during or after meals.

The drug has a mild effect, is well tolerated, economical, convenient to use, and effective.

Used with caution in epilepsy. According to the basic instructions, it is contraindicated for epilepsy, although side effects are rare in practice.

2.7. Among other nootropics are used for the treatment of enuresis: Semax, Instenon, Gliatilin, Cortexin, Cerebralizin, Actovegin, Kogitum, Aminalon.

Nootropic drugs Recommended by repeated courses for 1-6 months. Their combinations with vitamins and sedative vascular preparations are possible. It is accepted in neurological practice to refrain from polypharmacy. Treat with 1-2 drugs to reduce the likelihood of side effects from drug interactions (cocktail). The interactions of most nootropics and other drugs have not been fully studied, their effectiveness and safety have not been confirmed.

3. With a small bladder capacity, treatment is possible antispasmodics or anticholinergics .

Driptan(oxybutynin hydrochloride) in tablets of 0.005 g (5 mg) can be used in children from 5 years of age for the treatment of nocturnal enuresis caused by:

• Instability of the bladder function.
• Violation of urination due to disorders of neurogenic genesis (detrusor hyperreflexia).
• Idiopathic disorders of detrusor function (motor urinary incontinence).

Driptan is an antispasmodic. It has a direct antispasmodic, myotropic and m-anticholinergic effect. Relaxes the muscle surrounding the bladder (detrusor). Increases the volume of the bladder. Reduces the frequency of detrusor spasms, restrains the urge to urinate.

And due to the peripheral M-cholinolytic action of driptan, parasympathetic hypertonicity is eliminated, which suppresses reflex contractions of the bladder.

Frequent painful spasms in the muscles surrounding the bladder are eliminated, and the tone in the sphincter (the muscle that holds urine) increases. The urine is retained longer in the bladder.

With nocturnal enuresis Driptan is recommended for children over 5 years old - by mouth 5 mg 2 times a day starting at half the dose to avoid unwanted side effects. For adults, the dose of Driptan is 5 mg 3 times a day. The latter is recommended just before bedtime. The course of treatment is 1-2 months. The tablet can be divided or crumbled.

During treatment, you should limit fluid intake at night.

Synonyms for Driptan - Novitropan, dream-apo, dreamtan-apo, sibutin.

Driptan's analogs are Uroflex, Roliten, Spazmex, Detruzitol, Spazmolit, Enablex, Toviaz, Urotol and Vesikar.

The effect of dryptan is potentiated by tricyclic antidepressants (like amitriptyline). When Driptan is combined with other anticholinergic drugs, an increase in its action is noted.
4. To drugs with the most pronounced effect for the treatment of enuresis currently recognized drugs containing a synthetic analogue of antidiuretic hormone.

Antidiuretic hormone normalizes the rhythm of urine production, reduces the production of excess urine at night.

4.1. Medications, which include a synthetic analogue of the pituitary hormone (vasopressin): Minirin.

Indications for minirin use: diabetes insipidus of central genesis; primary nocturnal enuresis in children over 6 years of age; nocturia (nocturnal polyuria) as symptomatic therapy.
Contraindications: hypersensitivity to desmopressin; polydipsia (with a urinary output of 40 ml / kg / day); heart failure and other conditions requiring the appointment of diuretics; hyponatremia; renal failure of moderate and severe; syndrome of inadequate production of ADH; children under 6 years of age.

Method of administration and dosage of minirin:

Sublingual (under the tongue) for absorption. Do not take a tablet with liquid! The dose of Minirin is selected individually.

Release form of the drug: tablets of 0.1; 0.2; 0.4 mg corresponds to 60 tablets sublingual; 120; 240 mcg.

Minirin should be taken 1-2 hours after a meal due to the fact that food intake reduces the absorption of the drug and, as a result, its effectiveness.

Selection of the minirin dose for primary nocturnal enuresis

It is important during the entire period of treatment to limit fluid intake in the evening: after 18 hours, it is not advisable to drink fluid or not more than 50-100 ml. The recommended course of continuous treatment is 3 months. If enuresis resumes within 1 week, it is required to continue taking minirin for the next 3 months.

Nocturia

The recommended starting dose for minirin is 60 mcg at bedtime. In the absence of effect within 1 week, the dose is increased to 120 mcg, subsequently - up to 240 mcg, with an increase in the dose with a frequency of no more than 1 time per week.

If, after 4 weeks of treatment and dose adjustment, an adequate clinical effect is not observed, it is not recommended to continue taking the drug.

4.2. Previously (before the release of minirin), more often, and now rarely, other drugs with antidiuretic hormone regulating the rhythm of urine production are used: desmopressin, adiuretin, emosynt, presinex .
4.2.1. A drug desmopressin in the form of tablets (200-400 mg) or in the form of a sublingual lyophilisate (120-240 mg) proved to be highly effective 70%, but also a high risk of relapse after stopping treatment. That is, while the drug is being taken, the course can be 2-6 months or more, then the nights are dry. Immediately after stopping ADH, most patients wet the bed.

Desmopressin nasal spray is not currently recommended due to the high risk of overdose.

4.2.2. Adiuretin
Active ingredient: Desmopressin (Desmopressin). Dosage form: drops, nasal tablets.

Contraindications: Hypersensitivity, anuria, edematous syndrome, decompensated CHF, polydipsia, the need for diuretic therapy, a predisposition to thrombosis. For intranasal administration - allergic rhinitis, nasal congestion, swelling of the nasal mucosa, upper respiratory tract infections, impaired consciousness, condition after surgery. With care: renal failure, bladder fibrosis, childhood (up to 1 year), old age, imbalance in water and electrolyte balance, potential risk of increased intracranial pressure, pregnancy.

Method of administration and dose of adiuretin:

Intranasal, sublingual. For adults, the average dose is 10-40 mcg / day (1-4 drops 2-4 times a day).

Children from 3 months to 12 years old - 5-30 mcg / day.

In case of primary nocturnal enuresis, the initial dose of adiuretin is 20 mcg before bedtime (2 drops) with ineffectiveness - 40 mcg. After 3 months, there should be a break in treatment for 1 week to assess the effectiveness of treatment.

Intranasally injected with the patient lying or sitting, with the head thrown back; the number of drops is adjusted by gently pressing the dropper included in the bottle closure.

Pharmacological action: An analogue of vasopressin (ADH) with a pronounced antidiuretic effect. Increases the permeability of the epithelium of the distal convoluted tubules for water and increases its reabsorption.

The onset of antidiuretic action with intranasal administration and oral administration - within 1 hour.

The maximum antidiuretic effect occurs with intranasal administration after 1-5 hours, with oral administration - after 4-7 hours.

The antidiuretic effect with intranasal administration lasts 8-20 hours, when taken orally in a dose of 0.1-0.2 mg - up to 8 hours, in a dose of 0.4 mg - up to 12 hours.

Side effects of adiuretin :

Headache, dizziness, nausea, rhinitis, nosebleeds, increased blood pressure, tachycardia, abdominal pain of a spastic nature, algomenorrhea, conjunctivitis, decreased tearing, skin hyperemia, allergic reactions, hyponatremia or water intoxication (confusion, edema, weight gain, weight gain, ); swelling, local hyperemia.

Overdose. Symptoms: plasma hypoosmolarity, water intoxication, leading to the development of seizures and other neurological and mental symptoms.

Treatment: drug withdrawal, restriction of fluid intake, in severe cases - slow intravenous infusion of concentrated saline solutions simultaneously with furosemide.

Special instructions: In order to avoid volume overload during treatment, control is necessary for the following groups: children and adolescents; elderly people with impaired water and / or electrolyte balance, with a risk of increased intracranial pressure.

5. Imipramine, widely used in the treatment of enuresis, provides only a moderate response rate of 50% and therapy is often accompanied by relapses of the disease. Moreover, cardiotoxic effects and deaths have been reported in overdose. Therefore, its use is not recommended at the moment.

Treatment of bedwetting by a psychiatrist

Methods of a psychiatrist in the treatment of enuresis:

1. Usage tranquilizers with sleeping pills to normalize the depth of sleep (Radedorm, Eunoktin).

Occurred from a combination of words: 1. from the Latin word anxietas - anxiety, fear; 2. From the ancient Greek word λυτικός - weakening.
3. Thymoleptics - drugs for mood correction.
Amitriptyline (Amisol, Tryptizol, Elivel) - in an average dose of 125-25 mg 1-3 times a day (in tablets and dragees of 10 mg, 25 mg, 50 mg).
4. Imipramine- a derivative of dibenzoazepine, is a tricyclic antidepressant.
Imipramine (milepramine) 10 mg and 25 mg tablets, used from 6 years of age.

The dose of imipramine is being selected: from the age of 6, it is gradually increased from 0.01 g to 0.02 g per day. From 8 to 14 years old: 0.03–0.05 g per day. After reaching "dry" nights, the dose of imipramine is gradually withdrawn.

Treatment of enuresis with herbs is widespread in our country. Traditional methods of treatment with medicinal plants have not been confirmed by any research. It has not been proven to be effective or safe. All herbs and fees, methods of application (baths, sitz baths, infusions, tinctures) are selected empirically, "by eye". Many patients prefer herbal medicine, mistakenly believing that there is less harm to health and more benefits. Moreover, such methods are very cheap: many herbs grow literally underfoot.

Let us give a list of herbs used for dysfunction of the bladder.

Symptoms of dysuric disorders and commonly recommended herbs.
1. Urinary incontinence (enuresis) is used by medicinal plants : chicory, strawberry color, fragrant violet herb, lemon balm, peppermint, St. John's wort, birch leaves and buds, knotweed, centaury, chamomile, parsley, burdock, aspen bark, wheatgrass roots.

2. Retention of urine is used by medicinal plants : yarrow, dill herb and fruit, licorice root.

3. Frequent urination is used by medicinal plants: chamomile, hops, lemon balm, motherwort, succession, valerian, purse, water shamrock.

4. Painful urination using medicinal plants : chamomile, lovage, flax seed, thyme, clover, calamus, celery, maple, willow, linden, yarrow, eucalyptus.

5. Blood in the urine (hematuria), medicinal plants are used : flax seed, pumpkin, linden, chamomile, St. John's wort.

Non-drug treatments
1. Regime measures.

1.2. The bed of a child with enuresis should be moderately hard.

1.3. In deep sleep, it is advisable to turn the child over several times a night.

1.4. Create a comfortable temperature regime in the child's bedroom (avoid hypothermia).

1.5. Go to the toilet before bed.

1.6. Wake up until full awakening 1-2 times at night to go to the toilet.

1.7. Turn on dim lighting in the bedroom (night light) throughout the night to prevent fears of the dark.

Should develop a reflex to wake up with the urge to urinate or restore lost function with secondary enuresis.

Do I need to wake up at night to empty the bladder?

Yes, you need to wake up at night. And preliminarily stipulate that one of the parents will wake up the child, then take him to the toilet or put him on the potty. Such an arrangement, upon awakening unexpectedly, will not cause a negative reaction in the child.

You should wake up until you are fully awake. Sometimes a child who has not woken up is planted on a potty, but this measure is not enough to develop the wake-up reflex. It is advisable to wake up in the middle of the night at a time when the child can observe motor restlessness during sleep.

The method used for awakening in adults and children with enuresis is alarm therapy ... For this, a bedwetting alarm clock is used as a convenient method in case of a violation of the wake-up reflex. The method has no side effects. The effectiveness of the application is up to 80%, and the relapse rate is less than 30%.

1.1. Proven, currently recognized, non-drug methods of treatment include alarm - therapy .

Urinary alarms (urinary alarms, bedwetting alarms) used to interrupt sleep after the first drops of urine appear. The patient will then wake up and be able to complete the process of urinating in the toilet. A reflex to awakening is gradually formed when the bladder is full.

• The urinary alarm clock has recently been applied in our country, with high efficiency and is widely used in the world.
• The sensor is located in the underpants, it is connected to the alarm clock, and reacts to the first drops of liquid. An audible or vibration alarm is triggered. The child immediately wakes up from the signal, stops urination, goes to the table with an alarm clock and turns it off. And then he himself goes to the toilet and urinates.

Determined that correct use of the bedwetting alarm leads to recovery after 2-3 months in 90% of children and 50% of adults.

The method of using a urinary alarm clock has conditions under which it will work: the child is over 7 years old, the patient must want to get rid of enuresis and must learn how to use the alarm clock himself.

1st generation enuresis alarm clocks: they have wires from the sensor to the alarm. 2nd generation urinary alarm clocks Is a wireless device.

With the large number of people with bedwetting around the world, it has become cost-effective for manufacturers to create a series of products to enhance their comfort.

Among special products for people with enuresis specialty sheets, thin mattress covers, adult diapers, bedwetting alarms from various manufacturers became available. They can be purchased from online pharmacies and specialized websites.

Hygiene items and devices help to expand opportunities and make life more convenient. It became possible, for example, to go to a children's camp or to visit with an overnight stay.

1.2. Using a conventional alarm clock to treat bedwetting.

So, consider the "budget option", without investment. This method of using a regular alarm helps some people.

As a rule, the mother knows at what time the child is expected to have enuresis. For example, enuresis is consistently observed at 2 am.

Technique for waking up on the alarm clock of a child with enuresis to train the reflex to wake up to urinate at night:

• First, 1 hour before the expected nighttime event, we set the alarm clock, that is, for 1 night. And we wake up the child to the toilet.
• After 2 weeks, we start the alarm clock already half an hour before the expected enuresis, that is, for 1 hour and 30 minutes. Then after 2 weeks - at 2 am.
• So, we will spend about 6 months for the alarm clock to ring at 7 o'clock in the morning, and the nights become dry.

Enuresis is not a reason to be sad, but a reason to be charged with optimism!

1.3. Methodology - bladder training ... This is a moderately helpful technique. If the child wants to pee, then we offer him: "Let's wait together for 1 minute, then let's go." This is a kind of training for the bladder, it helps some, you have to try.

Is it harmful to endure? Tolerate is not harmful at all, it trains the bladder.

Psychotherapy

After consulting a neurologist or pediatrician, it is often recommended to visit a psychologist to correct neurotic disorders.
Psychotherapy is carried out by child psychotherapists (psychiatrist or medical psychologist). Use suggestive and behavioral (behavior correction) approaches.
2.From the age of 10, effective method of suggestion and self-hypnosis ... The child, before going to bed, for 10 minutes, several times recites the "formulas" of self-awakening when urging to urinate, mentally imagines a feeling of fullness of the bladder and tunes in to the chain of his actions. Pronounces: “ I want to always wake up in a dry bed. While I sleep, the urine is locked tightly in my bladder. When I want to urinate, I wake up and get up on my own .»

3. Family psychotherapy.
Parents are encouraged to develop rules:

• 3.1. Be tolerant , balanced, avoid rudeness and punishment, do not shame children.
• 3.2. Observe a rational daily regimen.
• 3.3. Avoid overwork, stress, unnecessary negative and positive excitement; in particular, watching horror movies, noisy games before going to bed.
• 3.4. To instill in children with enuresis self-confidence and the effectiveness of the treatment. Tune in for recovery. Walk this path together with the child. Look to the future with optimism.

  4. Motivational therapy

Motivational therapy has shown high efficiency (up to 80%). Only from 5-6 years old it is possible to organize a method of motivational therapy, and only in children with intact intelligence.

Parents can enter a child reward system for "dry" nights.

It works like this: for dry nights, the baby receives a toy. The child understands that after "dry" 5-7 nights in a row, a prize awaits him.

If the child really wants something (a car, go to the park, money), he gets the desired reward. For this, the child himself daily conducts a special " urinary calendar »With notes: for dry nights he draws the sun, and for wet nights - clouds or rain.

Should enter and second rule by which child changes bed and underwear himself after episodes of urinary incontinence ... This is negative feedback for the child to seek to avoid bedwetting.

Diet therapy

Should limit throughout the day and especially 3 hours before bedtime food and drinks containing caffeine or with a diuretic effect: chocolate, coffee, cocoa, cola and other carbonated drinks, watermelon.
One of the treatments is decreased fluid intake in the afternoon, which reduces the likelihood of bedwetting.
In the diet, significantly limit the intake of any liquid (soup, porridge, juice, fruit) after 17 hours. Do not drink the child unnecessarily, but cut the amount drunk by more than half of the usual.

We divide the daily volume of liquid into 3 parts: 40% of the liquid should be drunk before 12 noon, 40% of the volume of the liquid - from 12 to 17 hours, 20% - after 17 hours.

• From special diets for nocturnal enuresis, it became widespread diet of N.I. Krasnogorsky , which increases the osmotic pressure of the blood and promotes water retention in the tissues, which reduces urination.

• In the morning, fluid intake is not limited. You can drink as needed (as much as you want).
• For lunch, drink 1 glass (250 ml) of liquid.
• For an afternoon snack, half a glass (125 ml) of liquid is drunk.
• After 17 hours, fluid intake is significantly reduced.
• Nothing is drunk for dinner.
• Before going to bed, the patient is given a little salt (2.0-3.0 g table salt) in the form of pickled cucumber, salted bread or a piece of 50 g herring with black bread.

This diet is prescribed for up to 2 months.

In children, there is no need to adhere to such a strict Krasnogorsky diet.

It is only important limit fluid intake before bed , that is on do not drink abundantly at night!

Salty practically does not help. No food products (neither sweet nor salty) can solve the problem of enuresis. If you eat salty, you will want to drink. The child will wake up in an hour to drink, and after 3 hours he will wet the bed in his sleep.
Diet does not cure enuresis, it does not provoke it. Diet does not solve the problem, but it is one of the effective factors.

Physiotherapy for enuresis

It is important to take into account the form of dysfunction of the bladder: hypotonic or hyperreflex.

1. More often there is a hyperreflex neurogenic bladder, in which the muscle covering the bladder is spasmodic and the sphincter that escapes urine is atonic. With such a hyperreflex form of bladder dysfunction, techniques with antispasmodic and sympathomimetic effects are shown to help relax the detrusor and reduce the sphincter.

1.1. Antispasmodic methods: electrophoresis of anticholinergics, antispasmodics, paraffin therapy, ultrasound therapy.

1.1.1. Electrophoresis of anticholinergics. Apply atropine (0.1% solution), platifillin (0.03% solution), 0.2% aminophylline solution on the bladder area, daily or every other day, current density 0.03-0.05 mA / cm2, 10 -15 minutes; course of 10 procedures.

A good effect in practice, which is why it is often prescribed by neurologists, physiotherapy for the treatment of enuresis: electrophoresis with 0.1% atropine solution to the bladder area ... Thanks to electrophoresis, the spasmodic muscle that encloses the bladder relaxes and the urinary filling of the bladder increases. And the tone of the sphincter increases. The urine is held firmly in the bladder.

For electrophoresis, you will need to order a solution from a pharmacy with a doctor's prescription.

How to write a prescription for atropine electrophoresis in the bladder area:

Rp .: Solutionis Atropini sulfatis 0.1% 200.0
M.D.S .: For electrophoresis.

1.1.2. A variant of combined physiotherapy: bipolar electrophoresis - atropine is injected from the anode (on the lower thoracic segments of the spine), from the cathode (in the perineal region) - caffeine-sodium benzoate.

1.1.3. Paraffin applications on the bladder area or as "half shorts" at a paraffin temperature of 40-42 ° C, for 20-30 minutes, every day or every other day; a course of 10 procedures. Thermal procedures have an antispasmodic, relaxing effect. With enuresis, warmth is indicated; cooling should be avoided.

1.1.4. Paravertebral ultrasound therapy to the lumbar region (LI-LIII) and to the bladder region ... The intensity of exposure is 0.1-0.4 W / cm2, labile, 3-5 minutes per zone, daily or every other day; a course of 10 procedures. Ultrasound therapy activates blood flow, restores the innervation of the bladder muscles.

2. With hyporeflex neurogenic dysfunction of the bladder, detrusor hypotension and sphincter hypertonicity are noted. In case of bladder hyporeflexia, methods with stimulation of the bladder detrusor and having a choline-like effect (myostimulating methods) are effective.

2.1. Myostimulating methods: diadynamic currents, CMT therapy, electrophoresis of cholinomimetics.

2.1.1. Diadynamic currents (DDT) of the bladder area , OR current, duration of the procedure is 5-7 minutes, daily or every other day, for a course of 10 procedures. DDT causes the sphincter myofibrils to contract rhythmically, stimulating the obturator function of the bladder.

2.1.2. Sinus-modulated currents (CMT) to the bladder area - apply II RR, modulation frequency 30 Hz, modulation depth 75-100%, daily or every other day; 10 procedures per course. CMT also activates the contraction of the sphincter, creating conditions for urinary retention.

2.1.3. Administration of drugs by electrophoresis to the bladder area. Got spread electrophoresis with proserin , current density 0.03-0.05 mA / cm2, daily or every other day; 10 procedures per course. The drugs are used: proserin (0.1% solution), galantamine (0.25% solution) on the bladder area.

Write a prescription for proserin for electrophoresis:

Rp .: Sol. Proserini 0.1% 200.0

M.D.S .: For electrophoresis.

Write out a prescription in Latin for galantamine for electrophoresis:

Rp .: Sol. Galanthamini hydrobromidi 0.25% 200.0

M.D.S .: For electrophoresis.

3. Techniques with antispasmodic and vasodilating action have shown an effect on the spinal centers of urination regulation.

3.1. Acupuncture

3.2. Stimulating massage (segmental zones in the lumbosacral region, lower abdomen, back and inner surfaces of the legs, soles).

4. For neurotic disorders, methods with a sedative effect are shown.

4.1. Sedative methods: electrosleep, Shcherbak's galvanic collar, electrophoresis with sedatives:

4.1.1. Electrosleep-therapy has a sedative or activating effect. Electrosleep leads to the accumulation of serotonin (the hormone of pleasure) in the subcortex due to the activation by conduction currents of serotoninergic neurons in the dorsal nucleus of the suture.

The procedures are carried out at a pulse frequency of 10-20 Hz, the duration of the procedure is 20-30 minutes, every day or every other day or 2 days in a row with a break for the third; course of 10 procedures.

4.1.2. Galvanic collar according to Shcherbak ... A current strength of 6-16 mA is used, for 5-15 minutes, daily or every other day; a course of 10 procedures.

There is a decrease in sensory impulses in the brain stem due to the activation of voltage-dependent potassium channels, hyperpolarization of the excitable membranes of the peripheral nerve fibers of the collar region, which leads to a balance of inhibitory processes in the cerebral cortex.

Galvanization reduces pathological sensitive impulses due to the activation of voltage-dependent potassium channels, hyperpolarization of excitable membranes of peripheral nerve fibers in the collar region. The result is a balance between inhibition and excitation in the cortex.

4.1.3. Variants electrophoresis with different effects - endonasal or on the collar zone electrophoresis of medicinal substances (calcium, novocaine, bromine, magnesium).

4.1.4. Hydrotherapy: salt-conifers , coniferous-valerian, oxygen, nitrogen or pearl baths at a temperature of 35-37 ° C.

4.1.5. Music therapy

5. For the correction of autonomic regulation disorders, vegetative-corrective techniques are used: galvanization by the orbital-occipital technique, UV irradiation of segmental zones in erythemal doses, infrared laser therapy, peloid therapy.

5.1. Galvanization by the orbital-occipital technique at a current density of 0.02 mA / cm2, the duration of the procedure is 10-30 minutes, daily or every other day; 10 procedures per course. Galvanization enhances blood flow to subcortical structures, reticular formation, diencephalon and midbrain; normalizing the balance of sympathetic and parasympathetic reactions.

5.2. Infrared laser therapy segmentally, the area of ​​projection of the bladder and the perineal zone in combination with general exposure (reflexotherapy points or zones of the apical impulse, thymus), exposure frequency 5-50 Hz (1000 Hz for acupuncture points), exposure time 1-2 minutes per area.

5.3. Mud therapy (peloid therapy). The use of therapeutic mud by application on the projection of the shorts. The optimum temperature of the mud is 38-40 ° C, the duration of the procedure is 15-20 minutes, daily or every other day; a course of 7-15 procedures.

Due to the influence of biologically active substances of silt and peat mud, the adrenal glands overproduce their own hormones - glucocorticoids and catecholamines. It has a general and local stimulating, healing, regulating effect.

5.4. Thermal procedures - paraffin - ozokerite applications on the lumbar spine or bladder area.

• Physiotherapy is prescribed for enuresis by a physiotherapist , after a specified diagnosis by a neurologist with recommendations for the regimen, treatment. An individual rational set of physiotherapy procedures makes the treatment effective and complex, that is, aimed at different points of application.
• It is possible to carry out 2-3 repeated courses of physiotherapy with an interval of 2 weeks - 6 months.

Treatment results for bedwetting

Analyzing my 20-year practice as a neurologist in hospitals, clinics and private medical centers, the statistics are as follows.

• As a result of the treatment of patients with enuresis almost 50% have persistent and long-term remission immediately after the first course of treatment. Starting treatment at 4-12 years of age, complete recovery occurs.
• In 10%, after treatment, there is a decrease in enuresis by 2-3 times. Repeated courses of treatment are required.
• In 10% after treatment, remission is observed for 2-6 months. Repeated courses of treatment are required.
• In 10%, the effect of treatment is weak, perhaps a decrease of 2 times against the background of therapy, immediately after the end of the course, all symptoms resumed to the same degree.
• In 3%, enuresis stops on its own, without therapy, at the age of 7-12 years.
• 10% of patients do not comply with the doctor's recommendations, the effect of treatment is insignificant, since they did not begin to be treated.
• 10% have partial improvement after 1 course of treatment; with a repeated course in 4-6 months - a significant improvement, after 3 courses of treatment in 6-12 months, recovery.
• The remaining 7% have other, rarer variants.

Conclusion on the results of treatment : comprehensive, individually tailored treatment of enuresis is effective up to 80%. There is a recovery or significant improvement after the first or repeated courses of treatment.

1. Daily regime
2. Balanced diet. Restricting fluid intake at night.
3. Wake up at night to urinate in the toilet. Apply a bedwetting alarm.
4. Rational psychotherapy. Keep a urinary diary.
5. Drug treatment: Hopantenic acid (pantocalcin, pantogam) 0.5 to 1 tablet * 2 times a day, morning and evening, for 2 months. Driptan 5 mg, 1 tablet * 2 times a day, morning and evening, for a course of 2 months.
6. Physiotherapist consultation.
7. Coniferous sea baths # 10 at home.
8. Appearance in 2-3 months.

So, for the treatment of enuresis, the production of reflex to awakening -wake up at night, use a bedwetting alarm; activation of maturation of urination regulation - nootropics; correction of neurosis - psychotherapy, sedatives; symptomatic methods - driptan, minirin, physiotherapy, special water regime. About 80% of people with bedwetting experience significant improvement or recovery after rational individual therapy.

In the video, the pediatrician's recommendations: general rules and regimen for enuresis.

For 2 videos psychotherapy for enuresis - pay for dry nights?

At 3 video exercises to strengthen the muscles of the pelvic floor. Exercise for enuresis. Start with the instructor, do it first as it goes. Over time, the technique is honed, motor dexterity, plasticity develops, the muscles of the pelvic floor and the whole body are strengthened. Be healthy!

The mechanism of occurrence of stress urinary incontinence in women is associated with insufficiency of the urethral or vesicular sphincters and / or weakness of the pelvic floor structures. An important role in the regulation of urination is assigned to the state of the sphincter apparatus - with changes in the architectonics (the ratio of muscle and connective tissue components), the contractility and extensibility of the sphincters is disturbed, as a result of which the latter become unable to regulate urine output.
Normally, the continence (retention) of urine is provided by a positive gradient of urethral pressure (i.e., the pressure in the urethra is higher than in the bladder). Involuntary flow of urine occurs when this gradient changes to negative. An indispensable condition for voluntary urination is a stable anatomical position of the pelvic organs relative to each other. With the weakening of the myofascial and ligamentous apparatus, the support-fixation function of the pelvic floor is disturbed, which may be accompanied by a prolapse of the bladder and urethra.
The prerequisites for stress urinary incontinence in women may be obesity, constipation, dramatic weight loss, hard physical labor, and radiation therapy. It is known that women who have given birth are more likely to suffer from urinary incontinence, while the number of births is not so important as their course. The birth of a large fetus, a narrow pelvis, episiotomy, ruptures of the pelvic floor muscles, the use of forceps - these and other factors are predetermining for the subsequent development of incontinence.
Involuntary urination is usually observed in patients of menopausal age, which is associated with age-related deficiency of estrogen and other sex steroids and the atrophic changes in the organs of the genitourinary system that arise against this background. Operations on the pelvic organs (oophorectomy, adnexectomy, hysterectomy, panhysterectomy, endourethral interventions), prolapse and prolapse of the uterus, chronic cystitis and urethritis contribute to the development of stress urinary incontinence in women. The immediate producing factor is any tension that leads to an increase in intra-abdominal pressure: coughing, sneezing, brisk walking, running, sudden movements, lifting weights and other physical effort.
The pathogenesis of urgent urinary incontinence in women is associated with impaired neuromuscular transmission in the detrusor, leading to overactive bladder. In this case, with the accumulation of even a small amount of urine, a strong, intolerable urge to miction arises. The prerequisites for the onset of urgency are the same as in stress incontinence, and various external stimuli (sharp sound, bright light, water pouring from the tap, etc.) can act as provoking factors.
Reflex incontinence can develop as a result of damage to the brain and spinal cord (trauma, tumors, encephalitis, stroke, multiple sclerosis, Alzheimer's disease, Parkinson's disease, etc.). Iatrogenic incontinence occurs as a side effect of certain drugs (diuretics, sedatives, adrenergic blockers, antidepressants, colchicine, etc.) and disappears after the withdrawal of these drugs.