A case report of nocturnal enuresis

Dr Shashank HS

ABSTRACT: Nocturnal enuresis (NE) is involuntary urination that occurs at night during sleep without any inherent suggestion of frequency of  bedwetting or pathophysiology. There are a number of treatment options  available for NE; such as drug therapy, bladder training, positive reinforcement, and the enuresis night alarm. It requires patience, persistence and motivation. Several behavioural approaches can be used for treatment such as enuresis night alarm therapy and various skills oriented components. A thorough homoeopathic case taking and treating with an individualised homoeopathic remedy of single dose gives an assured result. Case with marked peculiar symptom can be made basis of prescription and not all cases requires repertorization. 

Keywords: Nocturnal enuresis, bedwetting, enuresis, homoeopathy, single dose, peculiar symptom.

INTRODUCTION:
Nocturnal enuresis (NE) is defined as “involuntary voiding of urine that occurs while sleeping that can happen at an inappropriate and socially unacceptable time and place” and due to which its negative impact occurs on the quality of life of the affected children and their families. It is most common in boys, with a ratio of three boys for every girl until the age of 15. Enuresis should be differentiated from continuous or intermittent incontinence or dribbling. The bed is usually soaking wet in enuresis, compared to incontinence in which there is loss of urine without normal emptying of the bladder.

More than 85% children attain complete diurnal and nocturnal control of the bladder by five years of age. The remaining 15% gain continence at approximately 15% per year, such that by adolescence only 0.5-1 % children have enuresis. Up to the eleventh year, enuresis is twice as common in boys as it is in girls; thereafter, the incidence is similar or slightly higher in girls.

Enuresis is called primary when the child has never been dry and secondary when bed wetting starts after a minimum period of six months of dryness at night.

Enuresis may be comorbid with mood and emotional disorders and also has a high level of comorbidity with attention deficit hyperactivity disorder (ADHD). Part of emotional disorder such as anxiety, expression and insomnia are experienced by persons who have elimination disorders related to distress and social stigma

Classifications

  Enuresis classified on the basis of the time of occurrence into the following three subtypes: 

• Nocturnal Enuresis:  Passing urine during sleep. 
• Diurnal Enuresis: Leakage of urine during waking hours. 
• Monosymptomatic or uncomplicated NE: Normal voiding at night with absence of symptoms. 
• Polysymptomatic or complicated NE: Bedwetting at day time with symptoms urgency, frequency, constipation and encopresis. 
• Nocturnal and diurnal Enuresis, also known as nonmono-symptomatic enuresis.

Aetiology:

• NE is hereditary, children whose parents were not enuretic have only a 15% incidence of bedwetting and when one or both parent were enuretics, the rates increases to 44% and 77% respectively
• From the difficulty in waking up when the bladder is filled.
• excessive nocturnal urine production and nocturnal bladder hyperactivity
• Can be drinking late in the evening or not passing urine before going to sleep, resulting in excessive urine volume.
• Another cause may be a low amount of antidiuretic hormone during the night which controls the production of urine.

Goals of treatment 

The following are goals of management for NE 

• To stay without bedwetting on particular occasions such as sleepover at night or day. 
• To decrease the frequency of wet nights. 
• To decrease the impact of enuresis on the child and family. 
• To avoid recurrence of bedwetting. 

For achieving the above goals lifestyle and behavioural changes play an important role.

Primary management of enuresis is behavioural modification and positive reinforcement and it should be start with educating the child as well as parents about the condition, which can be achieved through :

• -Behavioural Management.
• -Night urine alarm therapy.
• -Pajama (Under wear) Device
• -Mechanism of action of Night urine Alarm Device
• -Waking schedule

CASE REPORT : A female patient of age 10 years visited our A. M. Shaikh Homoeopathic Hospital on 22/07/2019 with her father who described her case in detail with the presenting complaint of Bed wetting since 5 years.  

History of presenting complaint
Patient came with the complaint of bed wetting at night and daytime as well; there is no single dry night since 5 years.At times she passes urine 2-3 times at night and once during her day/evening sleep.

 No H/O Night terrors or Nightmare.

Treatment history: Has consulted an allopathic paediatrician for the above mentioned complaint and was on treatment for 3years with no desirable improvement, so wilfully seeking homoeopathic treatment.

Past history: No H/O any major illness or any remarkable events occurred since birth.

Family history: Nothing significant. No family history of enuresis.

Milestones: 

• Neck holding – 4^th month
• Monosyllable speech – 7^th month 
• Crawling – 9^th month.
• Sitting without support by 10^th month.
• Walking without support – 14^th month.
• Normal speech with meaningful words – after18 months.
• Personal History:  

Diet : Vegetarian,

Appetite :Not adequate, hardly eats a roti at times.

Thirst : 1 – 1.5 ltrs / day,  

Micturition : D/N : 3-4/2-3, 

Stools : Once/day, Regular, Soft.

Desires : Spicy food.

Life Space Investigation :

• Birth history : Full term normal hospital delivery.  Mother had absolutely healthy pregnancy throughout the term. Mother was not a known case of Hypertension, Diabetes Mellitus, Hypothyroidism. No H/O any insult (injury) at birth.
• Post delivery – till date. : Patient is born and brought up in Kadoli, Belagavi. No remarkable events since birth.
• She is good in studies, mingles with people easily. She gives debate and speaks  freely without fear in-front of people and she has won in almost all the debate she has participated yet she is timid. She cannot takes / tolerates the pain when other people are quarrelling (reaction sympathetic). She is that sensitive she cannot even tolerate the fight in movies and serials. If she sees any beggar on road she tends to lend her tiffin.

General Physical Examination :
Patient is moderately built and moderately nourished,   No pallor, cyanosis, icterus, clubbing, oedema, lymphadenopathy,  Temperature : 98.6º F. (Afebrile),  Thermals : Hot,  Height :129cms,  Weight :26kgs, Birth Weight : 2.75kgs,  Pulse rate :84 bpm, Respiratory cycle : 18cpm.

Clinical diagnosis :Primary enerusis.

Totality of symptoms :

• Bedwetting at night and daytime.
• Desires spicy food.
• She cannot tolerate when other people are quarrelling (reaction – sympathetic), She is that sensitive she cannot even tolerate the fight in movies and serials. If she sees any beggar on road she tends to lend her tiffin
• Hot patient.

Analysis of symptoms :

Common symptoms	Uncommon symptoms
Bed wetting.	She cannot tolerate when other people are quarrelling.
	Timid  but speaks in public.
	Desires spicy food

Prescription: Causticum200  HS  1dose

Basis of prescription : This case has been prescribed without repertorization as we found the substantial / peculiar symptom ( sensitive to emotional disturbances) for prescription while case taking.

Follow up’s : (written as it is expressed by father)

• 29/07/2019

Father said patient has passed urine only twice during her sleep since last week.

Complaints are better by 50%.

Prescribed  Placebo BD for 15 days.

• 19/08/2019

Patient has passed urine during day sleep only once since past 10days.

No bedwetting at night since 10 days.

Appetite has improved, father said she herself asks and have food.

Patient is better by 75%.

Prescribed  Placebo  BD for 15 days.

• 03/09/2019

Bedwetting only once at day sleep and no bedwetting at night since 1 month.

Feeling generally better.

No fresh complaints.

Prescribed  Placebo  BD for 15 day. 

Conclusion : Enuresis can be successfully treated with detailed homoeopathic case taking with individualised homoeopathic medicine along with  encouragement, a positive attitude and motivation are important components of treatment to become dry. Punishment and criticism has no role to play in care. Children with enuresis get always benefit from a caring attitude of parents. A positive approach by the physician and care taker is also important role to play for putting confidence and to increase compliance.

References :

1. Ghai. O. P, BaggaArvind, Pual. V.K; Ghai essential paediatrics; 8^th edition revised and enlarged; CBS Publications and distributors Pvt. Ltd.; NewDelhi; 2013, P-504.
2. Kliegman, M. Robert, Stanton, F. Bonita. Geme, St.  Schor; Nelson Textbook of  Paediatrics; 20^th edition; ELSEVIER; Philadelphia; 2016; 
3. http://dx.doi.org/10.5350/Sleep.Hypn.2019.21.0168. Sleep and hypnosis : a Journal of Clinical Neurosciences and Physiopathology.

Dr Shashank H  S
Dept of Paediatrics PG Part 1
A M Shaikh Homoeopathic Medical College , PG Research Centre &  Hospital, Belagavi.
Under the guidance of :Dr Nahida M Mulla. _{M.D (HOM); MACH}
Prof. and HOD Paediatrics
A M Shaikh Homoeopathic Medical College , PG Research Centre &  Hospital, Belagavi.