Enuresis

Enuresis is an uncontrolled leakage of urine at a time when the child's surroundings already consider it normal for the child to control mikci. According to the International Consultation on Incontinence, enuresis is the involuntary leakage of urine at night in children over the age of 5, more often than twice a month, unless a congenital or acquired defect central nervous system and urinary tract is detected. Most children urinate at night (enuresis nocturna). There are always intervals between urination when the child can handle micturition. Urinary incontinention is a condition where the baby is practically never able to control urine leakage and his diapers/laundry is permanently damp/wet. The cause is mostly a hyperactive bladder detrusor.

Classification

 * primary enuresis – the child has never checked for micturition;
 * secondary enuresis – the child begins to urinate again after a previous dry interval (at least 6 months);
 * mental stress, divorce of parents, birth of a sibling, etc.;
 * urination at night and during the day – urinary tract infections, urolithiasis.

Or:
 * (primary) monosymptomatic (night) enuresis (80 % cases) – urination in a child without additional anatomical pathology of the urinary tract and without a history of significant bladder dysfunction;
 * secondary enuresis - more severe organic or functional disorder.

Epidemiology
Enuresis is a very common phenomenon. When starting school at the age of 6, about 10% of children still urinate, at the age of 5 5%, at the age of 20 1-3% of people. Occasionally, about 0.5-1% of adults urinate.

Etiopathogenesis
The causes are multifactorial. Genetic predisposition plays a role in monosymptomatic nocturnal enuresis based on a functional bladder disorder. At night, diuresis is increased to nocturnal polyuria - over 130% of the capacity of the bladder. Urine has a lower osmolality. Other causes include urinary tract anomalies; spina bifida occulta; tethered cord syndrome; neurogenic bladder.

Diagnostics
Disorders of micturition:
 * anamnesis: dry break, psychomotor development, stress factors;
 * micturition card: fluid intake, number of micturitions (normal is 4-8 per day), amount of urine in individual portions (weighing dry and wet diapers);
 * bladder capacity: 30ml + (age in years × 30); in children over 12 years: 300-400 ml;
 * uroflowmetry: the child should start urinating immediately after being asked to micturize, without visible effort, the flow of urine should be strong, uninterrupted;
 * physical exam: external genitalia (phimosis, labial synechia), linen, anal anus, lumbosacral region (skin depressions? → MR of spinal canal and spinal cord); height, weight, blood pressure;
 * basic urine test, specific density of morning urine (standard:> 1010 g / l);
 * event. ultrasound of the uropoietic tract and basic functional examination of the kidneys;
 * in case of micturition failure – micturition cystourethrography (MCUG), event. urodynamic examination;
 * postmixture residue – ultrasound within 5 minutes after micturition (repeatedly detected residue> 20 ml → functional defect of emptying).
 * delayed start of micturition, connection of abdominal press during micturition, weak and intermittent current - susp. functional bladder disorder or infravesical obstruction;
 * restraint maneuvers - the child feels the need for micturition, but delays it by crossing the lower limbs, climbing to the toes and squatting on the heels, which press on the perineum;
 * postmixture dribbling - in a child, immediately after micturition, uncontrolled leakage of urine occurs;
 * vaginal reflux (influx) - during micturition, urine enters the vagina and then flows freely from there;
 * low frequency of micturition is often associated with faecal emptying disorder and encouprosis.

Therapy
In monosymptomatic nocturnal enuresis, regimen measures are indicated, such as fluid restriction in the late afternoon and evening. The patient keeps an enuretic diary, and a reward system for dry nights is introduced. Psychological care is added as needed.

Nejrychleší efekt má farmakologická terapie využívající analog antidiuretického hormonu (desmopressin acetát). Minirin-Melt se sublingválně aplikuje před spaním, významně snižuje objem moči, ale často se objevuje návrat enurézy po vysazení. Při předávkování hrozí riziko retence tekutin až otrava vodou (bolesti hlavy, nauzea, zvracení až tonicko-klonické křeče). Dále je možné předepsat tricyklická antidepresiva (imipramin hydrochlorid), perorální aplikace, po vysazení často návrat enurézy. Při předávkování jsou patrné závažné CNS příznaky, GIT komplikace, kardiotoxicita.

The fastest effect is pharmacological therapy using "" an analogue of antidiuretic hormone "(desmopressin acetate).  Minirin-Melt  is administered sublingually before bedtime, significantly reducing urine volume, but often recurrence of enuresis after discontinuation. In case of overdose, there is a risk of "fluid retention to water poisoning" (headaches, nausea, vomiting to tonic-clonic convulsions). It is also possible to prescribe  'tricyclic antidepressants'  (imipramine hydrochloride), oral administration, often after return of enuresis after discontinuation. In case of overdose, severe CNS symptoms, GIT complications, cardiotoxicity are evident.

Nejlepší dlouhodobý účinek mají enuretické alarmy. Do postele či spodního prádla dítěte se vloží elektrické vodiče napojené na zdroj o nízkém napětí. Elektrický okruh se zapojí, pokud se v oblasti elektrod objeví moč (stačí několik ml), zazní alarm, dítě se probudí a zadrží mikci. Terapie vyžaduje velkou spolupráci rodiny. Enuréza mizí cca za 1–3 měsíce, po vysazení relaps, ale výrazně méně často než u desmopressinu.

Na dráždivý močový měchýř se využívají anticholinergika (oxybutynin).

Prognóza
Monosymptomatická enuréza většinou ustoupí spontánně, prognóza ostatních forem závisí na příčině. U starších dětí je pomočování závažný stresový faktor, snižuje jejich sebevědomí; u rodičů často klesá tolerance vůči enuréze a směřuje k trestání enuretiky.

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 * Enkopréza
 * Inkontinence moči v dospělosti