Holistic approach of homoeopathy for management of nocturnal enuresis in paediatrics

Abstract

Nocturnal Enuresis also called bed wetting is involuntary urination while asleep after the age at which staying dry at night can be reasonably expected i.e. ≥5 years of age. It is a widespread and distressing condition that can have a deep impact on the child’s behaviour and on their emotional and social life. It is also particularly stressful for the parents or guardians. Bedwetting affects normal daily routines and social activities such as sleep hours or school trips. It also generates much more serious feelings and behaviours, such as a sense of helplessness and lack of hope and optimism, feelings of being different from others, feelings of guilt and shame, humiliation, victimization and loss of self-esteem. Homoeopathy has a great scope in the treatment of Nocturnal Enuresis because of its dynamic, individual and holistic concept where individual is considered for the treatment not the disease.

Keywords: Nocturnal Enuresis, children, Evaluation, motivational therapy, alarm therapy, Holistic approach, homoeopathy

Introduction 

Nocturnal enuresis is a disorder in which episodes of urinary incontinence occurs during sleep in children ≥5 years of age. More than 85% of children attain complete diurnal and nocturnal control of the bladder by 5 years of age. The remaining 15% gain continence at approximately 15% per year, such that by adolescence only 0.5%–1% children have enuresis. Nocturnal enuresis prevalence rates vary from 3.5% to 56.4% in different geographical regions and countries.

DSM‑5 criteria for the diagnosis of enuresis are as follows:(1)

• Repeated voiding of urine into bed or clothes, whether involuntary or intentional. 
• The behaviour either (a) occurs at least twice a week for at least 3 consecutive months or (b) results in clinically significant distress or social, functional or academic impairment. • The behaviour occurs in a child who is at least 5-year-old (or has reached the equivalent developmental level). 
• The behaviour cannot be attributed to the physiologic effects of a substance or other medical condition. 

Classification of Enuresis 

1. On The Basis of The Timing of Micturition  

Nocturnal: voiding urine at night.

Diurnal: voiding urine when awake. 

Further Nocturnal enuresis can be classified:

1. Primary Nocturnal Enuresis- (PNE) 

The most common type of enuresis, accounting for 90% of cases, is called primary nocturnal enuresis (PNE). In PNE, children have the ability to control their bladders during the day but have never been dry at night for a continuous six-month period. PNE can be classified as mono-symptomatic if it occurs only during sleep and is not accompanied by any other lower urinary tract symptoms. Children with mono-symptomatic nocturnal enuresis do not require further evaluation. 

1. Secondary Nocturnal Enuresis 

Children are completely dry at night for a period of at least 6 months and then begin wetting again. 

1. According to the Presence of other symptoms  

1. Mono-symptomatic/ uncomplicated nocturnal enuresis: Normal voiding occurs at night in bed in the absence of other symptoms referable to the urogenital /gastrointestinal tract. 
2. Polysymptomatic/complicated nocturnal enuresis: Bedwetting is with daytime symptoms which are mostly urgency of urine, frequency, and chronic constipation.(3)

Aetiology 

1. a) Genetic: If one parent had primary nocturnal enuresis (PNE), the risk for a child to develop PNE is approximately 40%. If both parents had PNE during their childhood, the risk increases to about 70%. 
2. b) Physiological factors: Some evidence suggests that children with enuresis may have lower secretion of antidiuretic hormone (ADH) at night, experience deep sleep, and have delayed maturation of urethral sphincter control. 
3. c) Psychological factors: Prolonged anxiety, hostility, acute stress, or traumatic experiences can contribute to secondary enuresis, where a child who has previously achieved bladder control starts bedwetting again. 
4. d) Increased bladder irritability: Enuresis can be caused by conditions such as urinary tract infections or severe constipation, which increase bladder irritability. 
5. e) Polyuria: Secondary enuresis may occur in cases of diabetes mellitus or diabetes insipidus, conditions characterised by increased urine production. 
6. f) Organic causes: Certain organic conditions like spina bifida or ectopic ureter can be associated with enuresis. 
7. g) Faulty learning: Failure to develop appropriate reflex bladder control, leading to the inhibition of bladder emptying, can contribute to enuresis. 
8. h) Situational changes: Alterations in eating, drinking, or sleeping habits, as well as significant life changes, can sometimes trigger enuresis episodes. (3, 4)

Pathophysiology 

Enuresis can be caused by abnormalities in both the storage and voiding phases of bladder function. 

 The storage phase – It involves the bladder acting as a reservoir for urine, and its capacity is influenced by bladder size and compliance. As children grow, their storage capacity increases. However, factors like repeated infections or outlet obstruction can decrease compliance, leading to bladder muscle hypertrophy. 

 The voiding phase -In this phase the bladder contracts in coordination with the opening of the bladder neck and the external urinary sphincter. Any dysfunction in the coordination or sequence of voiding of urine causes enuresis. Various reasons can cause this dysfunction. One example is bladder irritation, which can lead to irregular contractions of the bladder and a lack of synchronization in the voiding sequence, thus contributing to enuresis. Bladder irritation can be triggered by conditions such as urinary tract infections (UTIs) or any external pressure on the bladder. (3,6)

Evaluation

Careful history helps determine whether enuresis is primary or secondary, whether any daytime symptoms are present, whether any voiding difficulty is present.(9) Information related to urinary stream and presence or absence of voiding symptoms, such as slow stream, splitting or spraying, intermittency, hesitancy, straining, and terminal dribble should be recorded, as it will help in indicating the underlying pathologies. Detailed family history should also be obtained.(10)

Frequency-volume charts/voiding diaries with frequency and volume charting of urine output and fluid intake for at least 2 days, with a record of daytime accidents, bladder symptoms and bowel habits for at least 7 days is useful.(3)

Treatment

General advice should be given to all enuretic children but active treatment need not begin before the age of six years. Caffeinated drinks like tea, coffee fluid in-take during the day as 40% in the morning, 40% in the afternoon and 20% in the evening are recommended (3). The first step in treating Primary nocturnal enuresis is to educate the child and parents about the condition and provide reassurance regarding spontaneous resolution (9). Medication should be initiated in children >5 years only if non-pharmacologic measures fail (7). The first line of treatment is usually non pharmacological, comprising motivational therapy and use of alarm devices. Motivational therapy involves a combination of providing reassurance, emotional support, eliminating guilt, and rewarding the child for dry nights.(7) Alarm therapy with an enuresis alarm is the most effective strategy for curing nocturnal enuresis. Success rates of 66%–70%. Enuresis alarm consists of a sensor device attached to the child’s underwear or to a mat under the bed-sheet, and an alarm placed on the bedside or attached to the child’s collar. The sensor on the device is activated when bedwetting occurs. Alarm therapy requires treatment for 6–16 weeks. (9)

Homeopathy: A Holistic Approach 

Homeopathy is a natural therapeutic system that aims to stimulate the body’s innate healing abilities. It follows the principle of “like cures like,” using highly diluted substances derived from plants, animals, and minerals to trigger a healing response. Homeopathic medicines are individualized based on the unique symptoms and constitution of the patient. Unlike conventional medicine, homeopathy treats the whole person, taking into account physical, mental, and emotional aspects.(2)

Homoeopathic medicines:

1. Calcarea carbonica: Complaints of children who are fat, fair and flabby. Much emission of urination at night. Sour vomiting of children during dentition with tendency to eat indigestible things such as chalk, pencil etc. 
2. Causticum: chilly patient. Enuresis during first sleep at night. Enuresis from slightest excitement. Particularly in Children during first sleep worse in winter and ceases or Becomes more moderate in summer with great debility. 
3. Cina: Cina is suitable for children who grind their teeth during sleep (bruxism) and experience restless sleep. Bedwetting may be accompanied by an itchy nose, rectal itching, or abdominal pain. The child is irritable and rubs the nose. The urine is turbid, white, and turns milky on standing. Increased appetite is another prominent symptom that indicates Cina. 
4. Dulcamara: Enuresis after some disease of bladder. Worse from cold or damp. Child desires different things but rejects on receiving them. Copious turbid foul smelling urine. 
5. Equisetum hyemale: Enuresis day and night, it acts well when it remains a mere force of habit, after removal of primary cause, dreams of seeing crowd of people. Profuse urine. Incontinence of urine in children with dreams or night mares. 
6. Kreosotum: chilly patient. Irritable, peevish, dissatisfied. Enuresis with dream of urination in a decent manner, wets bed at night. Enuresis during first part of sleep, from which it is difficult to arouse child. Sudden urge to urinate.
7. Lycopodium: Lycopodium is indicated when bedwetting is accompanied by digestive issues, such as bloating, constipation, or flatulence. These children may exhibit low self-confidence and fear failure. Lycopodium supports gastrointestinal health and addresses associated bedwetting symptoms.
8. Medorrhinum: In children where there is a psychotic history of Nocturnal Enuresis. Weak memory, fear in the dark as if someone behind him/her. 
9. Natrum muriaticum: Craving for salt. Aversion for bread and fats. Urine pass involuntarily when walking and coughing, has to wait a long time for it to pass if others are present. 
10. Pulsatilla: This remedy is appropriate for emotionally sensitive children who crave attention and reassurance. Bedwetting may occur due to anxiety, especially when feeling abandoned or rejected. Pulsatilla helps address emotional imbalances and promote overall well-being. 
11. Rhus toxicodendron: chilly patient. Bed wetting in children of older age group. Nocturnal enuresis in boys.
12. Sabal serrulata: Due to paralysis of sphincter, constant desire to pass urine at night. 
13. Sepia officinalis: chilly patient. Involuntary urination during first sleep. Bed is wet as soon as the child goes to sleep, very offensive urine. Child is dull, depressed, moody indolent with a greasy skin. Disinterested in work worse from change of weather.
14. Sulphur: Wetting bed at night copious discharge of children who suffer from chronic cutaneous eruption. Desires sugar. (5,8)

Conclusion

In homeopathy, accurate case-taking is crucial for selecting the appropriate remedy. A skilled homeopath will evaluate the child’s physical symptoms, mental and emotional state, medical history, and family background. The chosen homeopathic medicine will be tailored to the child’s unique symptom profile and administered in the appropriate potency and frequency. Homoeopathy with the holistic approach can be used for the treatment of nocturnal enuresis in paediatrics.

References 

1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington, VA: American Psychiatric Association; 2013. p. 355-7.
2. Bakson Homoeopathy Homoeopathy for All, Aug 2016, Vol. 18 Issue (200), pg. 50-53 
3. Ghai O.P., Paul Vinod K., Bagga Arvind, Ghai Essential Paediatrics, 7th Edition, CBS Publishers And Distributors, 2009, Pg. 35, 36 
4. Gupta S. The short textbook of Paediatrics, 11th edition, 2009. 
5. Homoeopathy for mother and child care, Chap. 48, 2, 199.
6. IAP Textbook of Paediatrics, 2nd Edition, Jaypee Brothers Medical Publishers (P) Ltd., New Delhi, 2002, Pg. 484, 804. 
7. Lawless MR, McElderry DH. Nocturnal enuresis: Current concepts. Pediatr Rev 2001;22:399-407.
8. Lilienthal Samuel, Homoeopathic Therapeutics, B. Jain Publishers (P) LTD., 2011, Pg. 178, 179. 
9. Ramakrishnan K. Evaluation and treatment of enuresis. Am Fam Physician 2008;78: 489-96.
10. Takeda M, Araki I, Kamiyama M, Takihana Y, Komuro M, Furuya Y. Diagnosis and treatment of voiding symptoms. Urology 2003;62(5-2):11-9. 24.
11. Vande Walle J, Rittig S, Bauer S, Eggert P, Marschall Kehrel D, Tekgul S. American Academy of Pediatrics; European Society for Paediatric Urology; European Society for Paediatric Nephrology; International Children’s Continence Society. Practical consensus guidelines for the management of enuresis. Eur J Pediatr 2012;171:971-83.

About the Author: