- Email: [email protected]
Treatment of Enuresis in Female Children
-~THE JOURNAL OF UROLOGY
Vol. 72, No. 6, December 1954 Printed in U.S.A.
TREATMENT OF ENURESIS IN FEMALE CHILDREN A. C. ABERNETHY AND E. M. TOMLIN Frnm the Department of Urology, United States Naval Hospital, Bethesda, Md.
Enuresis has been recognized as an important symptom complex since the earliest published literature. The Papyrus Ebers, written about 1550 B.C., prescribed a remedy for "incontinence of urine." 1 It has been defined as the involuntary discharge of urine after the age of three years. That age has been rather well accepted as the time ·when normal children acquire the ability to control micturition. The incidence of enuresis has been variously reported as sixteen to twenty-six per cent of children; ho-wever, it is estimated that there would be a much higher incidence if all children with enuresis were seen by a physician. Nocturnal enuresis alone occurs in approximately sixty to eighty per cent, and diurnal enuresis alone in only five per cent. Twenty to forty per cent may have both. 2 The etiology and pathogenesis of enuresis are not definitely established as demonstrated by the varied theories offered by the numerous contributors on the subject in the literature. Obviously, the cause is not the same in each child. Enuresis is only a symptom, and it is the responsibility of the pediatrician, urologist and psychiatrist to discover the immediate cause in each case. Bakwin3 has listed four principal theories of pathogenesis as follows: The urologic viewpoint which holds ·with the early students on this subject that enuresis is due to an anatomic defect; the theory of Holt and Howland that enuresis is an undesirable habit, the result of improper training; the psychiatric school that enuresis is a disorder of personality; and his own theory that enuresis is an hereditary abnormality in bladder function, the foremost characteristic of which is an urgent need to empty the bladder. The importance of correction of the enuretic problem is obvious. It is essential for the normal mental development of the child and his acceptance in any society that he be continent of urine. It is important for the peace of mind of the parents that their child be normal in this respect. It is even more important that this symptom, rather common in children, not be carried into adult life where the individual with enuresis is even more a social outcast than he was as a child, and in whom failure to correct an organic lesion in the urinary tract may well lead to permanent damage. The treatment of enuresis has been as varied as the theories concerning its pathogenesis have been numerous. Treatment has progressed from the use of juniper berries, cyprus, and beer in the sixteenth century B.C.,1 the use of a The views expressed are those of the authors and are not to be construed to represent those of the United States Navy or of the Naval Service at large. Read at annual meeting, Mid-Atlantic Section of American Urological Association, Washington, D. C., April 22, 1954. 1 Glicklich, L. G.: An historical account of enuresis. Pediatrics, 8: 859-876, 1951. 2 Campbell, M.: Clinical Pediatric Urology. Philadelphia: W. B. Saunders Co., 1951. 3 Bakwin, H.: Enuresis in children. J. Pediat., 34: 249-262, 1949. 1163
1164
A. C. ABERNETHY AND E. M. TOMLIN I
burned, powdered cock's trachea in the sixteenth century A.D.,1 to the nu:j:nerous methods employed today. In addition to treating any generalized illness in the child, modern treatment may consist of psychotherapy, rewards, condationed responses, medical management, or local urological treatment of organic lesions. The psychotherapeutic approach is based on the belief that enuresis is the symptom of a basic personality disorder. The use of various electrical apparatus~s is an attempt to condition the child to awaken from the ringing of a bell or ligliting of a light when he begins to Inicturate in bed, and thus overcome his enuresis. Medical management has included attempts to prevent the child from s~eeping so soundly, attempts to increase the irritability and thus the sensation qf a full bladder, hormonal therapy, and antispasmotic drugs including belladom).a and, more recently, banthine. 4 Each of these methods has been reportedly suqcessful on some cases. But since it is a well recognized fact that enuresis is only a symptom qf some underlying disease, then it is obvious that, as in all other symptom complexes, the underlying etiology should be first deterinined in an attempt to : decide whether or not the projected therapy will be treating the underlying Cf.l,USe. If the enuresis is, as many feel, simply an undesirable habit trait from poor t~aining, then the mechanical methods of awakening the child with nocturnal ~nuresis should be sufficient. If the enuresis is due to a personality disorder, then psychotherapy is indicated. However, if the enuresis is on the basis of an organic pathologic entity, whether that be inherited, congenital, or acquired, that entity must be found and treated, not only to relieve the child of his immediate pfoblem, but to prevent permanent or longstanding damage to the urinary tract.; We do not feel that all enuretic children, or all enuretic female children necessarily have organic disease. However, we do feel that a rather high inpidence of urethral and bladder disease will be found if these children, whose primary admission symptom is enuresis, are completely studied. In the past, there h~s been a reluctance on the part of the parent and the doctor to submit an enurettc child to a complete urological workup which would involve pain and an ane~thetic. With modern cystoscopic instruments, advances in anesthesia, and imlproved urographic media, the problems of a complete urological examination haye been Ininimized. Campbell,2 Bakwin8 and Everett 6 all state that enuretics who do not ~espond to routine pediatric treatment within two to three months, or who havej pyuria along with their enuresis, should have cystoscopic exaininations. This contention we have followed, and have received excellent co-operation from the p$diatric clinics in Naval Medical facilities in our area. In the Urology Clinic at the U.S. Naval Hospital, Bethesda, Maryland te have followed a routine practice of obtaining excretory urograms and per~orining panendoscopy on all enuretic children referred to us. General anestheti¢s have j
1
O'Malley, J. F. and Owens, R.H.: Banthine therapy for enuresis. Mo. Med., 50: 188189, 1953. 5 Everett, H. S.: Gynecological and Obstetrical Urology. Baltimore: Williams 'nd Wilkins Co., 1947, p. 239. 4
1
ENURESIS IN GIRLS
1165
been required for panendoscopic examination on the younger children. Some of the older children have been very co-operative with only topical anesthetics. We do not feel that we have inflicted any serious psychic trauma on any of these children. The incidence of organic disease we have found is much higher than that reported by most contributors, possibly because only refractory enuretics or those with pyuria have been referred to us by a number of pediatric clinics, and we have no way of ascertaining the total number of enuretics seen by those clinics, nor the percentage of their refractory cases that we have seen. vVe are limiting our discussion to the female enuretic children treated in our clinic during the past 2 years, because each case appeared to follow a very similar pattern. The commonest lesion found Yrns a narrow urethra, with resultant edema of the bladder neck, low-grade chronic trigonitis, and, in many, the bladder wall had become trabeculated to overcome the narrmv urethral outlet. These findings are not peculiar to enuresis. A number of articles recently have been published drawing attention to similar findings in female children as the cause for chronic recurring infections. We feel that there is a definite relationship between the problem of the refractory enuretic child and the child with recurrent urinary tract infections. The treatment is very similar, i.e., the eradication of infection and the dilatation of the urethra as many times as is indicated along -with bladder dilations when indicated. The use of banthine or other antispasmotic drugs along with local treatment of the urethra and bladder will undoubtedly result in the highest percentage of cures of these combined problems. During the past 2 years, nineteen female children, ranging in ages from 3½ to 10 years, have been referred to us with the primary problem of enuresis. Of this group, seventeen had only nocturnal enuresis, and two had both nocturnal and diurnal enuresis. Eighteen had been enuretic since birth, and one had become enuretic six months prior to our examination, following an episode of measles. Seven had no complaints other than enuresis, nine had recurrent cystitis, two had recurrent cystitis and pyelonephritis, and one was seen in acute urinary retention. Excretory urograms and panendoscopic examinations were performed on each of these children as soon after the first visit as was compatible with the state of any infection persent. The results of the excretory urograms showed evidence of chronic pyelonephritic damage to one kidney in two of the children. Bilateral renal damage was demonstrated in none. Panendoscopic examination revealed the pathological process in one child to be a spastic bladder neck secondary to a spina bifida with damage to the parasympathetic innervation of the bladder. In one child, obstruction was found to be due to scar tissue resulting from the removal of a urethral diverticulum 1 year prior to her first visit to us. In fifteen of the remaining cases, urethral strictures required dilation with sounds before a cystoscope could be introduced. Edema and evidence of chronic inflammatory changes were felt to be important in 11 cases. In 9 cases, trabecula-
1166
A. C. ABERNETHY AND E. M. TOMLIN
tions were found in the bladder wall. A reduced bladder capacity was found in four of the cases with capacities of less than 100 cc. In all of the 19 cases referred to us, some pathologic entity was present which we felt could account for the enuresis. We feel that this may well indicate the possibility that the incidence of local organic disease as an etiologic factor may be much higher than has previously been reported. Treatment consisted of first eradication, if possible, of any infection :present, using appropriate antibiotics or chemotherapeutic agents. Then followed ,a series of urethral dilations at intervals of 1 to 3 weeks, depending largely on the child's response to therapy. These urethral dilations were carried out in all except one case without anesthesia. The one exception was the youngest child in the group, only 37:z years old. The children were extremely co-operative, most of them eager to report on their progress, and only moderately reluctant to have the painful dilation performed. Bladder dilations to capacity were performed on the 4 children with small capacities under general anesthetics, on three occasions each. Of the 19 children treated, fifteen were completely relieved of their enuresis following urethral dilations ranging in number from two to eighteen. Three children had marked improvement in their enuresis, converting from nightly to weekly or bimonthly enuresis, and one was cured of her diurnal enuresis, but continued to have nocturnal enuresis. Those children with recurrent urinary infections were controlled, and with the exception of the two with gross anatomic lesions, their infections were completely cured. The two not cured were kept under control with continued antibiotics or chemotherapeutics and periodic urethral dilations. SUMMARY
A limited series of 19 cases of enuresis in female children, ranging in ages from
3½ to 10 years, has been presented. Seventeen of these children had no developmental defect to explain their enuresis, but all seventeen had endoscopic pathologic findings which were considered worthy of treatment. Two of the children had developmental defects to account for the enuresis. Of these 19 children, fifteen were completely relieved of their enuresis and recurrent infections, four were definitely improved from the treatment as outlined. CONCLUSION
Local lesions of the urethra, bladder neck, and bladder mucosa are definite etiologic factors in the enuresis seen in female children. By early observat~on and treatment of these entities, the child and the parents may be relieved of an unfortunate situation, and the future health of the individual may be preserved. It is believed that many children with enuresis are never seen by a mrologist, though they have not responded to other methods of treatment. It is felt that we should be more active in bringing this problem before the profession by calling its attention to undergraduates as well as to our colleagues through our county societies and other organizations.
Vol. 72, No. 6, December 1954 Printed in U.S.A.
TREATMENT OF ENURESIS IN FEMALE CHILDREN A. C. ABERNETHY AND E. M. TOMLIN Frnm the Department of Urology, United States Naval Hospital, Bethesda, Md.
Enuresis has been recognized as an important symptom complex since the earliest published literature. The Papyrus Ebers, written about 1550 B.C., prescribed a remedy for "incontinence of urine." 1 It has been defined as the involuntary discharge of urine after the age of three years. That age has been rather well accepted as the time ·when normal children acquire the ability to control micturition. The incidence of enuresis has been variously reported as sixteen to twenty-six per cent of children; ho-wever, it is estimated that there would be a much higher incidence if all children with enuresis were seen by a physician. Nocturnal enuresis alone occurs in approximately sixty to eighty per cent, and diurnal enuresis alone in only five per cent. Twenty to forty per cent may have both. 2 The etiology and pathogenesis of enuresis are not definitely established as demonstrated by the varied theories offered by the numerous contributors on the subject in the literature. Obviously, the cause is not the same in each child. Enuresis is only a symptom, and it is the responsibility of the pediatrician, urologist and psychiatrist to discover the immediate cause in each case. Bakwin3 has listed four principal theories of pathogenesis as follows: The urologic viewpoint which holds ·with the early students on this subject that enuresis is due to an anatomic defect; the theory of Holt and Howland that enuresis is an undesirable habit, the result of improper training; the psychiatric school that enuresis is a disorder of personality; and his own theory that enuresis is an hereditary abnormality in bladder function, the foremost characteristic of which is an urgent need to empty the bladder. The importance of correction of the enuretic problem is obvious. It is essential for the normal mental development of the child and his acceptance in any society that he be continent of urine. It is important for the peace of mind of the parents that their child be normal in this respect. It is even more important that this symptom, rather common in children, not be carried into adult life where the individual with enuresis is even more a social outcast than he was as a child, and in whom failure to correct an organic lesion in the urinary tract may well lead to permanent damage. The treatment of enuresis has been as varied as the theories concerning its pathogenesis have been numerous. Treatment has progressed from the use of juniper berries, cyprus, and beer in the sixteenth century B.C.,1 the use of a The views expressed are those of the authors and are not to be construed to represent those of the United States Navy or of the Naval Service at large. Read at annual meeting, Mid-Atlantic Section of American Urological Association, Washington, D. C., April 22, 1954. 1 Glicklich, L. G.: An historical account of enuresis. Pediatrics, 8: 859-876, 1951. 2 Campbell, M.: Clinical Pediatric Urology. Philadelphia: W. B. Saunders Co., 1951. 3 Bakwin, H.: Enuresis in children. J. Pediat., 34: 249-262, 1949. 1163
1164
A. C. ABERNETHY AND E. M. TOMLIN I
burned, powdered cock's trachea in the sixteenth century A.D.,1 to the nu:j:nerous methods employed today. In addition to treating any generalized illness in the child, modern treatment may consist of psychotherapy, rewards, condationed responses, medical management, or local urological treatment of organic lesions. The psychotherapeutic approach is based on the belief that enuresis is the symptom of a basic personality disorder. The use of various electrical apparatus~s is an attempt to condition the child to awaken from the ringing of a bell or ligliting of a light when he begins to Inicturate in bed, and thus overcome his enuresis. Medical management has included attempts to prevent the child from s~eeping so soundly, attempts to increase the irritability and thus the sensation qf a full bladder, hormonal therapy, and antispasmotic drugs including belladom).a and, more recently, banthine. 4 Each of these methods has been reportedly suqcessful on some cases. But since it is a well recognized fact that enuresis is only a symptom qf some underlying disease, then it is obvious that, as in all other symptom complexes, the underlying etiology should be first deterinined in an attempt to : decide whether or not the projected therapy will be treating the underlying Cf.l,USe. If the enuresis is, as many feel, simply an undesirable habit trait from poor t~aining, then the mechanical methods of awakening the child with nocturnal ~nuresis should be sufficient. If the enuresis is due to a personality disorder, then psychotherapy is indicated. However, if the enuresis is on the basis of an organic pathologic entity, whether that be inherited, congenital, or acquired, that entity must be found and treated, not only to relieve the child of his immediate pfoblem, but to prevent permanent or longstanding damage to the urinary tract.; We do not feel that all enuretic children, or all enuretic female children necessarily have organic disease. However, we do feel that a rather high inpidence of urethral and bladder disease will be found if these children, whose primary admission symptom is enuresis, are completely studied. In the past, there h~s been a reluctance on the part of the parent and the doctor to submit an enurettc child to a complete urological workup which would involve pain and an ane~thetic. With modern cystoscopic instruments, advances in anesthesia, and imlproved urographic media, the problems of a complete urological examination haye been Ininimized. Campbell,2 Bakwin8 and Everett 6 all state that enuretics who do not ~espond to routine pediatric treatment within two to three months, or who havej pyuria along with their enuresis, should have cystoscopic exaininations. This contention we have followed, and have received excellent co-operation from the p$diatric clinics in Naval Medical facilities in our area. In the Urology Clinic at the U.S. Naval Hospital, Bethesda, Maryland te have followed a routine practice of obtaining excretory urograms and per~orining panendoscopy on all enuretic children referred to us. General anestheti¢s have j
1
O'Malley, J. F. and Owens, R.H.: Banthine therapy for enuresis. Mo. Med., 50: 188189, 1953. 5 Everett, H. S.: Gynecological and Obstetrical Urology. Baltimore: Williams 'nd Wilkins Co., 1947, p. 239. 4
1
ENURESIS IN GIRLS
1165
been required for panendoscopic examination on the younger children. Some of the older children have been very co-operative with only topical anesthetics. We do not feel that we have inflicted any serious psychic trauma on any of these children. The incidence of organic disease we have found is much higher than that reported by most contributors, possibly because only refractory enuretics or those with pyuria have been referred to us by a number of pediatric clinics, and we have no way of ascertaining the total number of enuretics seen by those clinics, nor the percentage of their refractory cases that we have seen. vVe are limiting our discussion to the female enuretic children treated in our clinic during the past 2 years, because each case appeared to follow a very similar pattern. The commonest lesion found Yrns a narrow urethra, with resultant edema of the bladder neck, low-grade chronic trigonitis, and, in many, the bladder wall had become trabeculated to overcome the narrmv urethral outlet. These findings are not peculiar to enuresis. A number of articles recently have been published drawing attention to similar findings in female children as the cause for chronic recurring infections. We feel that there is a definite relationship between the problem of the refractory enuretic child and the child with recurrent urinary tract infections. The treatment is very similar, i.e., the eradication of infection and the dilatation of the urethra as many times as is indicated along -with bladder dilations when indicated. The use of banthine or other antispasmotic drugs along with local treatment of the urethra and bladder will undoubtedly result in the highest percentage of cures of these combined problems. During the past 2 years, nineteen female children, ranging in ages from 3½ to 10 years, have been referred to us with the primary problem of enuresis. Of this group, seventeen had only nocturnal enuresis, and two had both nocturnal and diurnal enuresis. Eighteen had been enuretic since birth, and one had become enuretic six months prior to our examination, following an episode of measles. Seven had no complaints other than enuresis, nine had recurrent cystitis, two had recurrent cystitis and pyelonephritis, and one was seen in acute urinary retention. Excretory urograms and panendoscopic examinations were performed on each of these children as soon after the first visit as was compatible with the state of any infection persent. The results of the excretory urograms showed evidence of chronic pyelonephritic damage to one kidney in two of the children. Bilateral renal damage was demonstrated in none. Panendoscopic examination revealed the pathological process in one child to be a spastic bladder neck secondary to a spina bifida with damage to the parasympathetic innervation of the bladder. In one child, obstruction was found to be due to scar tissue resulting from the removal of a urethral diverticulum 1 year prior to her first visit to us. In fifteen of the remaining cases, urethral strictures required dilation with sounds before a cystoscope could be introduced. Edema and evidence of chronic inflammatory changes were felt to be important in 11 cases. In 9 cases, trabecula-
1166
A. C. ABERNETHY AND E. M. TOMLIN
tions were found in the bladder wall. A reduced bladder capacity was found in four of the cases with capacities of less than 100 cc. In all of the 19 cases referred to us, some pathologic entity was present which we felt could account for the enuresis. We feel that this may well indicate the possibility that the incidence of local organic disease as an etiologic factor may be much higher than has previously been reported. Treatment consisted of first eradication, if possible, of any infection :present, using appropriate antibiotics or chemotherapeutic agents. Then followed ,a series of urethral dilations at intervals of 1 to 3 weeks, depending largely on the child's response to therapy. These urethral dilations were carried out in all except one case without anesthesia. The one exception was the youngest child in the group, only 37:z years old. The children were extremely co-operative, most of them eager to report on their progress, and only moderately reluctant to have the painful dilation performed. Bladder dilations to capacity were performed on the 4 children with small capacities under general anesthetics, on three occasions each. Of the 19 children treated, fifteen were completely relieved of their enuresis following urethral dilations ranging in number from two to eighteen. Three children had marked improvement in their enuresis, converting from nightly to weekly or bimonthly enuresis, and one was cured of her diurnal enuresis, but continued to have nocturnal enuresis. Those children with recurrent urinary infections were controlled, and with the exception of the two with gross anatomic lesions, their infections were completely cured. The two not cured were kept under control with continued antibiotics or chemotherapeutics and periodic urethral dilations. SUMMARY
A limited series of 19 cases of enuresis in female children, ranging in ages from
3½ to 10 years, has been presented. Seventeen of these children had no developmental defect to explain their enuresis, but all seventeen had endoscopic pathologic findings which were considered worthy of treatment. Two of the children had developmental defects to account for the enuresis. Of these 19 children, fifteen were completely relieved of their enuresis and recurrent infections, four were definitely improved from the treatment as outlined. CONCLUSION
Local lesions of the urethra, bladder neck, and bladder mucosa are definite etiologic factors in the enuresis seen in female children. By early observat~on and treatment of these entities, the child and the parents may be relieved of an unfortunate situation, and the future health of the individual may be preserved. It is believed that many children with enuresis are never seen by a mrologist, though they have not responded to other methods of treatment. It is felt that we should be more active in bringing this problem before the profession by calling its attention to undergraduates as well as to our colleagues through our county societies and other organizations.