Enuresis.
Synonym:—Incontinence of urine; nocturnal incontinence; bed-wetting.
Definition:—Lack of control, either voluntary or involuntary, of the urethral sphincter, as a result of which the urine escapes from the bladder when any quantity has accumulated.
Etiology:—The condition is ascribed to causes of nervous origin almost exclusively, whether it occur in the young or in the aged. It is exhibited in several forms. There is the habitual nocturnal incontinence of childhood, or the incontinence of youth, or a neurotic or feeble habit of those who are powerless to control either the vesicle or rectal sphincter at times, after excitement or active exercise. There is the condition of incomplete control of adults, and that form of imperfect control which is common to women at middle life, or during the menopause, when any straining or sneezing or coughing will cause the urine to escape from the bladder. Finally there is that most inconvenient and distressing form of constant dribbling, common to those who are paralyzed, to epileptics, and to the feeble-minded, and the aged.
Only in rare cases is the condition due to irritating urine, or to the presence of a foreign body, or foreign growths in the bladder. The irritation is either due to hyperesthesia and undue sensitiveness, or anesthesia of the nerve filiments and muscular atonicity of the bladder walls. Paralysis, local or general, affecting the nerves of this structure, will result in enuresis. This condition occurs from diphtheria, from scarlet fever, and as the result of prolonged direct pressure of the head of the fetus in puerperal cases. Reflex irritation is an occasional cause, it is common to young boys who suffer from phymosis, and with all youths who practice masturbation. In advanced life the difficulty is probably due to centric faults. Occasionally it is of cerebral origin, and quite commonly it is due to some lesion of the spinal cord.
The condition may also be induced by worms, by gastric irritation or indigestion, and by the previous occurrence of urinary retention, which may have resulted in overdilatation of the bladder. It may also occur congenitally, from a misplacement of the ureter, or from some other deformity, as in hypospadias.
Symptomatology:—The only symptoms of this condition are the escape of urine with the inconvenience, discomfort or disgust that it occasions. There is seldom any local irritation, yet in a few cases the condition finally causes local irritation and ulceration. Nocturnal incontinence in children, exhibits no symptoms, but these patients usually are nervous, poorly nourished, and of slower growth from some obscure cause.
Treatment:—The patient should be restored to as perfect health as is consistent with the existing conditions of life. This alone will sometimes cure the difficulty. I have corrected many cases by the persistent use of small doses of strychnin, which corrects the impairment of the nerve filaments. I have given children the one-five-hundredth of a grain, several times a day with good results. In other cases, local irritation from hyperemia and consequent incontinence is satisfactorily cured by the use of belladonna. This agent strengthens the capillary circulation and equalizes the flow of the blood in the parts. In occasional cases it will be advantageous to give these two or three remedies alternately every two or three hours. In other cases, minute doses, both of belladonna and nux vomica may be given in conjunction. The use of belladonna and rhus aromatic will cure a certain class of cases. Rhus aromatic and thuja may be satisfactorily combined in a few cases of the incontinence of childhood. The latter remedy will assist also in the control of the difficulty in middle life and in old age. It has many strong advocates, but I have not succeeded with it as well as with some other remedies. It may be given in conjunction with strychnin, the latter in quite considerable doses in paralytic cases; occasionally the use of electricity in mild form will accomplish a cure. In irritable cases it is sometimes necessary to give a nerve sedative, and to relieve local engorgement by means of agents which will produce capillary contraction. For this purpose sodium bromide and ergot will be found beneficial.
In all cases the local irritation must be removed, and irritating conditions of the urine must be removed. Excess of acidity or alkalinity must be neutralized, and the urine must be rendered bland and non-irritating. Further careful examination must be made to discover any cause of reflex irritability, and this must be removed. Often surgical measures are necessary to accomplish this latter result.
