ABSTRACT: Nocturnal enuresis or night time urinary incontinence, commonly called bedwetting or sleep wetting, is involuntary urination while asleep after the age at which bladder control usually occurs. Bedwetting is a common childhood urologic complaint and one of the most common pediatric health issues. Enuresis is notoriously difficult to treat and is frequently related to psychological factors. The emotional impact of enuresis on a child and family is considerable. Children with enuresis are commonly punished and are at risk for emotional and physical abuse. Numerous studies of children with enuresis report feelings of embarrassment and anxiety, loss of self-esteem, and effects on self-perception, interpersonal relationships, quality of life, and school performance. The condition can be successfully treated with homoeopathic medicines but require a long term follow – up. The present article focuses on management of this medical condition with our medicines.

1. Nocturnal enuresis in children
Dr. Smita Brahmachari,Dr. Smita Brahmachari,
M.D. (Repertory) from N.I.H., Kolkata.M.D. (Repertory) from N.I.H., Kolkata.
S.M.O., Dept. of AYUSH,S.M.O., Dept. of AYUSH,
Govt. of NCT Delhi.Govt. of NCT Delhi.

2. NocturNal eNuresisNocturNal eNuresis
(bedwettiNg)(bedwettiNg)
• Involuntary discharge of urine at night by children old enough to
be expected to have bladder control
– Persists beyond the age of 5 years
– Total bladder control never achieved or relapsed
– Incidence of more than twice weekly
– Continent during the day
– Types of nocturnal enuresis (NE)
• PNE (primary) when bladder control has never been
attained
• SNE (secondary) previously dry for a at least six months.
Adapted from Canadian Paediatric Society. Management
of primary nocturnal enuresis. Paediatrics & Child Health
2005;10(10): 611-4.

3. NE: It’s NOT the Child’s FaultNE: It’s NOT the Child’s Fault
• Bedwetting is a medical condition, a behavioural and
psychological disorder in children.
• It is mostly caused by the lack of naturally occurring
messenger that reduces urine production to a non-bedwetter’s
volume at night
– Leads to an overproduction of urine, often more than a
child’s small bladder can hold
• As the children grow, most will eventually stop wetting the
bed.

4. classificatioNclassificatioN
• Primary (PNE): bedwetting persisting
from early age due to delayed
maturation of voiding mechanism.
• Secondary (SNE): wets bed after
remaining dry for variable period with a
underlying cause……UTI; DM; Renal
abnormality and failure must be ruled
out.

5. iNcideNceiNcideNce
• Most of the children start having
bladder control after the age of 4 yrs.
• About 15 – 20% of children wet bed
after the age of 5 years and about 5%
of 10-year old children continue
bedwetting.
• Occurs more commonly in boys aged
4 – 11 years than girls.

6. Patients’ PersPectivePatients’ PersPective
• A survey reported that 68% of parents said that their child’s paediatrician
had never addressed bedwetting during a routine visit, regardless of the
child’s age1
• Most parents believe that NE is not a physical condition and are
uncomfortable initiating a dialogue with physicians1
• Most parents (80%) believe that children wet the bed because they are
stressed or worried, or in some cases simply out of laziness.
• Inadequate treatment of NE has psychological ramifications including
impaired personal, social and emotional behaviour2,3
Adapted from :
Dunlop et al.,Clinical Paediatrics 2005;44:297-303 1
.
Fergusson et al. Pediatrics 1986; 78: 8842
Butler et al. BJU intern 2002; Vol 89; issue 3;295-73

7. etiOLOGYetiOLOGY
• Familial predisposition is commonly seen.
• Emotional and psycho-social factors: stressful home life…conflict
between parents, starting school, a new sibling, or moving to a new
home; habitually ignoring the urge to urinate and poor daytime toilet
habits. Emotional and behavioural issues are not causative, but
influence treatment outcome.
• Physical causes are rare, but may include: UTI, Seizure disorder,
Diabetes Insipidus, Diabetes Mellitus, ADHD, Down’s syndrome,
Chronic renal disease, Chronic constipation…full bowels put
pressure on the bladder; deep sleep and arousal disorder, lower
spinal cord lesions and congenital malformations of genitourinary
tract.
• Diminished functional bladder capacity.
• Slow development of bladder control.

8. esOteric vieWesOteric vieW
• The bladder is the reservoir in which all the substances excreted by the kidneys as urine await
their opportunity to leave the body. The pressure caused by the sheer bulk of urine eventually
forces us to release it, and this leads to a feeling of relief.
• The urge to urinate is also linked conspicuously to certain types of situation in which we are
being put under psychological pressure…..whether they be examinations, therapy or
whatever….involving anticipatory fears or stress – related conditions. The pressure which is
initially experienced psychologically is shifted down into the bladder and here experienced in
the form of actual physical pressure. Pressure always demands of us that we let go and relax.
If this fails to occur a the psychological level, we are obliged to allow it to happen physically
via bladder.
• If a child spends all day under strong pressures (whether from parents or from school) that it
can neither let go nor express its own needs, nocturnal bed wetting solves several problems at
once: it provides the chance to let go in response to the pressures being experienced, and at the
same time it offers the child the opportunity to condemn its all-powerful parents to utter
helplessness. By way of this particular symptom, in fact, the child is able to return in safely
disguised form all the pressure that it is put under during the day.
Adapted from: Dethlefson and Dahlke. The Healing Power of Illness. Ist ed. Reprinted.
Brisbane: Element Books Limited, 1994.

9. Impact of Enuresis on Children
• Psycho-social impact
– Low self-esteem
– Shame, embarrassment
– Guilt
• Parents become intolerant of the bedwetting
• Interferes with age appropriate peer activities

10. ManaGeMent chart

11. Signs and symptoms
The history should address the following:
• Hydration history
• Daytime voiding pattern
• Number and timing of episodes of bedwetting
• Sleep history (should include the times the child goes to bed, falls asleep, and awakens in the
morning. Parents should be asked to make a subjective assessment of the child’s depth of
sleep. The presence of restless sleep, snoring, and the type and frequency of nocturnal arousals
(e.g., nightmares, sleep terrors, or sleepwalking) should be determined. Whether the child has
experienced periods of dryness and the circumstances of these episodes should also be
determined.)
• Nutrition history (Many children with enuresis do not drink appreciable amounts of liquids
during the school day, arrive home from school thirsty, and drink most of their daily fluids in
the 4 or 5 hours before bedtime, a pattern that favors nocturnal production of urine.)
• Behavior, personality and emotional status of the child (Basic and revealing information
includes whether the child has experienced teasing by family or friends or has self-restricted
participation in school, sleepovers, or trips.).
• If the history is not clear, request that the family record fluid intake, daytime voiding, and
episodes of bedwetting for at least a 2-week period.

12. TreaTmenT schedule
• Follow up: long term treatment is usually
required.
• Assess after every 10- 15 days to evaluate the
improvement.
• Symptoms better (episodes of bedwetting
decrease in frequency and dry nights)….stop
treatment and follow for few days.
• Symptoms worsening….episodes of
bedwetting become more frequent. Needs
referral.

13. reFerralreFerral
• Symptoms worsening:
– Episodes of bedwetting become more frequent.
– Rashes on the bottom and genital area.
– Burning sensation or pain when urinating.
– Disturbed sleep.
• Reassess the case and manage under the
pediatrician/ psychiatrist.

14. General manaGemenTGeneral manaGemenT
Advice to the parents
• Remove guilt feeling in the child.
• Support and reassure the child.
• Do not punish or blame the child.
• Reduce child’s evening fluid intake especially before sleep.
• Child should pass urine before bedtime.
• Set a goal for the child of getting up at night to use the toilet.
• Reward child for dry nights.
• Advice daytime rehearsal aimed at increasing the holding time of bladder. When
the child feels the urge to urinate, he or she should go to bed and pretend he or she
is sleeping. He or she should then wait a few minutes and get out of bed to use the
toilet.
• Conditioning devices, which cause an alarm to sound as soon as the voided urine
touches the bed sheet. It is important to check the child’s hearing before starting
treatment. The alarm causes inhibition of further micturition and the child awakens.
If properly used, it is an effective method of therapy.

15. HOMOEOPATHIC
APPROACH
Through out the whole urinary tract, we find the latent symptoms
of all the miasms. Psora and sycosis take an active part in the
production of disease in these organ. It is the tubercular state
which causes nocturnal enuresis in children, as soon as they fall
asleep. Urine is copious, they wet everything. These cases can
only be cured by getting at the pseudo-psoric diathesis and by
selecting medicine which covers the pseudo-psoric base, like
Calcarea carb., Calcarea phos., Lycopodium, Sarsaparilla etc. In
tubercular diathesis, especially in the nervous or neurotic
patients, urine is pale, colorless and copious with little solid
deposit. The urine of this type of patients is often offensive and
easily decomposed, the odor is musty, like old hay, or it is foul
smelling, even carrion like.

16. HOMOEOPATHIC MEDICINESHOMOEOPATHIC MEDICINES
SYMPTOMS INDICATED MEDICINES
Awakens with urging; chronic; at night,
during 1st
sleep, child is roused with difficulty
KREOSOTE
After bladder seemed to be emptied HELONIAS
At night, in children, in latter part of night,
even if they have urinated during night and
drank no water
CHLORALUM
At night floods the bed 5-6 times FERRUM and PHOSPHORIC ACID
Before midnight BRYONIA and PULSATILLA
After midnight PULSATILLA and RUTA
From midnight till morning PLANTAGO
First sleep CAUSTICUM and SEPIA

17. HOMOEOPATHIC MEDICINESHOMOEOPATHIC MEDICINES
SYMPTOMS INDICATED MEDICINES
In obstinate cases, during full moon, with
H/O of eczema
PSORINUM
From worms URANIUM NITRICUM
With strong smelling urine MEDORRHINUM
A stout light – haired boy ARG NIT
In boys of light complexion SEPIA
In boys RHUS TOX AND SILICEA
Adolescence LAC CAN
In fat children, red face, sweats easily,
catches cold easily
CALCAREA CARB
Pale, lean children with large abdomen, who
love sugar and highly seasoned food and
abhor to be washed
SULPHUR

18. HOMOEOPATHIC MEDICINESHOMOEOPATHIC MEDICINES
SYMPTOMS INDICATED MEDICINES
In children with acidity of stomach NATRUM PHOS
With general debility CALC PHOS
In children who grow too rapidly PHOSPHORUS
In anaemic children FERRUM IOD
In weakly children CHINA
In nervous children GELSEMIUM
In little girls PULSATILLA
From infancy to a girl at the age of 16 NUX VOM
In children where urine is scanty, acrid, loaded
with uric acid and its deposits
PLANTAGO
After being accused of theft HYOSCYAMUS
When there is no tangible cause except a habit EQUISETUM HYMENALE
After fright STRAMONIUM
After injuries of head SILICEA

19. HOMOEOPATHIC MEDICINESHOMOEOPATHIC MEDICINES
The above medicines are listed
in Synthesis Repertory and
Repertory of Hering’s Guiding
symptoms of our Materia
Medica under the Rubric
Bladder – Urination – Involuntary.

20. THANK YOU