Pathogenesis of nocturnal urinary incontinence in children

June 22, 2018 18:30 | Disease Treatment
Endocrine-vegetative theories reflect the attempts of a number of authors to explain the occurrence of nocturnal urinary incontinence as a violation of the function of endocrine glands. It is believed that with this disease against the background of plurigandular insufficiency, the activity of the insular pancreas apparatus is mainly disrupted.

VE Treukhov found that bedwetting can occur with normal( 51% of the examined), decreased( 36%) or elevated( 13%) adrenal function. The author believed that with pronounced changes in the excretion of 17-ketosteroids, patients with urinary incontinence, along with other therapeutic agents, should be prescribed appropriate hormonal drugs. He examined the functional disorder of the adrenal cortex and testicles with bedwetting as a consequence of a general violation of correlation in the body with the active participation of the central nervous system in this process.

Content:
Urinary incontinence in children
Urinary incontinence in women

Pathogenesis
Causes of development
Psychoneurological examination
Instrumental diagnosis
Treatment and prevention
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Indeed, in some cases, the cause of cortical dysregulation may be the endocrine changes that occur whenthe action of extreme stimuli. Effects can be different, ranging from local body reactions( specific manifestations) to the emergence of a number of general reactions of a stereotyped nature, that is, independent of the qualitative characteristics of the stimuli. To the above, the doctrine of stress is closely adjoined, in which the main position is that with strong external influences( neuropsychic, physical, infectious, pharmacological), the release of hormones in the anterior lobe of the pituitary gland and, subsequently, hormones of the adrenal cortex. Further development of the theory of stress was the research of L. Kh. Garkavi and co-authors, who in the experiment established that physiological adaptation reactions develop in response to the action of various stimuli - weak( training reaction) and medium strength( activation reaction).These reactions occur during the normal life of the body and are the nonspecific basis of physiological processes, while excessive stimuli represent a nonspecific basis for the appearance of pathological processes, that is, when stress occurs, pathological adaptation occurs. This is due to damage and energy costs. On the contrary, with the activation reaction in the central nervous system, moderate physiological excitation predominates, in the endocrine system, an increase in the secretion of mineralocorticoids or normal secretion of glucocorticoids. The activity of the sexual glands, the thymic-lymphatic system increases, relative lymphocytosis appears, the blood coagulation system normalizes or there is a shift towards hypocoagulation. The activation reaction is effective for protecting against excessive loads, contributing to the normalization of both increased and low blood pressure, useful for the prevention of inflammatory processes.

In most people, the disappearance of urinary incontinence by the time of puberty is associated with an increase in the function of endocrine glands, in particular sex glands. However, this disease often disappears before puberty occurs. Sometimes endocrinopathy can be observed with bedwetting as a concomitant symptom. It was suggested that bedwetting is associated with a hypothalamic disorder. In support of this, the symptoms of vegetative changes observed in patients with this pathology, such as marble skin color, acrocyanosis, hyperhidrosis, stop hypothermia, diffuse pyloromotor reflex, were cited.

BI Laskov found that in persons who, after treatment of nocturnal incontinence, chronaxy values ​​were normal in the region of innervation of II-III sacral segments of the spinal cord, the result of treatment was persistent, and in patients with high chronaxy indexes relapses of the disease. He concluded that the majority of patients with urinary incontinence had a functional condition of the cerebral cortex, and some of them also had inductive induction links between the cortex and the subcortex.

Comparing 125 children with urinary incontinence at the age of 6-9 years with children of the control group, Lovibond in 1964 found that 85% of parents of children from both groups were regularly planted on pots. However, in the group of healthy children, the planting was started earlier. It is believed that bedwetting occurs as a result of belated or incomplete development of arbitrary regulation of urination. Sometimes a pathological conditioned reflex can join this( the presence of a constantly wet bed leads to the fact that the child has temporary reflex connections, which leads to the fact that the whole environment of sleep is a conditioned stimulus causing urination).So, one of the reasons for the occurrence of nocturnal urinary incontinence can be the absence or incorrect hygienic education of the child. If the upbringing is correct, but there are reasons that violate the normal conditioned reflex activity( pathological impulses from the affected organs, chronic intoxication, etc.), then there are two possible variants of the onset of this disease. First, when the pathological state of the affected organ is expressed, the conditioned reflex that appears in patients in a state of wakefulness may not occur in their sleep state. In this case, only unconditioned reflex connections still act. With smaller disorders, the spread of the conditioned reflex occurs during sleep, although with delay, its effect is weak and unstable. If the dream is deep, then the conditioned reflex is not realized, unconditioned reflex mechanisms come into play and the patient urinates under him. With a shallow sleep, a conditioned reflex awakening occurs. Such an unstable state can be fixed for a long time. With age, the presence of nocturnal urinary incontinence acquires the character of a neurotic factor, which leads to other disorders of the basic nervous processes that cause the appearance of pseudo-conditioned reflex connections. Therefore, with proper education in some children, bedwetting stops only to 4-6 and even to 8-10 years.

Various functional disorders that occur in the cerebral cortex lead to the development of nocturnal incontinence in children with a weak type of higher nervous activity. The rapid exhaustibility of cortical cells, the weakness of the excitatory process, the difficult formation of conditioned reflexes also predispose to this disease. Due to the reduced excitability of the cerebral cortex during sleep, its regulatory effect on the underlying parts of the nervous system decreases, resulting in increased excitability of the spinal centers. Various adverse factors can lead to a violation of higher nervous activity and in a child with a strong type of it. The emergence of imperative urges or involuntary urination may be associated with fright, excitement, on the basis of which then bedwetting can then develop. In this case, the increased flow of impulses coming from the cerebral cortex extends to its lower parts and spinal cord, causing an involuntary contraction of the muscular tissue of the internal organs( in particular, the bladder) and the inhibition of voluntary movements. Subsequently, despite the fact that the influence of the psychogenic factor is eliminated, the formed focus of increased excitation in the subcortical nodes continues to exist. In this case, the impulses coming from the bladder that has spontaneously contracted during sleep will be perceived only by subcortical structures, as a result of which involuntary urination will occur. Consequently, to superstrong stimuli should be attributed, in the first place, mental trauma. It is necessary to take into account the fact that the overstrain of higher nervous activity and the occurrence of nocturnal urinary incontinence can result both from a momentary strong emotional impact( fright) and less pronounced long-term psychogenic effects( intimidation, punishment, etc.).

We believe that the disruption of the activity of conditioned reflex mechanisms controlling the functional state of the bladder during sleep depends not only on changes in the dynamic equilibrium between the basic nervous processes in the central nervous system. If we consider the system of regulation of urination as a motor analyzer, then it has a sensitive part that senses irritations. Its origin is in the interoceptors of the bladder. It sequentially closes on the peripheral( automatic), spinal( reflex), subcortical( complex reflex) and cortical( conditionally reflex) levels with its motor( executive) part. It must be taken into account that the centers at all levels are paired, innervating their own side;However, the cortical areas receive afferent impulses that go mainly from the opposite side( most of the efferent, control signals arrive on the same side).Consequently, disorders of the regulation of the act of urination can occur at any level of the motor analyzer, which is responsible for this function. They can be congenital( developmental abnormalities) or acquired, anatomical or functional, as well as anatomical-functional. As a result, this affects the function of the cortical part of the motor analysor( sensitive, motor and frontal parts).

Considering the above, one can agree with the opinion of those authors who consider the motor disorders of the bladder as the basis for the development of bedwetting.

More on the pathogenesis:
Deep sleep as the cause of bedwetting
Secondary bed wetting in children
SA Shirokova and ET Magomedova were examined by skin electromyography methods of 52 patients with urinary incontinence aged 4 to 14years;of them, 12 had involuntary bowel movement, and 10 had constipation. Three groups of patients were identified. In the 1st included 27 people - they had a decrease in the rhythmic activity of potential fasciculations in the muscles of the legs and muscles - extensors of the back. Defined hypotonia and hypotrophy of the muscles of the legs and gluteal muscles. The second group included 15 children with an over-segment type of changes in muscle electrogenesis, characterized by increased synergistic activity and a decrease in the activity of voluntary contraction. Neurologically, spasticity of knee and achilles reflexes, signs of cervical peripheral insufficiency were revealed. The third group included 10 children, who had signs of a combination of anteropathy and cortico-spinal cord types of disturbed muscle electrogenesis. They have gluteus in the buttock muscles( in 6 children) and leg muscles( in 3), hypotonia of the leg muscles( in 6), diffuse hypotonia of the gluteus muscles( in 4), tension of the extensor of the trunk( in 4).The authors believe that one of the reasons for bedwetting is the natal conditioned violation of the functional state of the spinal center of urination at the level of the segments of the spinal cord. Depending on the nature of the changes, the violation of the nervous regulation of the muscle that pushes out urine and its blocking apparatus can occur along a peripheral, spastic and mixed type. In this case, pathogenetic treatment in each individual case will be different. In another work, E. Magomedova points out that the presence of cerebral insufficiency in children can contribute to the occurrence of nocturnal incontinence. However, an important factor in the development of urinary incontinence is the inborn inferiority of the cervical and lumbar spinal cord thickening. In these cases, the secondary weakness of the sphincters of the bladder and rectum develops, the effort of the child's will only to some extent manages to control the reduction of sphincters.

In electromyographic examination of 238 patients with urinary incontinence performed using catheter electrodes inserted into the urethra, GF Kolesnikov and co-authors observed shifts in the electroactivity( effective value of the voltage of the biopotentials) of the bladder, the area of ​​the sphincter of the urethra and the internal sphincter. Patients were divided into 4 groups. In patients of the 1st group, a decrease in the level of biopotentials of all the examined neuromuscular structures was noted;in the 2 nd group - an increase in the level of electroactivity of the muscle that pushes urine;in the third - the asymmetry of electroactivity of the right and left zones of innervation of the sphincter of the urethra;in the fourth, there are individual characteristics characteristic of other groups.

It can be concluded that one of the causes of urinary incontinence is a functional failure of the regulation of the neuromuscular structures of the bladder and its obstructive device that perform the act of urination. It can be insignificant( only the asymmetry of the electroactivity of the right and left half of the sphincter of the urethra is noted), then bedwetting is rarely seen( 1-2 times per month).In other cases, there is a sharp decrease in the contractile activity of the bladder and sphincters;involuntary urination occurs every night, often combined with encopresis. However, it is also possible to increase the tone of the bladder, due to its enhanced reflex excitability;along with night urinary incontinence, patients have a private imperative urge to urinate during waking hours. These data are confirmed by the results of combined electromyographic studies and measurements of pressure in the bladder. Some authors see the cause of night incontinence in the atony of sphincters or in hypertension of the muscle of the bladder. Our research has shown that these changes are much more difficult. Thus, in the patients of the 1st group the following combinations of changes are distinguished: a sharp decrease in the tone of the bladder and sphincters;normal tone of the bladder and reduced tone of the sphincter;decreased tone of the sphincter of the urethra. In patients of the 2nd group, the tone of the sphincter of the urethra was normal or decreased, the tone of the internal sphincter corresponded to the norm: under normal or decreased tone of the sphincter of the urethra, there was an increase in the tone of the internal sphincter;It is characteristic that against a background of moderately increased tone of both sphincters, the tone of the bladder was sharply increased. An asymmetry of the tone of the right and left sides of the sphincter of the urethra was detected. It turned out that with the retention of the fluid, the contractile activity of the sphincter of the urethra( determined by cystometry with electromyography) does not reach those values ​​that are observed in the norm.

The distribution of patients according to the indicated traits into 4 groups is in some measure consistent with the point of view of this issue by I. M. Prorudominsky and co-authors who identified 3 forms of urinary incontinence: the 1st - cortical-subcortical form - is observed more often than others and occurs due tomental trauma, inattentive care for children, improper education, unfavorable environmental conditions, craniocerebral trauma and intoxication, general asthenia, hereditary burden;2 nd - spinal - occurs as a result of traumatic injuries and diseases of the spinal cord of various genesis;3rd - neuroreceptor - develops due to irritation of nerve endings of the bladder, sphincters, glans penis, genital and pelvic nerves, HI resulting from trauma, inflammation, intoxication and other causes. Neurological symptoms and electromyographic data obtained by us in the examination of patients of the 1 st group suggest that they have a violation of reflex regulation at the level of the spinal cord( as evidenced by a decrease in the tone of the bladder and sphincters), that is, bedwetting that emergedin these patients, can be attributed to the spinal form of the disease. In patients of the 2nd group, the inferiority of reflex regulation manifests itself mainly at the level of the cerebral cortex and subcortical region, and therefore its inhibitory effect on the underlying parts of the nervous system decreases and the tone of the bladder rises, which is characteristic of the cortical-subcortical form of the disease. Patients of groups 3 and 4 have a combined disorder of reflex regulation at different levels.

Thus, neurophysiological data indicate that the pathogenesis of nocturnal urinary incontinence is more complex than previously thought. Function disorders can occur at different levels of the nervous system, beginning with the bladder and its blocking apparatus( interoceptors, neuromuscular endings, etc.) and ending with the cerebral cortex;they can be isolated or multiple. The results of electrophysiological studies indicate the possibility of conducting an objective diagnosis of the functional state of the bladder and its constipation apparatus not only with bedwetting but also with other neurogenic disorders of urination;they provide a basis for developing a methodology for the pathogenetic treatment of these diseases. Along with this, a problem arose associated with the development of new methods for studying the functional state of subcortical structures, as well as cerebral cortex in patients with urinary incontinence.

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