Nocturnal Enuresis (Bedwetting)

  • Nocturnal enuresis or bedwetting is intermittent night-time urinary incontinence.  
  • Relatively common in children.  
  • 5-10% of children at seven year of age may continue to have bedwetting.  
  • Primary – when child has never been dry for at least six months.  
  • Secondary – when child initially achieved dry period of more than six months and started wetting again.
  • Bed wetting has significant secondary stressful, emotional and social consequences for the child and their caregivers.
  • Boys are known to have more chances of bedwetting than girls at any age.  
  • Hereditary factors are known to influence this condition.  History of bedwetting in either or both parents significantly increase the chance of having bedwetting in child.

Causes of bedwetting

  • High arousal threshold – child does not wake up when bladder is full.  
  • Imbalance between night time urine output and bladder capacity.  
  • Alteration in chronobiology of micturition in which circadian clock in kidney, brain and bladder is disturbed.
  • Symptoms such as habitual snoring, apneas, excessive sweating at night and mouth breathing leads to secondary bedwetting.  

Diagnostic tests

  • The diagnosis is mainly made by history-taking.  
  • Complete two to three days fluid intake diary and voiding diary is recorded to rule out any urinary tract pathology and excessive water drinking habit.  
  • Night time urine output can be recorded by measuring wet diaper weight.  Excessive night time urine production is calculated measuring diaper weight used night time.  
  • Urine examination for infection.  
  • Physical check up by doctor.  
  • Ultrasound and urine flow test (uroflowmetry) if prior surgery was done or suspecting urinary tract pathology.  
  • Checkup by ENT doctor if sleep disorder breathing present.      

Treatment

  • Many children stop bedwetting with age; so wait and watch can be observed for age upto five –six year age.  
  • Normal and regular drinking habits with bowel and bladder habits are encouraged.  
  • Wetting alarm system – use of a device that is activated by getting wet. The goal is that the child wakes up by the alarm, action is to repeat the awakening and therefore change the high arousal to a low arousal threshold. High success rates are noted with this therapy.  
  • Medical therapy – Used in children with high urine output at night. Desmopressin tablet or sublingual tablet is used. Imipramine is another commonly used drug.  

Ten tips to improve urological health

  1. Consume fluid intake of 2.5-3.0 litre/day in regular interval to maintain constant hydration.
  2. Drink cranberry juice to help prevent UTIs.
  3. Maintain weight in healthy range.
  4. Avoid smoking.
  5. Limit the intake of salt and caffeinated products.
  6. Empty your bladder before going to bed.
  7. Limit fluid intake 2-3 hours prior to sleep at night.
  8. Avoid prolonged holding of urine.
  9. Regular Kegal exercises to strengthen the pelvic floor muscles.
  10. Front -to- back direction cleaning of genitals in women to prevent UTIs.

Absent testes in scrotum or empty scrotum (Undescended Testes/ Cryptorchidism)

  • Absence of either testis from its normal position in scrotum is called undescended testis.
  • It is most common congenital abnormality found in male genitalia.
Undescended testis (Cryptorchidism)

Classification

  • Congenital – Undescended testis present since birth
  • Acquired – testis which has migrated up that has been previously noted to be present in scrotum
  • Location wise – Inguinal (groin), Intra-abdominal, Ectopic (not in path of normal descent)

Causes of undescended testis

  • Developmental disorder of the gonads by either environment or genetic factors.
  • Maternal smoking
  • Premature birth

Effects of undescended testes

  • Undescended testis of one side can affect the function of normally descended other testis also.
  • Impaired semen parameters
  • Impaired fertility
  • Hypogonadism (testosterone deficiency)
  • Tumors in the undescended testis

Treatment

  • Surgical treatment is mainstay of management.
  • In infants and early age, surgical correction with bringing testis down into scrotum is done.
  • In adults with intra-abdominal testis, and having normal opposite testis, orchiectomy is usually considered. However if both testes are intra-abdominal, surgical correction to bring testes down into scrotum is considered.

Hydrocele – common cause of scrotal swelling

  • Hydrocele is the accumulation of fluid inside the covering of the testis called tunica vaginalis and cause the swelling of scrotum.
  • Hydrocele is present in newborn and disappear at around one year of age.
  • Persistance of fluid inside the scrotum or development at later adult age due to various reasons cause this disease.

Symptoms

  • Painless scrotal swelling
  • Discomfort or heaviness in scrotum
  • Redness or severe pain if fluid inside gets infected

Causes

  • In children, the hydrocele may be due to the peristance of fluid normally present at birth.
  • In adult age, hydrocele is due to various reasons such as testis infection (orchitis), epididymis infection (epididymitis), testis tumor, trauma, after varicocele surgery or other testis surgery.

What are the risks of hydrocele

  • Hydrocele fluid can get infected.
  • Hydrocele can hamper sperm production or the quality of sperms.
  • Swelling can get increased to lead impairement of quality of life or pain in it.

Diagnosis

  • Diagnosis of hydrocele is mainly done by doctor after physical examination.
  • Ultrasound of the scrotum region is done to look for any infection inside or to look for underlying cause lead to the formation of hydrocele.
  • Blood or urine test may be required to rule out infection of other causes of hydrocele.

Treatment

  • In newborns, hydrocele may resolve of its own.
  • Opinion of the doctor for conservative management is required to rule out any underlying testicular cause.
  • In adult age or in baby boys where hydrocele fail to resolve and causing symptoms to the patient, doctor look for any cause that leading to fluid formation. If no such cause found, surgical evacuation of fluid along with removal of fluid forming covering of the testis so as to prevent re-accumulation of fluid. 

Know about symptoms, diagnosis and treatment of kidney stones/calculi

  • Kidney stones or otherwise called renal calculi or nephrolithiasis are deposits of combination of various minerals inside the kidney.
  • The constituents of these stones are normally excreted into the urine.
  • Excess concentration of these minerals in the urine leads its crystallization and further stone formation.
  • Various reasons of stone formation include less water intake, dietary factors, excessive calcium level in blood due to Vitamin D deficiency or hormonal imbalance, excess body weight, urinary infections, certain drugs intake etc.
  • Kidney stones are often diagnosed with ultrasound or CT scan test and its management depends on various factors.

Symptoms

  • Dull aching Flank or back pain
  • Radiating pain to lower abdomen
  • Pain while passing urine
  • Colicky pain (pain that comes and go in intervals or waves)
  • Blood in urine
  • Passing cloudy urine
  • Fever
  • Nausea/vomiting

Diagnosis

  • Combination of various tests are done.
  • Blood tests – Tests to look for elevated calcium or uric acid, Vitamin D deficiency, Parathyroid hormone.
  • Urine tests- Urine tests are done to look for active infection. Recurrent infections lead to stone formation. Also 24 hour urine test is done to find the cause of recurrent stone formation.
  • Imaging – Imaging in form of Ultrasound, IVP or CT scan is often used to look for the exact number of stones, its size, location inside kidney, hardness of stone. It also helps the doctor in deciding the treatment to be undertaken for stones.

Treatment

  • Small kidney stones do not require any surgical treatment and kept on surveillance. General mesures such as plenty of oral fluids, painkillers and alkalizers are often used.
  • Large kidney stones are treated with one or other surgical therapy. These include-
  • ESWL – Extracorporeal shock wave therapy uses various kind of shock waves to break the stone by vibration. Doctor chooses which stone to be treated with this therapy. Patient is placed on machine and stone is focused on machine and sound waves then break the stone. Procedure last for about 30-40 min. Small broken stones then passes in urine in following days.
ESWL set up
  • PCNL (Per – cutaneous Nephro-lithotomy) – In this surgery used for large stone, small endoscope is passed through the the cut (<1cm) given in back of the patient. Small instruments passes through this endoscope such as laser and other to break the stone and then these small broken pieces are removed with other instrument. Surgeon may also stent at the end of surgery.  
PCNL procedure
  • RIRS (Retrograde Intra Renal Surgery) – This surgery involves passing the small endoscope (ureteroscope) is passed through the urethra up into the kidney and subsequently the stone is broken with laser machine. This laser breaks and convert the stone into sand particles which gets flushed in urine in following days. Doctor may place a stent in this surgery.  
RIRS procedure
  • Parathyroid gland/adenoma removal – Sometimes the cause of recurrent stone formation lies in parathyroid gland which becomes overactive. It is situated in the front of neck behind thyroid gland. This involves either complete removal of parathyroid gland removal or removal of a small part of it. 

Prevention of stone disease

  • Drink plenty of oral fluids to maintain urine output of about 1.5-2.0 litre/day.
  • Take low salt diet.
  • Cut down the animal protein intake.
  • Cut down oxalate rich diet such as rhubarb, beets, okra, spinach, sweet potatoes, nuts, tea, chocolate and soy products. Calcium rich diet can be safely taken and not avoided.
  • Recurrent calcium stone formers may be prescribed by doctor with certain medicines such as thiazide or potassium citrate.
  • Uric acid stone formers may be given with Allopurinol or oral alkalizer is given.
  • Infection stone former may be treated with antibiotic to keep the urine free of infection.