Osteopathic treatment for Enuresis Nocturna in early childhood

Definition of Enuresis Nocturna:Wetting in sleep at least two nights a month at the age of 5 without daytime symtoms or urinary tract infections”

Bed wetting in children is the most common urological symptom: 15-20% of 5-year-olds suffer from this condition and it is very often observed in children over the age of 5 years.

The urinary system has many roles such as cleansing the blood and ridding the body of metabolic waste products, regulation of PH, regulation of blood pressure and more. The final filtration of the blood by kidneys called urine. The kidneys filter about 200 litres of filtrate every day but the urine, the final waste content is about 2 litres per day. The capacity of the bladder can be from 1 – up to 2 litres. The minimum amount of 150-500ml is needed to trigger the micturition reflex or Bladder Stretch Reflex. The stretch receptors in the bladder wall transmit nerve impulse to the sacral region of the spinal cord to generate a spinal reflex. The parasympathetic neural outflow causes contraction of the detrusor muscle and relaxation of the involuntary internal urethral sphincter. At the same time, the spinal cord inhibits somatic motor neurons, resulting in the relaxation of the skeletal muscle of the external urethral shincter. The micturition reflex is active in infants and disappears with maturity. Children learn to override the reflex by controlling the external shincter by will. This reflex may be preserved after spinal cord injuries that results in paraplegia or quadriplegia. Voluntary micurition requires an intact spinal cord and functional pudendal nerve, arising from the sacral plexus which is the main nerve of the perineum. This nerve can be damaged, most commonly by childbirth or injuries.

The urine passes through the ureter and is propelled by waves of peristalsis into the bladder. The quality and quantity of the urine depends on how much water is intake, exercise, outside temperature, sweating and other factors.

The bladder is a hollow organ of smooth muscle and connective tussues. It belongs to the lower urinary tract. The bladder collects urine from both ureters. It is located in females anterior to the uterus, posterior to the pubic bone and anterior to the rectum. In males between the pubic bone and rectum and is supported by the prostate. The bladder is partially retro peritoneal which could be important for osteopathic treatment. The bladder is connected to the surrounding area by the periheral layer or connective tussues – fascia.

The function of the bladder is to store urine until it is excreted through the urethra by contracting the bladder muscle, the Detrusor. The urethra transports urine from the bladder to the outside of the body. The uretra is the only urologic organ that has an anatomical difference between males and females. In female urethra length is about 4 cm, and in males about 20 cm. To excrete the urine – Micturition – many voluntary and involuntary actions are involved controlled by the autonomous and motoric nervous system and anatomical structures. Failure of nervous control leads to a loss of control of urination/micturition, called incontinence. Voiding is regulated by an invoulunary autonomic nervous system, controlled internal urinary sphincter and voluntary skeletal muscle that forms the external urinary sphincter which relies on conciously preventing relaxation of it. This process is organized by urethral reflexes known collectively as the “Guarding reflex”. The mechanisms that are involved in the storage and periodic elimination of urine undergo marked changes during prenatal and postnatal development. In the fetus, before the nervous system has matured, urine is eliminated from the bladder by non-neural mechanism. At later stage of development voiding is regulated by primitive reflex pathways that are organized i the spinal cord. As the human CNS matures postnatally, reflex voiding is eventually brought under the modulating influence of higher brain centres. I adults injury or disease of the nervous system can lead to the reemergency of primitive reflexes. Karl-Erik Andersson and Anders Arner (American Physiological Society) have described the Spinal Galants Reflex: It is the reflex that hinders bladder and bowel movement control. It can be triggered by light pressue on the lower bakck that causes uncontrollable spinal movement, which could mean that even your child’s bed sheets could activate urination, causing bedwetting long after your child is aready potty trained….

Why would a normal, healthy child retain some primitive reflexes? When there are inferferences in the nervous system, usually due to vertebral or cranial subluxations as the child develops, it interferes with the intergration of the primitive reflexes. Other factors include things such as falls, traumas, lack of tummy time and delayed or skipped creeping or crawling.

Osteopathic treatment approaches for paediatric enuresis are very important and can suport the system to restore and adapt and to realighn the tissues and the nervous system.