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Enuresis Adalah Keadaan Tidak Dapat Menahan Keluarnya Air Kencing Yang

Enuresis Adalah Keadaan Tidak Dapat Menahan Keluarnya Air Kencing Yang

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Enuresis
adalah keadaan tidak dapat menahan keluarnya air kencing yang bila terjadi ketika tidur malam hari disebut
enuresis nocturnal
. Hal ini masih dianggap normal bila terjadi pada balita dan apabila masih dialami anak usia di atas 5tahun perlu mendapat perhatian khusus. Kasus ini tejadi hanya sekitar 1 diantara 100 anak yang tetap ngompol setelahusia 15 tahun. Pada sebagian besar kasus ngompol dapat sembuh sendiri sampai anak mencapai usia 10-15 tahun.Enuresis sendiri dikelompokkan menjadi
enuresis primer
, dimana anak yang sejak lahir hingga usia 5 atau 6 tahunmasih tetap ngompol tetapi bila anak pernah ‘kering’ sedikitnya 6 bulan dan mendadak ngompol lagi makadikelompokkan pada
enuresis sekunder.
Umumnya enuresis primer lebih banyak terjadi. Berdasarkan hasilpenelitian enuresis jenis ini dapat terjadi karena adanya faktor keturunan, apabila kedua orang tua memiliki riwayatngompol maka 77% anaknya akan mengalami hal serupa. Bila hanya salah satu orang tua ada riwayat enuresis makaakan terjadi 44% pada anakkya dan bila kedua orang tua sama sekali tidak ada riwayat, kemungkinan terjadi enuresispada anaknya hanya sekitar 15 %.
Apakah harus selalu keturunan?E
nuresis primer disebabkan :
Faktor genetik
Keterlambatan matangnya fungsi susunan syaraf pusat. Normalnya bila kandung kemih sudah penuh maka dikirimpesan ke otak untuk mengeluarkan kencing dan balasan dari otak ialah agar kandung kencing dapat menahan sampaisi anak siap ke toilet tetapi pada keadaan keterlambatan matangnya fungsi susunan syaraf pusat maka proses initidak terjadi sehingga anak tidak dapat menahan kencing dan ngompol.
Gangguan tidur. Tidur yang sangat dalam (deep sleep) akan menyebabkan anak tidak terbangun pada saat kandungkencing sudah penuh.
Hormon anti diuretik kurang. Hormon ini membuat produksi air kencing dimalam hari berkurang tapi bila hormonkurang maka air kencing diproduksi terlalu banyak yang menyebabkan anak jadi ngompol.
Kelainan anatomi, misalnya kandung kencing yang kecil.
E
nuresis sekunder disebabkan :
Stres kejiwaan: pelecehanseksual, mendapat adik baru, kematian dalam keluarga.
Kondisi fisik terganggu: infeksi saluran kencing, diabetes, sembelit bahkan alergi. Jadi ngompol itu tidak selalu disebabkan oleh faktor keturunan tetapi oleh banyak faktor lain.
Treatment
Enuresis ini dapat diatasi tanpa obat dan dengan obat untuk anak berusia diatas 7 tahun yang tidak berhasil diatasitanpa obat. Prinsip pengobatan yaitu membuat kandung kencing dapat menahan lebih banyak kencing dan membantuginjal untuk mengurangi produksi kencing. Pengobatan dengan obat-obatan tentulah memiliki efek samping.
Obat-obat yang dipakai yaitu,
dessmopressin
merupakan sintetik analog arginin vasopresin, bekerja mengurangiproduksi air kencing dimalam hari dan mengurangi tekanan dalam kandung kencing (intravesikular). Efek sampingyang sering adalah iritasi hidung bila obat diberikan melalui semprotan hidung dan sakit kepala bahkan menjadiagresif dan mimpi buruk, tapi hilang dengan pemberhentian obat. Dessmopresin diberikan sebelum tidur.Obat lain yang dapat yaitu
imipramin
yang bersifat antikolinergik tapi mekanismenya belum dimengerti. Ada teoriyang mengatakan obat ini menurunkan kontraktilitas kandung kencing sehingga kemampuan pengisian kandungkencing dan kapasitanya diperbesar. Imipramin mempunyai efek yang buruk terhadap jantung.
Cara mengatasi tanpa obat :
-
terapi motivasi (motivational therapy)
dengan memberikan hadiah pada anak bila tidak ngompol, hal ini dilihat dari catatan harian ngompol anak, biladalam 3-6 bulan tidak berhasil maka dicari cara lain.
-
terapi alarm (behaviour modification)
alarm diletakkan dekat alat kelamin anak, bila anak mulai ngompol maka alarm berbunyi sehingga anak terbangundan menahan kencingnya dan selanjutnya orang tua membantu anak meneruskan buang air kecil di toilet. Cara inidapat dikombinasikan dengan terapi motivasi. Perubahan positif akan terlihat sekitar 2 minggu atau beberapabulan. Cara ini memiliki keberhasilan 50 % hingga 70%
-
latihan menahan keluarnya air kencing
(bledder training exercise)
cara ini dilakukan pada anak yang memiliki kandung kencing yang kecil
-
terapi kejiwaan
(physiotherapy),
terapi diet,terapi hipnotis
(hypnotherapy)
belum banyak dilakukan pada penanganan enuresis primer. Terapi diet yaitumembatasi makanan yang memiliki efek terhadap episode enuresis seperti yang mengandung coklat, soda, kafein.
M
engatasi anak ngompol bukanlah suatu hal yang mudah. Hal ini diperlukan kerja sama antara orang tua, anakbahkan dokter. Sebagai orang tua kita harus menyingkapi masalah ini dengan penuh kesabaran dan pengertiankepada anak dengan tidak memojokkan atau mengolok-oloknya.Anak justru harus diberi motivasi dan kasih sayang agar terbentuk kepercayaan diri sehingga mereka dapatmengatasi masalah ngompol pada dirinya. Karena ngompol yang berlarut-larut akan mengganggu kehidupan sosialdan psikologis yang akan menghambat pertumbuhan dan perkembangan anak itu sendiri. (TSH-08)Sumber : -http://familydoctor.org/  -http://wrm-indonesia.org/- http://www.aafp.org/afp/20030401/1499.html
 
Kliegman: Nelson Textbook of Pediatrics, 18th ed.
Copyright © 2007 Saunders, An Imprint of Elsevier   Elimination Disorders 22.3Enuresis(Bed-wetting) 
 Enuresis
is defined as the voluntary or involuntary repeated discharge of urine into clothes or bed after a developmental age when bladder controlshould be established. Most children with a mental age of 5 yr have obtained bladder control during the day and night. The diagnosis of enuresisis made when urine is voided twice a week for at least 3 consecutive months or when clinically significant distress occurs in areas of the child'slife as a result of the wetting (see also Chapters 5 and 543 ). The prevalence of enuresisat age 5 yr is 7% in males and 3% in females. At age 10yr, it is 3% in males and 2% in females, and at age 18 yr, it is 1% in males and extremely rare in females. Evidence suggests different rates of  bed-wetting by ethnicity and culture.ETIOLOGY.Twin studies show a marked familial pattern, with documented concordance rates of 68% in monozygotic twins and 36% in dizygotic twins.Linkage studies have implicated multiple chromosomes, particularly chromosome 22, with varying patterns of transmission. Beyond geneticfactors, the cause of enuresislikely involves a complex web of physiologic and perhaps psychologic factors. Children with nocturnalenuresis may hyposecrete arginine vasopressin (AVP) and also may be less responsive to the lower urine osmolality associated with fluid loading. Tubular sodium-potassium exchange in the kidney, partly influenced by AVP secretion, is associated with nocturnalenuresis. AVP receptor function inthe tubule may be a key factor in the pathophysiology of the disorder. There may also be associations between sleep andenuresis. Althoughenuresismay occur at any stage of sleep, there is some support for a relationship between sleep architecture, diminished capacity to be arousedfrom sleep, and abnormal bladder function in patients withenuresis.The relationship betweenenuresisand psychologic functioning is complex. Older enuretic children have a higher incidence of psychopathologythan non-enuretic children, although no single disorder accounts for the group differences. Children with attention-deficit/hyperactivity disorder may be more likely to be enuretic than age-matched comparison children. Delayed maturation of bladder function may account for many cases of  primaryenuresis. Secondaryenuresisis associated with life stress and/or traumatic experiences, particularly in children who were late in first achieving nighttime dryness. The pediatrician should inquire about stressful events with all children who present with secondaryenuresis.Differing rates by culture suggest that child-rearing practices may also play an etiologic role.CLINICAL MANIFESTATIONS.Bed-wetting may be divided into the
persistent (primary) type,
in which the child has never been dry at night, and the
regressive (secondary)type,
in which a child who has been continent for 6 mo or longer then begins to wet the bed. Primaryenuresisrepresents approximately 90% of all cases. Further classification involves
nocturnalenuresis
(voiding urine at night), and
diurnalenuresis
(voiding urine while awake). Primarynocturnalenuresisis the most common. Diurnalenuresisis more common in girls and rarely occurs after the age of 9 yr. The most common cause of daytimeenuresisin the preschool or school-aged child is waiting until the last minute to void urine
(micturition deferral).
In addition tomicturition deferral, etiologic factors to consider in diurnalenuresisinclude urinary tract infection, chemical urethritis, associated constipation,diabetes, and giggle or stress incontinence. Children with both nocturnal and diurnalenuresis, especially in the presence of voiding difficulties,are more likely to have abnormalities of the urinary tract, and ultrasonography or uroflowmetry is indicated. Otherwise, anatomic abnormalitiesare rarely associated with either nocturnal or diurnalenuresisand invasive or costly studies are contraindicated. Urinalysis and urine culture willrule out both infectious causes and the elevated urine osmolality associated with diabetes.TREATMENT.Management of the child withenuresisshould begin with behavioral treatment. General guidelines for a 1st-line approach would be as follows:
1.
It is important to enlist the cooperation of the child to deal with the problem. Rewarding the child for being dry at night is a useful step.The child or parent can chart dry nights, and with each dry night, a small reward can be given. More substantial rewards should be givenfor increasing success. 
2.
The child should void before retiring. 
3.
Waking the child repeatedly to take him or her to the bathroom is not generally useful and may further engender or aggravate anger in thechild or parents. Enuretic children may be more difficult to awaken than age-matched peers. However, using an alarm clock to wake thechild once 2–3 hr after he or she falls asleep is indicated. 
4.
Punishment or humiliation of the child by parents or others should be strongly discouraged.Consistent dry bed training with positive reinforcement has a success rate of 85% or more. The use of conditioning devices (an alarm that ringswhen the child wets a special sheet) is often helpful in training the child to improve bladder capacity and avoidenuresis. In effect, these devices provide a consistent mode for behavioral retraining. Consent of the child should be a prerequisite for the use of such a device. Bell-and-pad alarmsystems have a success rate of approximately 75% across many studies, with relapse rates that are lower than those with pharmacologicintervention. These devices are simple and cost-effective.Psychotherapy for traumatized children with secondaryenuresismay be indicated, especially when behavioral training has failed and traumaticexperiences temporally associated with the onset of enuresisare noted. Once the child has successfully learned to stop wetting, overlearning(drinking just before bedtime) may be a useful adjunctive treatment; increasing bladder capacity over time guards against relapse.
Pharmacotherapy
for enuresisis 2nd-line treatment and should be reserved for cases in which behavioral treatment is unsuccessful. Comparisonof the bell-and-pad system vs imipramine and desmopressin acetate (DDAVP) shows lower relapse rates for the bell-and-pad system, althoughthe initial response rates are similar. Imipramine (Tofranil) at starting doses of 10–25 mg in children >5 yr and maximum doses of 75 mg inadolescents before bedtime has a success rate of approximately 50%, with a relapse rate of 30% or more even after 6 mo of treatment. Imipramineis associated with cardiac conduction disturbances and may be lethal in overdose. DDAVP can be administered orally or intranasally at bedtime.The fast action of DDAVP suggests a role for special occasions (such as overnight visits) when rapid control of enuresisis desired.Unfortunately, the relapse rate on discontinuation of DDAVP is very high, and 1 mo of treatment typically costs as much as a bell-and-padsystem (which can be used for several months, as necessary). DDAVP is also associated with rare side effects of hyponatremia and water intoxication, with resulting seizures.Email to Colleague Print Version 

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