Before any of us were old
enough to show off hip dance moves or rep some swag, nothing defined our level
of social "coolness" like a good 'ole sleepover. Have one or
two of those a month, and you were the mack daddy of your elementary school.
Sleepovers were the staple of our favorite childhood weekends. Unless, of course, you were like me and were one of the 5-7 million children who suffer from nocturnal enuresis, or in
children's terms, the big, bad B...bedwetting. Those of us in BL618
have been discussing the urinary system and I was curious as to the causation
of this childhood friendship destroyer (note: true friends don't care). Turns out, there are a lot of
causes, some better understood than others: genetics, liquid consumption before
bedtime, and high levels of caffeine consumption. Yes, the "no
drinks after 8:00 PM" rule worked a bit at reducing the damage done, but
the issue still remained nonetheless. This suggests there might be more
to the cause than thought.
Pediatric urologists have
found lower-than-normal levels of ADH in enuretic children, something not
surprising considering ADH's role in fluid retention. However, another
correlation has been found: constipation. Shockingly, a positive
relationship found between occult megarectum, or rectal distension, and
nocturnal enuresis dates back to 1986 when Sean O’Reagan made the discovery.
However, as discussed in a
2012 article in the Journal of Urology, occult megarectum remains to this day
as an unrecognized and undiagnosed cause of bedwetting. The reason for this phenomenon appears to
stem back to the basic question of, “Well, what is constipation in the first
place?” When O’Regan published the
correlation, he defined such as rectal enlargement (found via rectal
examination and use of anorectal manometry); however, many of the children
O’Reagan diagnosed with occult megarectum had normal, consistent bowel
movements.
Fast forward to today and
many urologists, pediatricians, and psychologists do not rely upon the use of
anorectal manomety to determine constipation.
Instead, they simply rely upon asking parents and/or the children if bowel
movements occur less frequently than one movement per day and if bowel
movements are hard to pass. That’s
it. Certainly these factors are in fact
symptoms of constipation, and if found, they certainly can be treated in order
to help manage bedwetting. But here is
where the problem lies: occult megarectum is a functional form of constipation; no typical constipation-like
symptoms are associated. As O’Reagan
himself found, children with occult megarectum have remarkably normal bowel
movements.
The take-home message? We have stemmed away from the use of rectal
radiography and instead rely solely upon patients’ encounters with symptoms in
order to diagnose constipation. In doing
so, occult megarectum, a viable cause of nocturnal enuresis, is completely
overlooked. So go ahead, mom, take away
that glass of water before bedtime.
Chances are, it’s not going to help.
Cited Source:
Hodges, S., & Anthony, E. (2011). Occult Megarectum—A Commonly Unrecognized Cause of Enuresis. Urology, 79(2), 421-424. doi:February 2012
Interesting article. I think this could shed some light on one of the causes of nocturnal enuresis, and how interesting that occult megarectum is typically asymptomatic. They admit in the study they aren't entirely sure if treatment (with laxatives) necessarily treated the symptoms of enuresis due to the retrospective nature of the study, but nonetheless, I think this is an example of physicians needing to think "outside the box" on a more regular basis to provide more accurate diagnosis and treatments.
ReplyDeleteI also think this brings up the question of why we don't use the equipment and technology when they are available to diagnose conditions such as occult megarectum. Yes, it can be expensive to do those tests and much more invasive than simply asking questions, but if there is suspicion of the condition at all, the equipment should be strongly considered. It's not always enough to ask questions and trust that the answers are correct. If a child is still wetting the bed after avoiding drinks at night, and we know that occult megarectum is a possible cause of nocturnal enuresis, why wouldn't we use rectal radiography and try to find the cause? Like Aaron said, I think physicians need to think of alternative options in order to diagnose the condition as quickly and accurately as possible.
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