ENURESIS

Nocturnal enuresis, or bed-wetting, is a complex disorder with poorly understood

pathogenicity and pathophysiology. It affects children all over the
world:77,352-354 approximately 5-7 million children in the United States355 and
as many as 30% of school-age children in Italy.353
Enuresis is defined as inappropriate or involuntary voiding during the night
at an age when urinary control should be achieved.I? It is classified as primary
nocturnal enuresis (PNE) when the child has never been dry at night, or secondary
nocturnal enuresis (SNE) when wetting follows a dry period usually after an
identifiable stress."?
The majority or up to 85% of PNE is monosymptomatic in that the
enuresis is not accompanied by other voiding disorders or daytime incontinence.
77,352,356 Most children with primary monosymptomatic bedwetting
have either a large night-time urine production and a normal bladder capacity,
or a small bladder capacity with normal urine production.W
By age 8 years, 87-90% of children should have night-time dryness. Enuresis
improves with maturity, with a natural, spontaneous remission rate of 15% per
year of age. 77 It is possible that different factors may be predominant in different
age groups.358

m .....Jatrtc acupuncture
ETIOLOGYAND PATHOPHYSIOLOGY
Both the etiology and pathophysiology of enuresis are still not well understood.
There appears to be a wide spectrum of possible pathogenic factors for
enuresis: functional/psychological causes, delayed maturation of the central
nervous system, genetic predisposition, and infrequently, organic/anatomic
dysfunction.

Functional/Psychological
Many investigators consider PNE as a disorder with a strong functional
component.359-361 Psychological factors may affect as many as 95% of children
with enuresis.361 It is interesting to note that fear reactions have been
reported to be significantly higher in enuretic children.354,362 Enuresis has
been linked to night terror, nightmares, and sleepwalking.363,364 Most likely,
this disorder is a highly complex interaction between somatic and psychiatric
factors.36o

eNS
Nocturnal enuresis may be due to a maturational lag in the development of
the central nervous system. 77 A popular theory posits that there is low nocturnal
vasopressin secretion resulting in high nocturnal urine output, which
explains why enuretics respond to DDAVP, an exogenous vasopressin.
However, there may be a more complex, dual CNS developmental delay in
both the afferent and efferent limbs: the central nervous system fails to recognize
and respond to bladder fullness or contraction during sleep, and also
fails to suppress the micturition reflex arc during sleep.365 The pathology
does not appear to relate to sleep physiology, since the sleep cycle appears
normal and enuretic episodes have been found to occur in every sleep
stage.360 There may in fact be a close correlation between biological and psychological
factors, in that extreme CNS disorganization may result in psychological
symptoms.366

Genetic Predisposition
PNE has a strong hereditary component. 353,358,366 Many families seem to manifest
an autosomal dominant mode of inheritance.P'' At this time, molecular
genetics have identified numerous loci on more than 10 chromosomes. 360,367

Organic/Anatomic Dysfunction
Organic factors are uncommon causes of PNE.77 Anatomic anomalies include
epispadias, ectopic ureter, spinal cord lesion, or urethral ohstruction.368 It can

also he a feature of many conditions, including renal,369 neurological and

organic disease states.370
Common pediatric condldons 223

SECONDARY ENURESIS
SNE accounts for about one quarter of patients with bed-wetting.V! There is
significant association of psychiatric problems with SNE,360,371 both causally
and reactively following the enuresis.360 The organic conditions that feature
primary enuresis can also be the cause of secondary enuresis.370 Enuresis has
also been associated with behavioral disorders, such as ADHD.372-375 SNE has
also been reported with trauma such as car and motor cycle accidents, which
may be due to psychological trauma or organic head trauma.376 SNE has been
reported to be associated with upper airway obstruction, which is difficult to
explain in the Western paradigm.377

Treatment
Although the condition is considered benign and mostly self-limiting, treatment
is warranted because of adverse personal, family, and psychosocial effects of the
disorder.355,358,378 Nocturnal enuresis delays early autonomy and socialisation
due to decrease in self-esteem and self-confidence356 and fear of detection by
peers.378 The child may be at increased risk for emotional or even physical
abuse from family rnembers.V''
The conventional treatment modalities are still controversial. Since the vast
majority of PNE resolves spontaneously with time, treatment should carry minimal
or no risk. The moisture alarm is both safe and inexpensive and should be
the treatment of choice in most cases358 but is the least often prescribed.366
Medical treatment should be placed in a biopsychosocial framework, with medication
prescribed in conjunction with psychosocial interventions.361,379

CHINESE MEDICINE

CurrentAcupuncture Data
The current literature is supportive of acupuncture as a possible treatment
modality for the enuretic child.38o Worldwide reports give validation to
acupuncture efficacy in the treatment of enuresis.352.381-391 The reported success
rate is as high as 98.2%.392
Acupuncture has been found to be successful both in decreasing occurrence
of enuresis during treatment and in exerting a persistent, long-term effect after
treatment.352,385.386 Parents also report a decrease in sleep arousal thresh01d.
386 The therapeutic efficacy improves with combined treatment of DDAVP
and acupuncrure.P'? Although the precise mechanism of acupuncture is still
unknown, a multidisciplinary approach that included acupuncture demonstrated
on EEG that treatment normalized activities of the cerebral cortex,389 and an
Italian study and a Russian report showed that acupuncture treatment was
effective in suppressing uninhibited bladder contractions and decreased bladder
instability.390,391 For those children who are fearful of invasive acupuncture,
simple acumassage has also been demonstrated to be beneficial to the enuretic
child.393

22.. Pediatric acupuncture

Etiology and Pathophysiology

Although it is not possible to precisely correlate the Western diagnosis of enuresis
with TCM impressions, PNE can be explained in the acupuncture paradigm
as Kidney Yang and Kidney Essence deficiency, and SNE as Spleen and Lung Qi
deficiency, and Yin Deficiency.

Kidney Yang and Kidney Essence Deficiency-PNE

Kidney Yang and Essence encompass wide spheres of vital human functions,
among them including Kidney Yang's influence in retention of urine in the bladder;
and in production of marrow, the brain; Kidney Esssence correlates to
heredity and developmental influences.
Kidney Yang enables the Bladder to hold and store urine and warms the
Lower Energizer. Constitutional Kidney Yang deficiency results in a cold Lower
Energizer, so that Bladder cannot regulate and store water well. This inability to

hold urine is worst at night when Kidney Yang is at the lowest level during the
Yin part of the diurnal cycle. A characteristic of Kidney Yang deficiency enuresis
is the release of large amounts of usually clear urine during sleep. The child
and the sheets are soaked and the child may wake up from the sensation of wetness.
Along with nocturnal enuresis there may be other signs and symptoms of
Kidney Yang deficiency: low pitched voice, facial pallor, cold extremities.
Fearfulness and insecurity, the emotions that correspond with the Kidney, are
frequently associated with enuretic children. In these children, the tongue may
be pale, and the pulse slow, weak, and deep.
Kidney Yang deficiency results in insufficient production of marrow, the
brain in Chinese medicine, which correlates well to the various postulates of
CNS immaturity in Western medicine.
Part of Kidney Essence is pre-Heaven or ancestral, which represents hereditary
influences on an energetic level that may translate in biochemical terms as
chromosomal loci. Development and maturation of organs are also influenced
by Kidney Essence, so that anatomic anomalies and organ dysfunctions may
reflect Kidney Essence deficiency.
Developmentally, children are in the Water phase of development, so that
Kidney and Bladder, the water organs, are most vulnerable.
Kidney Yang deficiency can also explain enuresis reported in Western
literature that is associated with trauma or surgery: the "shock" to the
system induces a transient Kidney Yang deficiency that manifests as enuresis.

Treatment
Restrict fluid at and after dinner to decrease urine production
Diet: avoid energetically Cold foods; avoid excess salt; increase Warming
foods
Keep warm, especially keep the abdomen warm, advise mothers not to dress
young children with abdomen partially exposed
KI-3 tonifies both Kidney Yin and Kidney Yang
KI-6, CV-4, SP-6 tonifies Kidney Yin/Essence
KI-7, BL-23 tonifies Kidney Yang
Common pediatric conditions 225

Use the Five-Element four-point protocol to disperse Cold from the Kidney,
and tonify both the Kidney Yin and Yang:
- Disperse Kidney Cold: tonify KI-2, HT-8; sedate KI-IO
- Tonify Kidney: tonify KI-7, LU-8; sedate KI-3, SP-3
- CV-6 to tonify Lower Energizer.

TCM and SNE

Spleen and Lung Qi Deficiency
In Chinese medicine, secondary enuresis that characteristically occurs after a .
period of dryness correlates to the presence of Spleen and Lung Qi deficiency.
These deficiencies often occur due to poor recuperation after previous illnesses,
due to the presence of other illnesses or stress that weaken the digestive and respiratory
systems. The Spleen and Lung regulate the body's water and expel
excess. Weak Spleen Qi cannot properly carry out the transformation and
transportation of fluids. Whereas a healthy Spleen prefers dryness, a weak
Spleen retains water. Weak Lung Qi cannot adequately carry out the functions
of governing the Qi of the body and regulating body fluid in the Upper
Energizer, which in turn interferes with proper water flow down to the Bladder.
Nocturnal enuresis ensues. Therefore, TCM explains well the Lung and Kidney
relationship that seems baffling to Western medicine.
Unlike PNE with Kidney Yang deficiency that typically manifests with copious
urine, the enuresis associated with Spleen and Lung deficiency is due to inadequate
regulation of fluid with inappropriate water retention, so that this type of
bed-wetting characteristically would be of very small volume. Any illness or
stress that diverts Qi away from the Lower Energizer would result in SNE: stress
from school work, excess playing of computer games, emotional crises such as
parental divorce or death of a close family member, could all divert Qi toward
the Upper Energizer where it is needed the most. Possible associated symptoms
may be facial pallor, poor appetite, lack of thirst, weak muscles, digestive and

respiratory symptoms. The tongue is pale and the pulse is thin, deep and slow.

Treatment
Avoid excessive sweet or spicy foods; also avoid Phlegm-producing, and Cold
foods
Change in lifestyle to provide plenty of rest and diversification of activities
Calming exercises
Tonify Spleen:
- Two points: tonify SP-2; sedate SP-l
- Four points: tonify SP-2, HT-8; sedate SP-l, LR-l
Tonify Lung:
- Two points: tonify LU-9; sedate LU-lO
- Four points: tonify LU-9, SP-3; sedate LU-lO, HT-8
Moxa CV-8 to tonify Middle Energizer
CV-17 to tonify Upper Energizer.

Yin Deficiency Enuresis

Numerous conditions can lead to secondary Yin deficiency enuresis: all chronic illnesses
can eventually lead to Yin deficiency; lingering pathogenic Heat that has not
226 Pediatric acupunctUre

been appropriately expelled with Heat illnesses continue to exhaust Yin; excess
consumption of energetically Hot foods, greasy and fried foods. Yin deficiency
often manifests as Yang excess syndromes. The most common one in the enuretic
child is Yang excess. This can be well explained by the Five-Element
Developmental Theory: the child has strong Wood vulnerabilities either because of
being in the Wood phase of development or because of having strong Wood tendencies
in the Water phase. The heavy sleep that is characteristic of the child can be
explained by Ethereal Soul, Hun. The Ethereal Soul resides in Liver Yin, which is
constitutionally deficient in children. Hun leaves the body during sleep, and
returns upon awakening. When there is Liver Yin deficiency, the Ethereal Soul
would wander more at night, resulting in the child being difficult to awaken ..

Treatment
Avoid excessive intake of sour or bitter foods; avoid taking medication
unnecessarily, especially over-the-counter pills
Teach the child Qigong calming exercises; parents can massage Yintang point
for calming
KI-6, SP-6, CV-4 to tonify Yin
BL-18 to tonify Liver Yin
BL-47 Hunmen, "Gate of the Ethereal Soul" to calm the Hun
LR-3 to subdue Liver Yang, and nourish Liver Yin
LR-13 to regulate Liver Qi, to harmonize Liver and Spleen 38,39,242- 245,
252,270,272,273,274