ENURESISNocturnal enuresis, or bed-wetting, is a complex disorder with poorly understoodpathogenicity and pathophysiology. It affects children all over theworld:77,352-354 approximately 5-7 million children in the United States355 andas many as 30% of school-age children in Italy.353Enuresis is defined as inappropriate or involuntary voiding during the nightat an age when urinary control should be achieved.I? It is classified as primarynocturnal enuresis (PNE) when the child has never been dry at night, or secondarynocturnal enuresis (SNE) when wetting follows a dry period usually after anidentifiable stress."?The majority or up to 85% of PNE is monosymptomatic in that theenuresis is not accompanied by other voiding disorders or daytime incontinence.77,352,356 Most children with primary monosymptomatic bedwettinghave either a large night-time urine production and a normal bladder capacity,or a small bladder capacity with normal urine production.WBy age 8 years, 87-90% of children should have night-time dryness. Enuresisimproves with maturity, with a natural, spontaneous remission rate of 15% peryear of age. 77 It is possible that different factors may be predominant in differentage groups.358

m .....Jatrtc acupunctureETIOLOGYAND PATHOPHYSIOLOGYBoth the etiology and pathophysiology of enuresis are still not well understood.There appears to be a wide spectrum of possible pathogenic factors forenuresis: functional/psychological causes, delayed maturation of the centralnervous system, genetic predisposition, and infrequently, organic/anatomicdysfunction.Functional/PsychologicalMany investigators consider PNE as a disorder with a strong functionalcomponent.359-361 Psychological factors may affect as many as 95% of childrenwith enuresis.361 It is interesting to note that fear reactions have beenreported to be significantly higher in enuretic children.354,362 Enuresis hasbeen linked to night terror, nightmares, and sleepwalking.363,364 Most likely,this disorder is a highly complex interaction between somatic and psychiatricfactors.36o

eNSNocturnal enuresis may be due to a maturational lag in the development ofthe central nervous system. 77 A popular theory posits that there is low nocturnalvasopressin secretion resulting in high nocturnal urine output, whichexplains why enuretics respond to DDAVP, an exogenous vasopressin.However, there may be a more complex, dual CNS developmental delay inboth the afferent and efferent limbs: the central nervous system fails to recognizeand respond to bladder fullness or contraction during sleep, and alsofails to suppress the micturition reflex arc during sleep.365 The pathologydoes not appear to relate to sleep physiology, since the sleep cycle appearsnormal and enuretic episodes have been found to occur in every sleepstage.360 There may in fact be a close correlation between biological and psychologicalfactors, in that extreme CNS disorganization may result in psychologicalsymptoms.366Genetic PredispositionPNE has a strong hereditary component. 353,358,366 Many families seem to manifestan autosomal dominant mode of inheritance.P'' At this time, moleculargenetics have identified numerous loci on more than 10 chromosomes. 360,367Organic/Anatomic DysfunctionOrganic factors are uncommon causes of PNE.77 Anatomic anomalies includeepispadias, ectopic ureter, spinal cord lesion, or urethral ohstruction.368 It can

also he a feature of many conditions, including renal,369 neurological andorganic disease states.370Common pediatric condldons 223SECONDARY ENURESISSNE accounts for about one quarter of patients with bed-wetting.V! There issignificant association of psychiatric problems with SNE,360,371 both causallyand reactively following the enuresis.360 The organic conditions that featureprimary enuresis can also be the cause of secondary enuresis.370 Enuresis hasalso been associated with behavioral disorders, such as ADHD.372-375 SNE hasalso been reported with trauma such as car and motor cycle accidents, whichmay be due to psychological trauma or organic head trauma.376 SNE has beenreported to be associated with upper airway obstruction, which is difficult toexplain in the Western paradigm.377TreatmentAlthough the condition is considered benign and mostly self-limiting, treatmentis warranted because of adverse personal, family, and psychosocial effects of thedisorder.355,358,378 Nocturnal enuresis delays early autonomy and socialisationdue to decrease in self-esteem and self-confidence356 and fear of detection bypeers.378 The child may be at increased risk for emotional or even physicalabuse from family rnembers.V''The conventional treatment modalities are still controversial. Since the vastmajority of PNE resolves spontaneously with time, treatment should carry minimalor no risk. The moisture alarm is both safe and inexpensive and should bethe treatment of choice in most cases358 but is the least often prescribed.366Medical treatment should be placed in a biopsychosocial framework, with medicationprescribed in conjunction with psychosocial interventions.361,379CHINESE MEDICINECurrentAcupuncture DataThe current literature is supportive of acupuncture as a possible treatmentmodality for the enuretic child.38o Worldwide reports give validation toacupuncture efficacy in the treatment of enuresis.352.381-391 The reported successrate is as high as 98.2%.392Acupuncture has been found to be successful both in decreasing occurrenceof enuresis during treatment and in exerting a persistent, long-term effect aftertreatment.352,385.386 Parents also report a decrease in sleep arousal thresh01d.386 The therapeutic efficacy improves with combined treatment of DDAVPand acupuncrure.P'? Although the precise mechanism of acupuncture is stillunknown, a multidisciplinary approach that included acupuncture demonstratedon EEG that treatment normalized activities of the cerebral cortex,389 and anItalian study and a Russian report showed that acupuncture treatment waseffective in suppressing uninhibited bladder contractions and decreased bladderinstability.390,391 For those children who are fearful of invasive acupuncture,simple acumassage has also been demonstrated to be beneficial to the enureticchild.39322.. Pediatric acupunctureEtiology and PathophysiologyAlthough it is not possible to precisely correlate the Western diagnosis of enuresiswith TCM impressions, PNE can be explained in the acupuncture paradigmas Kidney Yang and Kidney Essence deficiency, and SNE as Spleen and Lung Qideficiency, and Yin Deficiency.Kidney Yang and Kidney Essence Deficiency-PNEKidney 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 toheredity and developmental influences.Kidney Yang enables the Bladder to hold and store urine and warms theLower Energizer. Constitutional Kidney Yang deficiency results in a cold LowerEnergizer, 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 theYin part of the diurnal cycle. A characteristic of Kidney Yang deficiency enuresisis the release of large amounts of usually clear urine during sleep. The childand 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 ofKidney Yang deficiency: low pitched voice, facial pallor, cold extremities.Fearfulness and insecurity, the emotions that correspond with the Kidney, arefrequently associated with enuretic children. In these children, the tongue maybe pale, and the pulse slow, weak, and deep.Kidney Yang deficiency results in insufficient production of marrow, thebrain in Chinese medicine, which correlates well to the various postulates ofCNS immaturity in Western medicine.Part of Kidney Essence is pre-Heaven or ancestral, which represents hereditaryinfluences on an energetic level that may translate in biochemical terms aschromosomal loci. Development and maturation of organs are also influencedby Kidney Essence, so that anatomic anomalies and organ dysfunctions mayreflect Kidney Essence deficiency.Developmentally, children are in the Water phase of development, so thatKidney and Bladder, the water organs, are most vulnerable.Kidney Yang deficiency can also explain enuresis reported in Westernliterature that is associated with trauma or surgery: the "shock" to thesystem 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 Warmingfoods• Keep warm, especially keep the abdomen warm, advise mothers not to dressyoung 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 YangCommon 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 SNESpleen and Lung Qi DeficiencyIn 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 respiratorysystems. The Spleen and Lung regulate the body's water and expelexcess. Weak Spleen Qi cannot properly carry out the transformation andtransportation of fluids. Whereas a healthy Spleen prefers dryness, a weakSpleen retains water. Weak Lung Qi cannot adequately carry out the functionsof governing the Qi of the body and regulating body fluid in the UpperEnergizer, which in turn interferes with proper water flow down to the Bladder.Nocturnal enuresis ensues. Therefore, TCM explains well the Lung and Kidneyrelationship that seems baffling to Western medicine.Unlike PNE with Kidney Yang deficiency that typically manifests with copiousurine, the enuresis associated with Spleen and Lung deficiency is due to inadequateregulation of fluid with inappropriate water retention, so that this type ofbed-wetting characteristically would be of very small volume. Any illness orstress that diverts Qi away from the Lower Energizer would result in SNE: stressfrom school work, excess playing of computer games, emotional crises such asparental divorce or death of a close family member, could all divert Qi towardthe Upper Energizer where it is needed the most. Possible associated symptoms

may be facial pallor, poor appetite, lack of thirst, weak muscles, digestive andrespiratory 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 Coldfoods• 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 EnuresisNumerous conditions can lead to secondary Yin deficiency enuresis: all chronic illnessescan eventually lead to Yin deficiency; lingering pathogenic Heat that has not226 Pediatric acupunctUrebeen appropriately expelled with Heat illnesses continue to exhaust Yin; excessconsumption of energetically Hot foods, greasy and fried foods. Yin deficiencyoften manifests as Yang excess syndromes. The most common one in the enureticchild is Yang excess. This can be well explained by the Five-ElementDevelopmental Theory: the child has strong Wood vulnerabilities either because ofbeing in the Wood phase of development or because of having strong Wood tendenciesin the Water phase. The heavy sleep that is characteristic of the child can beexplained by Ethereal Soul, Hun. The Ethereal Soul resides in Liver Yin, which isconstitutionally deficient in children. Hun leaves the body during sleep, andreturns upon awakening. When there is Liver Yin deficiency, the Ethereal Soulwould wander more at night, resulting in the child being difficult to awaken ..Treatment• Avoid excessive intake of sour or bitter foods; avoid taking medicationunnecessarily, especially over-the-counter pills• Teach the child Qigong calming exercises; parents can massage Yintang pointfor 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