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Introduction

Shayyamutra or Enuresis is a condition involving age group above 5yrs and any sex. The prevalence at age 5 years is 7 percent for males and 3 percent for females. At age 10 years it is 3 percent for males and 2 percent for females, and at age 18 years it is 1percent for males and extremely rare for females3. General population studies carried out in India show that 2.5 percent in the age group of 0 to 10 years have enuresis4. The etiology of Nocturnal Enuresis is not well understood. Some of the etiological factors are as follows: a) Familial b) Inadequate / inappropriate toilet training c)Emotional stress d) Smaller maximum bladder capacities e) Children who are heavy sleepers (Atinidra) f) Some studies suggest that enuretic children had lower nocturnal ADH secretion rate as compared to normal subjects3.

Case Report

A 7yrs female came to OPD by her parents with the complaints of involuntary bed-wetting at night for at least three nights per week since 3-4 years. Her presenting complaint was bed wetting at night since childhood. She had taken treatment from different physicians for the same purpose for at least two years. She was free from any physical and mental illness despite some degree of shyness due to nocturnal enuresis. Her birth history was normal with full term normal vaginal delivery, birth weight of 2.7kg, no NICU admission, passage of urine within 24hrs and no congenital anomaly identified at the time of birth. Past history was unremarkable.

Clinical Examination

General Examination

1. Nadi- 96/min
2. Mala-Prakrut
3. Mutra- Prakrut, bed wetting at night
4. Jivha- Prakrut
5. Shabda - Prakrut
6. Sparsh - Prakrut
7. Drik - Prakrut
8. Akruti- Madhyama

Systemic examination                          

All Srotasa examination found to be normal except Annavaha, Manovaha and MutravahaSrotasa.

Laboratory Investigations

She was examined for CBC, Urine routine and microscopic, Ultrasonography of abdomen and pelvis. All investigations were normal.

Patient Consent: A written consent was obtained for publication of the case study.

Assessment Criteria for Diagnosis

The Diagnostic and Statistical Manual of Mental Disorders, 5thedition (DSM-5) defines the criteria for enuresis to be1

1. Voiding of urine at least two occurrences per week for at least three months.
2. The child must be at least 5yrs of age (chronologically or developmentally).
3. The child’s urinary incontinence must not be due exclusively to the direct physiological effects of a substance or a medical condition.

Intervention and Follow –ups

Discussion

According to Ayurveda, production of mutra is ultimately related with ‘Ahara’. Mutra and Purisha both are Mala or Kittabhaga (waste products) of Ahara. SamanaVayu, Pachaka Pitta, Purishdhara Kala have role in Mutranirman and Pakwashaya is said to be seat of urine formation5.Ayurveda formulation namely Vidangarishtam6 is used

in Udarkrimi and Prameha (Bhaishajya Ratnavali). The logical reference with etiological factors of Shayyamutra was used for treating patient with Vidangarishtam. It will act as a Mutra-sangrahaniya as well as anti-helmenthic.Ashwagandha is known for its calming effect on brain and is used as a good drug for Nidrajanana. Here, we are using the drug to relieve anxiety, stress and depression due to the lack of self-esteem. Ashwagandha is a good rasayana for Rasa, Mamsa and Shukra Dhatus. In this case, it will help to strengthen weak musculature and tone of urinary bladder which will ultimately increase the urine holding capacity of bladder.Amalaki  is another good Rasayana drug which possesses all above properties of Ashwagandha with additional benefit of Agnideepan, Aampachan, Anuloman and most important Pachan and Shoshan of Kleda which helps to reduce the quantity of urine produced.These all drugs collectively are very useful in management of Nocturnal Enuresis (Shayyamutra) with effects like Krimihar, Rasayana, Mutra-sangrahaniya, Agnideepan, Aampachan, Anuloman, Pachak and Shoshak of Kleda. They are also effective in increasing urinary bladder tone and reducing stress of the patient.As enuresis is a psychosomatic disorder, motivational therapy and behavioural modification plays a significant role in curing of enuresis. She was advised to drink up to 80% of required water before evening time and 20% after that7. Parents were advised to randomly awake her to void8 and give praise for dry nights9.

Conclusion

The Ayurvedic formulations used in present case study are very useful in treating Shayyamutra (Nocturnal Enuresis) and can be used in further cases having similar presentation.