Homoeopathy is said to be effective in many diseases and the data and philosophy of homoeopathy give great value to the drug treatment in cases of nocturnal enuresis.

The term enuresis means "to void urine". Nocturnal enuresis, also called bedwetting, is involuntary urination while asleep after the age at which bladder control usually begins. Bedwetting in children can result in emotional stress. At least 90% of enuretic children have primary nocturnal enuresis i.c., they wet only at night during sleep and have never had a sustained period of dryness. Diurnal enuresis (daytime wetting) is much less common, as is secondary enuresis which develops after a child has had a sustained period of bladder control. More than 85% of children attain complete diurnal and nocturnal control of bladder by 6 years of age. The remaining 15% gain continence at approximately 15% per year, such that by adolescence only 0.5%-1% children have enuresis. Primary nocturnal enuresis is common. The incidence is three times higher in boys than in girls. Most children with enuresis become continent by adolescence or earlier. The family history in such cases frequently reveals other members, especially fathers, who have had prolonged nighttime bedwetting problems. Although the cause of primary nocturnal enuresis is not established, it appears to be related to maturational delay of sleep and arousal mechanisms or to delay in development of increased bladder capacity. Etiologically, it is generally viewed as a developmental disorder or maturational lag that children will outgrow. The most common complication of enuresis is low self-esteem in response to criticism from caregivers and embarrassment if peers are aware of the problem. Older children with enuresis may be reluctant to attend sleep-overs and be self-conscious with peers. The first line of treatment is usually non-pharmacological, comprising motivational therapy and use of alarm devices. Pharmacotherapy is to be done if enuresis persists despite the institution of alarm and regular voiding habits. Imipramine, Desmopresin acetate is the preferred contemporary medication for treating children with enuresis in modern medicine. However, the common side effects include headache, nausea, upset stomach or stomach pain, diarrhea or flushing of the face (warmth, redness and tingly feeling) but in homoeopathy there is enough scope for treating nocturnal enuresis. Night time continence is a normal developmental process which a child attains as early as up to 6 years of age. Therefore, no treatment is required to be started before the age of 6 years. Daytime bladder control & coordination occurs by 4 years. As of now, genetic inheritance is known to be a strong factor along with family history of diabetes mellitus, renal diseases in both parents where spontaneous resolution either comes very late in life or even ended with therapy for diabetes mellitus type II. It is largely asymptomatic. Therefore, is a potential cause of not yielding to any therapeutic measure along with homoeopathy. In Homoeopathic parlance it can be classified as a "One sided disease" (Aphorism 173 stated- "The only diseases that seem to have but few symptoms belong chiefly to the class of chronic diseases). There are various other causes involved in Bed-wetting including emotional set back like- abandoned, fear psychosis in children etc.

Hypothesis for present Work:

Null Hypothesis: Improvement in cases of nocturnal enuresis with homoeopathic medicine Equisetum hyemale 3C potency is because of sampling variation and may be because of psychotherapy. The result is not statistically significant. Alternative Hypothesis: Improvement in cases of nocturnal enuresis with homoeopathic medicine Equisetum hyemale 3C potency is medicinal. The result is statistically significant. Research Question arising out of Hypothesis

1. What is the role of psychotherapy in children with nocturnal enuresis?

2. To investigate the effect of Equisetum hyemale in 3C potency in relieving & lessening down the frequency of enuresis.

Out come

At the end of study, I had seen that Equisetum hyemale 3C can effectively be proved as a standalone specific remedy in Nocturnal Enuresis.

Types Of Enuresis

1. Primary enuresis: When the symptom has always existed and the child has not been dried for a period longer than 6 months.

2. Secondary enuresis: When there has been a symptom-free interval of 6 months or years and then begins to wet the bed.

Aetiology

Psychological: >95%, Organic: UTI, Constipation, Polyuria, e.g., IDDM, Diabetes insipidus, poly-uric renal failure, Neurological, e.g. spina bifida, Renal structural abnormality, e. g. ectopic ureter. The etiology of nocturnal enuresis is not fully understood, although there are three common causes which are excessive urine volume, poor sleep arousal and bladder contractions. Bedwetting has a strong genetic component. Children whose parents were not enuretic have only a 15% incidence of bedwetting. When one or both parents were bedwetters, the rate jumps to 449% and 77% respectively. These first two items are the most common factors in bedwetting, but current medical technology offers no easy testing for either cause. There is no test to prove that bedwetting is only a developmental delay, and genetic testing offers little or no benefit. As a result, other conditions should be ruled out. The following causes are less common, but are easier to prove and more clearly treated. In some bedwetting children an increase in ADH production does not occur, while other children may produce an increased amount of ADH but their response is insufficient. Attention deficit hyperactivity syndrome (ADHD) children with ADHD are 2.7 times more likely to have bedwetting issues. Caffeine (caffeine increases urine production).

Reduced bladder capacity: Children with nocturnal enuresis often have a small bladder capacity compared to their peers. When these children sleep at night, their bladders are less able to hold all of their urine until morning.

Constipation

Chronic constipation can cause bedwetting. When the bowels are full, it can put a pressure on the bladder. Infection/disease Infections and disease are more strongly connected with secondary nocturnal enuresis and with daytime bedwetting. Less than 59% of all bedwetting cases are caused by infection or disease, the most common of which is a urinary tract infection.) More severe neurological-developmental issues patients with intellectual disabilities have a higher rate of bedwetting problems. One study of seven-year-olds showed that "handicapped and intellectually disabled children had a bedwetting rate almost three times higher than "non-handicapped children" (26.69% Vs 9.5% respectively), Psychological issues (e.g., death in the family, sexual abuse, extreme bullying) are established as a cause of secondary nocturnal enuresis, but arc very rarely a cause of primary nocturnal enuresis type bedwetting. Bedwetting can also be a symptom of a pediatric neuropsychological disorder called PANDAs l (Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections).

Sleep apnea

Sleep apnea stemming from an upper airway obstruction has been associated with bedwetting. Snoring and enlarged tonsils or adenoids are a sign of potential sleep apnea problems. ls)

Sleepwalking

Sleepwalking can lead to bedwetting. During sleepwalking, a sleepwalker may think he/she is in another room. When the sleepwalker urinates during a sleepwalking episode, he/she usually thinks that they are in the bathroom, and therefore urinates where they think the toilet should be. Cases of this have included opening a closet and urinating in it: urinating on the sofa and simply urinating in the middle of the room. Stress is a cause of people who return to wetting the bed. Researchers find that moving to a new town. parent conflict or divorce, arrival of a new baby, or loss of a loved one or pet can cause insecurity, contributing to returning bedwetting.

Type 1 diabetes mellitus

Nocturnal enuresis could be the presenting symptom of type I diabetes mellitus, classically associated with polyuria. polydipsia, and polyphagia: weight loss, lethargy and diaper candidiasis may also be present in those with new-onset disease.

Unconfirmed

Food allergies

Food allergies may be part of the cause in some patients. This is not well established, requiring further research,

Improper toilet training

This is another disputed cause of bedwetting. This theory was more widely supported in the last century and is still cited by some authors today. Some say bedwetting can be caused by improper toilet training, ol either by starting the problem when the child is too young or by being too forceful. Recent research has shown more mixed results and a connection to toilet training

has not been proven or disproven. According to American Academy of Pediatrics, more child abuse occurs during potty training than in any other developmental stage.

Dandelions

Dandelions are reputed to be a potent diuretic.

Aetiology of enuresis has been widely debated but is still not completely understood. Some of the common causes are listed below:

Primary enuresis:

-Delay in maturation of the relevant part of nervous system.

- Acquired control of bladder late.

-Organic causes

- Defect in urethral valve, adherent or elongated prepuce, phymosis in the boys.

- Ectopic ureter which may open in urethral part of vagina, hooded clitoris in girls.

-Over enthusiasm on the part of parents for toilet training leads to undue anxiety and enuresis.

- Scolding child for enuresis has negative impact on child. Secondary enuresis:

- Worry at home/school, birth of sibling, excitement like watching horror stories at nightime.

-Constipation, bladder calculi. urinary tract infection.

- Diabetes mellitus/ diabetes insipidus.

- Neurogenic bladder

- Erythema, eczema, pruritus

Dietary use of much sugar, too much coffee

- Worm infestation Traumatic

- After circumcision operation

-Catheterization

One of the most important things to keep in mind about urination is that the process is not under voluntary control. The individual parts and nerves of urinary system must work in unison for successful urination to occur. As the bladder muscles contract, the urinary sphincter relaxes, allowing urine to flow into the urethra and exit the body. The communication between the nerve and muscle groups that link the bladder and the brain is very complicated and explains the diferent ages at which children become dry. The following timetable shows the development of bladder control

- Ages birth-18 months: the child is unaware ofbladder filling or emptying.

- Ages 18-24 months: the child has conscious sensation ofbladder emptying.

- Ages 2-3 years: most children develop the ability to voluntarily stop urination and develop appropriate toileting skills.

-Ages 3-5 years: Most children have achieved urinary control and are dry both day and night.

Management

Behavioral modification: It may help the children to stay dry at night. These modifications are as follows -

Restricting fluids: Limiting a child's fluid intake after dinner is designed to reduce his urine production at night.

Nighttime waking: One of the techniques parents use to help children stay dry is to take them to the bathroom a few hours after they go to sleep.

Bladder therapy: This approach encourages children to increase their fluid intake during the day, to think about the sensation of a full bladder, to respond to their bladder at the first signal, and to fully empty their bladder each time they have to go.

Bedwetting alarm: Available in a variety of models, all alarms work on the premise of waking the child if the wetness sensor detects urine.

Psychotherapy: A treatment option for children with secondary enuresis due to a change or traumatic event in their life or for those experiencing a significant problem with self-esteem because of their bedwetting.

Before discussing the treatment of nocturnal enuresis, there are two important things to keep in mind. First, children do not wet the bed on purpose. Second, most pediatricians do not consider bedwetting to be a problem until a child is at least 6 years of age.

Simple behavioral methods are recommended as initial treatment. Enuretic alarm therapy and medications may be more effective but have potential side effects.

- Motivational therapy in nocturnal enuresis mainly involves parent and child education. Guilt should be allayed by providing facts.

- Bedwetting alarms: Physicians also frequently suggest bedwetting alarms which sound loud when they sense moisture. This can help condition the child to wake at the sensation of a full bladder. This is an effective method.

Statistical analysis:

Chi square test is performed to test the statistical significance of efficacy of homeopathic potency 3C over constitutional in nocturnal enuresis.

So, this test was performed to assess the statistical significance of Homoeopathic treatment to the patients suffering from nocturnal enuresis.

• Null Hypothesis (Ho): There is no difference in improvement rates of Experimental Group and Control Group.

. Alternative Hypothesis (H1): There is remarkable difference in improvement rates between Experimental Group and Control Group at 0.05 level of significance.

The 2X2 contingency table for assessment of the obtained results is shown below.

Table 1: Contingency table for assessment of results of this study, using Chi-Square test.

Total number of observations = 40 E (Expected Value) = RT X CT/GT O-Observed Value

E-ExpectedValue RT= Row Total

CT=Column Total GT= Grand Total χ2 = ∑(O-E)² /E

=∑ (33-29.75)²/29.75+(2-5.25)²/5.25+(1-4.25)²/4.25+(4-0.75)²/0.75

= 18.9356

DF (Degreeof Freedom) = (R-1) (C-1) DF - (2-1) (2-1)

DF=1

For degree of freedomof 1, the tabulated value of Chi-Square at P-0.05 is 3.84. Calculated value in the above case is 18.935 So, tcal > ttab.

So, P<<0>

• NH (H0) is rejected. • AH (H1) is accepted.

ALTERNATING HYPOTHESIS (H1): Improvement in cases of nocturnal enuresis with homoeopathic medicineEquisetum hyemale 3C potency is medicinal effect.The result is statistically significant.

The present study comprises the nocturnal enuresis and its Homoeopathic treatment. The study comprises randomly selected patients of a particular age group of different sex, religion and socioeconomic condition (n=40). The study was an observational, prospective, single blind, medicine-controlled study. First of all, a thorough case taking was done following the standard case-taking Proforma supplied by the Noble Homoeopathic Medical College & Research Institute. Proper analysis and evaluation of each case were searched out and repertorized by using the homoeopathic software Synthesis. Among the medicines that came out from the repertorization the final

selection was done after consulting homeopathic materia medica. Medicines were given in 3C potency by considering the case and the dose and repetition were maintained as far as practicable with the homoeopathic principle. The cases were followedat a regular interval of time of 7 days. It is of utmost importance to take every case properly to understand and interpret the symptoms of patients and to apply the knowledge of the study in the practical field and in clinical practice of homoeopathy. The present study comprises 40 cases of nocturnal enuresis, who attended the OPD of Noble Homoeopathic MedicalCollege & ResearchInstitute, Junagadh. While selecting the similimum the importance was given to totality of symptoms. The age distribution was shown in this study, the majority of cases were observed in the age group 06-10 years. The incidence of nocturnal enuresis in males (30 cases) is found slightly higher than females (10 cases). The numberof patients studiedin this experiment were only 40. Thecriteria for selection of 3C potency and repetition of doses in homoeopathy are not beyond question. Statistical test was carried out to find out the effectiveness of homocopathic treatmentof the patient suffering from nocturnal enuresis. Of the total 40 cases in which Equisetum hyemale 3C potency was prescribed in 35 cases, where 33 cases showed improvement and 02 cases showed no improvement under homoeopathic treatment. Whereas 5 cases were prescribed constitutional medicines, where 04 cases showed no improvement. Repertorial analysis is used as a guidingpath to find out the correct medicineand consultation with materia medica also needed for the selection of correct homoeopathic medicine.In the study of 40 cases it was seen that after thorough and proper case-taking of all the cases included for the study emergedsufficient amounts of characteristic generalas well as particular symptoms by which repertorization were easily done.

In this research an effort was made to show the efficacy of Homoeopathic potency 3C in the cases of nocturnal enuresis.Selected cases were between the age group of 07-15 years. The cases were diagnosed on the clinical presentations. 40 patients were taken for the study. 35 cases were in the experimental group and 5 cases were in the control group.All 35 cases of the experimental group were selected after careful analysis; Homoeopathic medicine in 3C potency was prescribed while constitutional medicineswere given to 5 cases of the control group. Follow up of the cases at a regularinterval of time of 7 days. Whilestudying nocturnal enuresisin detail I have noted that the drugshave been extensively proved again and again verifiedas regards to its clinical efficacy. Psychotherapy was given to all patients considering the social stigma attached to this disease. Psychotherapy played a key role in the management of the cases. The results obtained in the experimental group of patients who were prescribed Equisetum hyemale 3C potencywere encouraging. Almost 94% of patients showed improvement with the medicine. In this work the following inference was drawn.

1.Nocturnal enuresis is the deeper aspect of totality of symptoms which indicate correct similimum instead of the apparent pathology.

2.Homoeopathic treatment in 3C potency based on the totality of symptoms proved to be the best for the treatment.

3.Homoeopathic medicines in 3C potency are effective.

The study shows that the drug is effective in Nocturnal enuresis, but it is highly effective only when it is administered according to strict homoeopathic principles. Homoeopathy being a distinct mode of therapeutics offers both curative as well as palliative treatment with some limitations, On the contrary modern system of medicine only offers a palliative mode of treatment to the patients suffering from nocturnal enuresis. This research work enabled me to study the different aspectsof nocturnal enuresisin detail. In my observation most of the cases showed signs of improvement which are marked, moderate, and mild with the selection of similimum derived from the totality of symptoms. In this observational study I must say that Homoeopathy has a highly effective role in the cases of nocturnal enuresis and without any perceptible side effects.Thus, we can definitely improve the generalhealth of patients.So, the study showed that homoeopathy is a distinct mode of therapeutics that offers a curative treatment for nocturnal enuresis.

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