Enuresis

Photo by: Lorelyn Medina

Definition
Enuresis, more commonly called bed-wetting, is a disorder of elimination that involves the
voluntary or involuntary release of urine into bedding, clothing, or other inappropriate places. In
adults, loss of bladder control is often referred to as urinary incontinence rather than enuresis; it
is frequently found in patients with late-stage Alzheimer's disease or other forms of dementia .

Description
Enuresis is a condition that has been described since 1500 B.C. People with enuresis wet their
bed or release urine at other inappropriate times. Release of urine at night (nocturnal enuresis) is
much more common than daytime, or diurnal, wetting. Enuresis commonly affects young
children and is involuntary. Many cases of enuresis clear up by themselves as the child matures,
although some children need behavioral or physiological treatment in order to remain dry.
There are two main types of enuresis in children. Primary enuresis occurs when a child has never
established bladder control. Secondary enuresis occurs when a person has established bladder
control for a period of six months, then relapses and begins wetting. To be diagnosed with
enuresis, a person must be at least five years old or have reached a developmental age of five
years. Below this age, problems with bladder control are considered normal.

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Causes and symptoms

Symptoms
The symptoms of enuresis are straightforwarda person urinates in inappropriate places or at
inappropriate times. The causes of enuresis are not so clear. A small number of children have
abnormalities in the anatomical structure of their kidney or bladder that interfere with bladder
control, but normally the cause is not the physical structure of the urinary system. A few children
appear to have to have a lower-than-normal ability to concentrate urine, due to low levels of
antidiuretic hormone (ADH). This hormone helps to regulate fluid balance in the body. Large
amounts of dilute urine cause the bladder to overflow at night. For the majority of bedwetters,
there is no single clear physical or psychological explanation for enuresis.

Causes in children
The fourth edition of the Diagnostic and Statistical Manual of Mental Disorders , fourth
edition, text revision, or ( DSM-IV-TR ), does not distinguish between children who wet the bed
involuntarily and those who voluntarily release urine. Increasingly, however, research findings
suggest that voluntary and involuntary enuresis have different causes.
Involuntary enuresis is much more common than voluntary enuresis. Involuntary enuresis may
be categorized as either primary or secondary. Primary enuresis occurs when young children lack
bladder control from infancy. Most of these children have urine control problems only during
sleep; they do not consciously, intentionally, or maliciously wet the bed. Research suggests that
children who are nighttime-only bed wetters may have a nervous system that is slow to process
the feeling of a full bladder. Consequently, these children do not wake up in time to relieve
themselves. In other cases, the child's enuresis may be related to a sleep disorder.
Children with diurnal enuresis wet only during the day. There appear to be two types of daytime
wetters. One group seems to have difficulty controlling the urge to urinate. The other group
consciously delays urinating until they lose control. Some children have both diurnal and
nocturnal enuresis.
Secondary enuresis occurs when a child has stayed dry day and night for at least six months, then
returns to wetting. Secondary enuresis usually occurs at night. Many studies have been done to
determine if there is a psychological component to enuresis. Researchers have found that
secondary enuresis is more likely to occur after a child has experienced a stressful life event such
as the birth of a sibling, divorce or death of a parent, or moving to a new house.
Several studies have investigated the association of primary enuresis and psychiatric or behavior
problems. The results suggest that primary nocturnal enuresis is not caused by psychological
disorders. Bed-wetting runs in families, however, and there is strong evidence of a genetic
component to involuntary enuresis.
Unlike involuntary enuresis, voluntary enuresis is not common. It is associated with such
psychiatric disorders as oppositional defiant disorder , and is substantially different from
ordinary nighttime bed-wetting. Voluntary enuresis is always secondary.
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Causes in adults
Enuresis or urinary incontinence in elderly adults may be caused by loss of independent control
of body functions resulting from dementia, bladder infections, uncontrolled diabetes, side effects
of medications, and weakened bladder muscles. Urinary incontinence in adults is managed by
treatment of the underlying medical condition, if one is present; or by the use of adult briefs with
disposable liners.

Demographics
Enuresis is a problem of the young and is more common in boys than girls. At age five, about 7%
of boys and 3% of girls have enuresis. This number declines steadily in older children; by age 18,
only about 1% of adolescents experience enuresis. Studies done in several countries suggest that
there is no apparent cultural influence on the incidence of enuresis in children. On the other
hand, the disorder does appear to run in families; children with one parent who wet the bed as a
child are five to seven times more likely to have enuresis than children whose parents did not
have the disorder in childhood.

Diagnosis
Enuresis is most often diagnosed in children because the parents express concern to the child's
doctor. The pediatrician or family physician will give the child a physical examination to rule out
medical conditions that may be causing the problem, including structural abnormalities in the
child's urinary tract. The doctor may also rule out a sleep disorder as a possible cause. In many
cases the pediatrician can reassure the child's parents and give them helpful advice.
According to the American Psychiatric Association, to make a diagnosis of enuresis, a child
must have reached the chronological or developmental age of five. Inappropriate urination must
occur at least twice a week for three months; or the frequency of inappropriate urination must
cause significant distress and interfere with the child's school and/or social life. Finally, the
behavior cannot be caused exclusively by a medical condition or as a side effect of medication.

Treatments
Treatment for enuresis is not always necessary. About 15% of children who have enuresis
outgrow it each year after age six. When treatment is desired, a physician will rule out obvious
physical causes of enuresis through a physical examination and medical history. Several different
treatment options are then available.

Behavior modification
Behavior modification is often the treatment of choice for enuresis. It is inexpensive and has a
success rate of about 75%. The child's bedding includes a special pad with a sensor that rings a
bell when the pad becomes wet. The bell wakes the child, who then gets up and goes to the
bathroom to finish emptying his bladder. Over time, the child becomes conditioned to waking up
when the bladder feels full.
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Once this response is learned, some children continue to wake themselves help from without the
alarm, while others are able to sleep all night and remain dry. A less expensive behavioral
technique involves setting an alarm clock to wake the child every night after a few hours of
sleep, until the child learns to wake up spontaneously. In trials, this method was as effective as
the pad-and-alarm system. A newer technique involves an ultrasound monitor worn on the child's
pajamas. The monitor can sense bladder size, and sets off an alarm once the bladder reaches a
predetermined level of fullness. This technique avoids having to change wet bed pads.
Other behavior modifications that can be used alone or with the pad-and-alarm system include:

restricting liquids starting several hours before bedtime

waking the child up in the night to use the bathroom

teaching urinary retention techniques

giving the child positive reinforcement for dry nights and being sympathetic and
understanding about wet nights

Treatment with medications

There are two main drugs for treating enuresis. Imipramine , a tricyclic antidepressant, has been
used since the early 1960s. It is not clear why this antidepressant is effective in treating enuresis
when other antidepressants are not. Desmopressin acetate (DDAVP) has been widely used to
treat enuresis since the 1990s. It is available as a nasal spray or tablet. Both imipramine and
DDAVP are very effective in preventing bed-wetting, but have high relapse rates if medication is
stopped.

Alternative therapies
Some success in treating bed-wetting has been reported using hypnosis. When hypnosis works,
the results are seen within four to six sessions. Acupuncture and massage have also been used to
treat enuresis, with inconclusive results.

Psychotherapy
Primary enuresis does not require psychotherapy . Secondary enuresis, however, is often
successfully treated with therapy. The goal of the treatment is to resolve the underlying stressful
event that has caused a relapse into bed-wetting. Unlike children with involuntary enuresis,
children who intentionally urinate in inappropriate places often have other serious psychiatric
disorders. Enuresis is usually a symptom of another disorder. Therapy to treat the underlying
disorder is essential to resolving the enuresis.

Prognosis
Enuresis is a disorder that most children outgrow. For those who do receive treatment, the overall
success rate of behavioral therapy is 75%. The short-term success rate with drug treatments is
even higher than with behavioral therapy. Drugs do not, however, eliminate the enuresis. Many
children who take drugs to control their bed-wetting relapse when the drugs are stopped.
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Prevention
Although enuresis cannot be prevented, one side effect of the disorder is the shame and social
embarrassment it causes. Children who wet may avoid sleepovers, camp, and other activities
where their bed-wetting will become obvious. Loss of these opportunities can cause a loss of
self-esteem, social isolation, and adjustment problems. A kind, low-key approach to enuresis
helps to prevent these problems.

Resources
BOOKS
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th
ed. text revised. Washington DC: American Psychiatric Association, 2000.
Mace, Nancy L., and Peter V. Rabins. The 36-Hour Day. Revised and updated edition. New
York: Warner Books, Inc., 2001; by arrangement with The Johns Hopkins University Press.
Maizels, Max, Diane Rosenbaum, and Barbara Keating. Getting Dry: How to Help Your Child
Overcome Bedwetting. Boston: Harvard Common Press, 1999.
Sadock, Benjamin J. and Virginia A. Sadock, eds. Comprehensive Textbook of Psychiatry 7th ed.
Vol. 2. Philadelphia: Lippincott Williams and Wilkins, 2000.

PERIODICALS
Mikkelsen, Edwin J. "Enuresis and Encopresis: Ten Years of Progress." Journal of the American
Academy of Child and Adolescent Psychiatry 40 (October 2001):1146-1159.

ORGANIZATIONS
American Academy of Child and Adolescent Psychiatry. P. O. Box 96106, Washington, D.C.
20090. (800) 333-7636. <www.aacap.org> .
National Kidney Foundation. 30 East 33rd Street, Suite 1100, New York, NY 10016.
<www.kidney.org> .

OTHER
American Academy of Child & Adolescent Psychiatry (AACAP). "Bed-wetting." AACAP Facts
For Families Pamphlet #18. Washington, DC: American Academy of Child & Adolescent
Psychiatry, 1999.
"Bed-wetting." National Kidney Foundation. 2001 (cited 15 March 2002).
<www.kidney.org/general/atoz/content/ bedwetting.html> .
Read more: Enuresis - children, causes, DSM, effects, therapy, adults, drug, person
http://www.minddisorders.com/Del-Fi/Enuresis.html#ixzz1yJyZTzxj

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What is Motivational Therapy for Bedwetting?

It may sound like a weekend seminar at a hotel near the airport, but motivational therapy can be
a useful treatment for bedwetting. Your child should be an active and eager participant in the
process.
Motivational therapy involves a careful system of record-keeping and rewards. Your child tracks
whether the previous night was "wet" or "dry." This can be more interactive with the use of
visual reminders of progress. For example, each dry night can be rewarded with a sticker to place
on a calendar.
As longer periods of dryness are achieved, pre-arranged rewards can be earned. One possibility
might be earning a book after one week of staying dry. These rewards can be carefully selected
based on your childs interests.
This method leads to a successful period of 14 consecutive dry nights in 25 percent of cases. In
more than 70 percent of children, the number of bedwetting episodes will drop by more than 80
percent.

Is Motivational Therapy Right for My Child?

Motivational therapy is not right for every child. It works best in younger children who are
experiencing primary enuresis (that is, dryness during sleep has never been accomplished).
If your child does not take responsibility or have a role in the process, they are less likely to be
motivated to stop the bedwetting. Social pressure -- such as a desire to sleep away from the home
-- may motivate some older children. Furthermore, if the reward system is not desirable, it may
not serve its purpose.
It is important to remember that bedwetting is not the childs fault, and punishment should not be
part of the treatment. Instead, a positive and supporting environment, even with setbacks, should
be maintained.

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