Enuresis
Enuresis
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 the 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.
Causes and symptoms
Symptoms
The symptoms of enuresis are straightforward—a 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 , 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 bedwetters 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.
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, or 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 twice as common in boys as in 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, making a diagnosis of enuresis requires that 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.
Once this response is learned, some children continue to wake themselves without help from 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 appears to work in up to 60% of cases, although relapse occurs in about 50% of successful treatments. Desmopressin acetate (DDAVP), which acts as an antidiuretic, has been widely used to treat enuresis since the 1990s. It is available as a nasal spray or tablet and can effective in up to 65% of cases. Relapse rates with DDAVP can be as high as 80%.
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.
KEY TERMS
Bladder —A muscular sac in the lower abdomen that holds urine until it is discharged from the body.
Elimination —The medical term for expelling waste from the body.
Enuresis —The inability to control urination; bed-wetting.
Primary enuresis —Bed-wetting in a child who has not yet developed bladder control.
Secondary enuresis —Bed-wetting in a child who has established bladder control but has begun to wet the bed again, usually as the result of emotional stress.
Urinary incontinence —A term that is sometimes used for enuresis in adults. Urinary incontinence is often found in patients with late-stage Alzheimer’s disease or other adult-onset dementias.
Urinary system —The kidney, urethra, bladder, and associated organs that process urine and eliminate it from the body.
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. 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.
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 rev. Washington, D.C.: American Psychiatric Association, 2000.
Mace, Nancy L., and Peter V. Rabins. The 36-Hour Day. Revised and updated edition. New York: Warner Books, 2001; by arrangement with The Johns Hopkins University Press.
Maizels, Max, Diane Rosenbaum, and Barbara Keating. Getting Dry: How to Help Your Child Overcome Bed-wetting. 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): 1146–59.
ORGANIZATIONS
American Academy of Child and Adolescent Psychiatry. P. O. Box 96106, Washington, DC 20090. Telephone: (800) 333-7636. <http://www.aacap.org>.
National Association for Continence. P.O. Box 1019, Charleston. SC 29402-1019. Telephone: (800) 252-3337. <http://www.nafc.org>.
National Kidney Foundation. 30 East 33rd Street, Suite 1100, New York, NY 10016. <http://www.kidney.org>.
OTHER
“Bedwetting.” American Academy of Child & Adolescent Psychiatry (AACAP). AACAP Facts For Families Pamphlet, Number 18. Washington, DC: American Academy of Child & Adolescent Psychiatry, 1999.
“Bedwetting.” National Kidney Foundation. 2001. <http://www.kidney.org/general/atoz/content/bedwetting.html>.
“Enuresis.” National Library of Medicine. National Institutes of Health. (2005) <http://www.nlm.nih.gov/medlineplus/ency/article/001556.htm>.
National Guideline Clearinghouse. Practice Parameter for the Assessment and Treatment of Children and Adolescents with Enuresis. (2005) <http://www.guideline.gov/summary/summary/.aspx?doc_id=6510&nbr=004079&string=enuresis>.
“Urinary Incontinence in Children.” National Kidney and Urologic Diseases Information Clearinghouse. National Institute of Diabetes and Digestive and Kidney Diseases. (2006) <http://kidney.niddk.nih.gov/kudiseases/pubs/uichildren/index.htm>.
Tish Davidson, A.M.
Emily Jane Willingham, PhD