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About enuresis

Toileting issues are of great concern to many parents and can be source of family stress. Identification and appropriate treatment of a child's elimination disorder can help parents avoid ongoing disagreements and forestall behavioral or emotional problems. Many factors interact to cause elimination disorders - mastery of urine and bowel control is affected by a child's maturational level, intellectual capacity, cultural customs, and the dynamics of the parent-child relationships.

Enuresis refers to urination in clothing or bed beyond the age when children are expected to be toilet trained, in the absence of medical pathology.

Introduction

By the age of 3, or 5 at the latest, most children have achieved bladder control both day and night. When children continue to have trouble with this task they have enuresis, often referred to as bedwetting. To qualify for a diagnosis of enuresis, the child over the age of 5 must involuntarily pass urine, at night or during the day, at least twice a week for a period of three months. There are two basic types of enuresis: primary and secondary. A child who has never been trained (has not achieved a six-month period of dryness at night) falls into the primary enuresis group, the more common of the two. Secondary enuresis applies to children who have been dry up to a year and then start wetting again, usually between the ages of 5 and 8. A sub-category of secondary enuresis is transient, or temporary, enuresis, which may be brought on by trauma or stress, such as a divorce in the family, and may last anywhere from a couple of weeks to several months.

Real Life Stories

Jackson, aged 8 , a bright, athletic, seemingly self-confident youngster, had many friends and many social invitations. Although he enjoyed attending school functions and parties, he refused invitations to sleep at a friend's house. Jackson wet his bed almost every night and tried desperately to keep it secret, but when the class went on an overnight trip, his classmates found out and teased him. "I tried to stay up all night so I wouldn't wet, but I couldn't, and then the pee soaked through my sleeping bag."

Rob, 6 years old, had an erratic maturational pattern. Motor and speech milestones were attained slightly after the expected ages, and he fell behind academically. Consistent with his slow development in these areas, he also had difficulty in developing urine control; he wet his bed at night and sometimes wet his clothes in school. He would usually say he was too busy or too tired to go to the bathroom. Despite Rob's teacher's attempts to handle this privately, the other children found out and called him names. Rob's parents were confused about what to do; they didn't know if he was being willful, if there was an underlying physical condition, or they were being too tough on him.

What are the symptoms?

Children with enuresis urinate involuntarily at night or during the day. Many younger children, at about ages 5 and 6, are not especially bothered by their condition. Although they probably dislike waking up on wet sheets and facing their annoyed parents, they don't seem particularly distressed. As they get older, however, and become more interested in a social life, sleepover dates, and camp, enuresis becomes more of an interference in their lives, and secondary problems of avoidance behaviors or low self-esteem can emerge.

Subtypes (according to DSM IV)

• Nocturnal only. This is the most common subtype and is defined as passage of urine only during nighttime sleep. Typically, the child voids during the rapid eye movement (REM) stage of sleep, and may recall a dream that involves the act of urinating.

• Diurnal only. This subtype is defined as the passage of urine during waking hours. Diurnal enuresis is more common in females than in males and uncommon after age 9 years. The child most commonly wets in the early afternoon on school days. Diurnal enuresis is sometimes due to a reluctance to use the toilet because of social anxiety or a preoccupation with school or play activity.

• Nocturnal and diurnal. A combination of the two subtypes described above.

Who is likely to have it?

Bedwetting occurs in 40% of 3-year-olds, 30% of 4-year-olds, 20% of 5-year olds and 5% of l0-year olds. Enuresis is not considered to be a problem until the child is 5 or 6 years old. 10% of first-graders wet the bed at least once a month. Boys are more likely than girls to have enuresis, and the gender difference remains consistent, and at age l8, the prevalence is 1% for males and less for females.

Why does it happen?

Enuresis is NOT due to drinking too much fluid, laziness, desire to irritate the parents, or emotional problems, although emotional problems may result from the condition.

Although some may have a bladder that is slightly smaller than average, most children do not have physical abnormalities. Remaining dry at night requires neurological maturation, which varies for individual children.

A possible cause of enuresis is an abnormal regulation of a brain hormone called ADH (antidiuretic hormone), which determines the way that water is retained in the body. In some children with enuresis too little ADH is released at night, so that their bodies produce more urine than the bladder can handle.

Another theory is that children with enuresis simply sleep more deeply than those who stay dry at night. Heredity may also be a factor, since many children who wet the bed have a parent who may have also wet the bed. Approximately 75% of all children with enuresis have a first-degree biological relative who has it. If one identical twin has enuresis, 68% of the time the other twin will also have enuresis.

According to learning theory, children who achieve nighttime control do so through learning either to wake up and go to the bathroom or to inhibit urination once the first signals of a full bladder are experienced.

Some predisposing factors have been suggested, including delayed or lax toilet training, psychosocial stress, a dysfunction in the ability to concentrate urine, and a lower bladder volume threshold for involuntary voiding.

Associated problems

Enuresis can lead to behavior problems because of the guilt and embarrassment that may result. The problems depend on the degree of limitation on the child's activities, the effect on the child's self-esteem, the degree of social ostracism by peers, and the punishment and rejection on the part of caregivers. The prevalence of coexisting mental and other developmental disorders is higher than in the general population. Encopresis, Sleeping Disorder and Sleep Terror Disorder may be present.

How is it treated?

A medical screening, including family history, toilet training history, a urine culture and urinalysis, can determine whether medical problems are the cause or a contributing factor to enuresis. A small percentage of children with enuresis have medical problems, such as urinary tract infections, and require specialized treatment. Children with daytime wetting problems, regardless of the presence or absence of nighttime wetting, have been shown to have medical problems at a rate higher than among children who wet only during sleep.

Many children outgrow enuresis without treatment. For those who do not, behavioral techniques have been shown to be effective. Behavioral treatments try to eliminate bedwetting by directly training the child to control bladder functions during the night. A device called the bell and pad is used in many behavioral treatment plans. Somewhere in the bed there is a pad with a sensor that detects wetness. At the first sign of wetness the sensor causes a bell to ring, waking the child. The child then gets up, runs to the bathroom, and urinates in the toilet. This system can be made more effective when combined with a system of positive and negative reinforcement. Cleanliness training, or having the child strip the bed, put on clean sheets and change his pajamas, increases the child's motivation to get up when he hears the bell. Bladder training exercises can help the child wait longer between trips to the bathroom. Parental attitude and motivation are basic to the success of these programs.

Depending on the severity, a child may benefit from medication, which may physically limit the amount of urine output or keep him dry.

Questions & answers

Are there some practical things a parent can do to help a child who is struggling with bedwetting?

Reassure the child that he or she is not at fault. Limit the child's last substantial drink to two hours before bedtime. During the day, encourage the child to hold urine for long periods to increase the size and capability of the bladder. Before bedtime, make sure the child urinates so he starts the night with an empty bladder. Children with small bladders will probably have to learn to get up once or twice a night in order to stay dry. Some parents wake their child for trips to the bathroom. Setting up a sticker chart with rewards for dry nights is often helpful. Remember, toilet training takes a lot of patience, time and understanding.

Should a child, even an older one, wear diapers to bed?

For some children, it is helpful to wear thick underwear under the pajamas. Older children, however, may find this embarrassing. Diapers can also decrease the chance of the child feeling wet and interfere with training. Protect the bed. A washable mattress pad and a plastic sheet under the top sheet can help keep the bed dry. Reward the child for dry nights, but do not punish him for wet ones.

How should parents show their disapproval and frustration when a child seems to wet the bed deliberately?

Enuresis is not voluntary. Children do not wet their beds on purpose. Punishment, teasing and criticism will not help the problem, and can prolong it, causing an emotional problem. Support, sympathy, and encouragement are important. Take positive steps to show the child you want to help him solve the problem. It is also advisable to limit the attention given to the problem. Have the child be responsible for self-care. Teach him to get up and change his pajamas when he wets the bed. Keep a stack of extra pajamas, and teach the child to place a towel over the wet spot and get back into bed.

Do not permit siblings or other family members to tease the child. If a parent had enuresis at a young age, telling the child will relieve some of his anxiety.

What about the future for a child who bedwets. Should we just let a child outgrow it?

The problem may go away by itself. Some sources put the rate of symptom disappearance at 15 percent, lower with boys than with girls. However, the longer the child has enuresis the more likely he is to experience negative social consequences, including family dissension. If a child is 5 years old and enuresis persists for three months or more, most experts feel that intervention is warranted, and the possibility of a consultation with a mental health professional should be considered.