October 2004

Do youth who are enuretic (not due to a general medical condition) always have an emotional disorder?

Enuresis is the technical term used in reference to nocturnal (nighttime) or diurnal (daytime) voiding (releasing) of urine into the bed or clothes by a youth over 5 years of age. Approximately 5 to 10% of 6-year old children wet their beds. Boys are twice as likely as girls to have enuresis. For a youth to be diagnosed with enuresis, the event must occur twice a week for at least 3 months, or cause significant distress at home, school, or in social settings. Enuresis cannot be caused by a medical condition (e.g., diabetes, spina bifida, seizure disorder) or because of a substance (e.g., diuretics). When daytime or nighttime wetting persists beyond the age of 4 years, the youth is considered to have primary enuresis . When the ability to stay dry has developed normally and without intervention, but is followed by a period of wetting that lasts for 3 months or more, the child is considered to have secondary enuresis. The distinction between these two types is based on the child's physiological ability to control his or her urinary output. In cases of primary enuresis, this ability is usually compromised. Most cases of enuresis (80-90%) are of the primary type. Children with primary enuresis often have a family member who has the diagnosis of enuresis as well. In cases of secondary enuresis, the youth often has no physical problems impairing bladder control, but may be reacting to some emotional or psychological issues (e.g., new baby, domestic violence, death of a significant person or animal). Most children outgrow enuresis, but approximately 1% continue to have the disorder into adulthood.

Diagnostic Criteria (DSM IV) for Enuresis (not due to a general medical condition)

1. Repeated voiding of urine into the bed or clothes (whether involuntary or intentional)
2. The behavior is clinically significant, as manifested by either frequency (twice per week for at least 3 months) or clinically significant distress or impairment in social, academic (occupational), or other important areas of functioning.
3. Chronological age is at least 5 years (or equivalent developmental level).
4. The urinary incontinence is not due exclusively to the direct physiological effects of a substance (e.g., diuretics) or a general medical condition (e.g., diabetes, spina bifida, seizure disorder).

Specify type:

• Nocturnal Only
• Diurnal Only
• Nocturnal and Diurnal

Most children with enuresis do not have a coexisting mental disorder. However, the prevalence of coexisting developmental or emotional disorders is higher in youth with enuresis than in children without enuresis. Developmental delays, including speech, language, learning, and motor skills delays are often present in youth with enuresis. Encopresis (bowl movements in inappropriate places) sleepwalking, and sleep terror disorders may also be present. Some youth with diurnal (daytime) enuresis delay going to the bathroom because of social anxiety or over-involvement in an academic or social activity. These youth are more apt to have behavioral difficulties.

Even youth who have no preexisting developmental or emotional difficulties will often experience lowered self-esteem and increased anxiety because of the negative impact of enuresis on their peer and family relationships and their social activities. They are often teased or ostracized by their peers, punished or rejected by their caretakers, and afraid or unable to spend the night away from home. These youth may also develop a sense of failure and helplessness about their ability to control nighttime bedwetting.

What Can Family/Caretakers Do?

1. Make certain that the youth has had a thorough physical to rule out any underlying physical cause for the enuresis.
2. Become well informed about enuresis by asking questions and reading about it.
3. Discuss the problem and possible solutions openly, honestly, and compassionately with the youth.
4. With input from the youth and provider, discuss the most appropriate treatment plan for your family.
5. Be patient with yourself and the youth.

What Can the Mental Health Professional Do?

1. Become well informed about enuresis and inform youth and families about the two most effective methods for reducing or stopping enuresis:
• Wetness alarms - Condition the child to awaken at the sensation of impending urination, especially when they are paired with sphincter control exercises. By awakening the child with a loud noise immediately upon urinating, the child eventually awakens prior to the sound and is able to urinate in the bathroom. The alarm can also be used during daily exercises as a signal to interrupt the stream of urination, helping the child to learn an association between Wetness alarms - Condition the child to awaken at the sensation of impending urination, especially when they are paired with sphincter control exercises. By awakening the child with a loud noise immediately upon urinating, the child eventually awakens prior to the sound and is able to urinate in the bathroom. The alarm can also be used during daily exercises as a signal to interrupt the stream of urination, helping the child to learn an association between “hearing the buzzer” and “holding it.”
• Medications - Effective on a short term basis, but have poor long-term outcome. Desmopressin acetate (DDAVP) is an antidiuretic hormone that is administered by nasal spray. One drawback to DDAVP is that it is only effective when nasal passages are clear and absorption is maximal, making it useless during cold and flu season. Imipramine (Tofranil) is an antidepressant that also has anticholinergic effects (i.e., it suppresses the body's response to the neurochemical acetylcholine, thereby reducing bladder irritability).
2. Provide the youth and family with cognitive behavioral and/or family therapy to help them develop appropriate strategies to cope with the negative impact of the enuresis.