Enuresis (urinating on yourself): causes, symptoms and treatment

Enuresis is part of elimination disorders, corresponding to the group of psychopathologies related to the stage of childhood and development. Its manifestation is often the external sign of some type of internal and intense emotional discomfort of the child.

Even if wetting the bed is a very common phenomenon In childhood, this disorder is relatively poorly understood. Far from maintaining the unfounded belief of the commission of this type of behavior as voluntary acts and malicious intent on the part of the child, then we will explain the main characteristics that define this disorder.

What is enuresis?

Enuresis can be defined as the clinically significant difficulty to adequately exercise control of the sphincters in the absence of a cause, either organic or derived from the consumption of certain substances, clearly observable.

Among the diagnostic criteria, it is highlighted that the child must involuntarily carry out such elimination behavior in inappropriate situations with a frequency equal to or greater than twice a week for at least three months in a row.

In addition, this type of behavior must generate significant emotional distress in the different areas of the child's life and cannot be diagnosed before the age of five.

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Comorbidity and prevalence

Usually, the presence of enuresis is associated with the diagnosis of enuresis. somnambulism, night terrors and, above all, problems of impaired self-esteem, misunderstanding, and parental criticism. As a consequence of these circumstances, the isolation of the child is derived in terms of participation in activities that involve outings such as excursions or camps.

The prevalence in each sex varies according to age, being higher in younger boys and older girls, although the general proportion varies around 10% of the child population. Nocturnal enuresis is the most common. In most cases, a spontaneous remission occurs, mainly of the secondary type, but it can also continue until adolescence.

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Types of enuresis

Enuresis can be classified based on three different criteria: moment when theepisodes of uncontrolled sphincter, if it has preceded a time in which the child was able to control the pee and if it is accompanied by other concomitant symptoms.

Based on these criteria, we can establish the following types of enuresis.

1. Daytime, nocturnal, or mixed enuresis

Daytime wetting occurs during the day and is related to anxious symptomatology, more common in girls. The nocturnal type is more frequent and is linked to images referring to the act of urination during REM sleep. Mixed enuresis cases are those in which the episodes occur both during the day and at night.

2. Primary or secondary enuresis

The qualifier "primary" is applied if the child has not previously experienced a stage of sphincter control. In the case of enuresis secondary yes a control stage has been observed in the past for a minimum duration of six months.

3. Monosymptomatic or polysymptomatic enuresis

As its name suggests, monosymptomatic enuresis is not accompanied by any other kind of symptoms, while polysymptomatic is accompanied by other voiding manifestations such as frequency (increase in the number of daily urinations).

Causes

Without being able to count on today with a general consensus on what are the factors that cause enuresis, there seems to be some agreement in establishing an interaction between biological and psychological causes.

There are three kinds of explanations that shed light on the origin of this disorder.

1. Genetic theories

Genetic research has found that 77% of children diagnosed with enuresis belong to families where both parents presented this alteration during their childhood, compared to 15% of children from families with no antecedents.

In addition, a greater correspondence has been found between monozygotic twins than between dizygotic twins, which indicates a significant degree of genetic determination and heritability.

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2. Physiological theories

Physiological theories defend the existence of altered bladder function, as well as insufficient capacity in the bladder. On the other hand, a deficit action has been observed in the secretion of the hormone vasopressin or antidiuretic, predominantly at night.

3. Psychological theories

These theories advocate the presence of emotional or anxiety conflicts that lead to loss of control sphincter, although some authors indicate that it is the enuresis itself that motivates these alterations emotional

It seems that the experience of stressful experiences such as the birth of a sibling, the separation of the parents, the death of a significant person, the change of school, etc. may be associated with the development of the disorder.

The behaviorist current proposes a process inadequate learning of hygiene habits as a possible explanation for enuresis, also stating that certain parental patterns can negatively reinforce the acquisition of sphincter control.

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Intervention and treatment

Various are the treatments that have proven efficacy in enuresis intervention, although it is true that multimodal therapies that combine several of the components listed below have a more acceptable success rate.

Below we will describe the intervention techniques and procedures most used today in the treatment of enuresis.

1. Motivational Therapy

In enuresis, Motivational Therapy focuses on the decrease in anxiety and emotional disturbances comorbid with the disorder, as well as in working on the enhancement of self-esteem and in the improvement of the family relationship.

2. The Pee-Stop Technique

The "Pee-Stop" is based on the Token Economy operant technique. Once the anamnesis and prepared the functional analysis of the case through interviews with the parents and the child, prescribes the performance of a self-record on the evolution of enuretic episodes during each night. At the end of the week a point count is made and, in case of having reached a certain goal, the child receives a reward for the achievement obtained.

Simultaneously, follow-up interviews are carried out with the family, advice is given to increase the efficiency of bladder function and gradually set more and more goals advanced.

3. Dry Bed Training

This intervention program proposes a series of tasks divided into three differentiated phases in which fundamental principles of the operant conditioning: positive reinforcement, positive punishment, and overcorrection of behavior.

At first, together with the installation of a Pee-Stop device (sound alarm), the child is instructed in the so-called “Positive Practice”, in which the subject you will need to get out of bed to go to the bathroom repeatedly ingest a limited amount of fluids and go back to bed and go to sleep. After an hour he is awakened to see if he is able to endure the urge to urinate for longer. This procedure is repeated every hour that same night.

In case of wetting the bed, Cleaning Training is applied, by which the child must change both their own clothes and those of the bed that have been soiled before going back to sleep.

In a second phase, the child is awakened every three hours until he gets add seven consecutive nights without wetting the bed. At that moment, he goes to a final phase in which the alarm device is removed and he is allowed to sleep through the night without waking him up. This last phase ends when the child has achieved a total of seven nights in a row without wetting the bed.

For every successful night it is positively reinforced the child and for each night of non-control, Positive Practice should be applied immediately.

4. Bladder distention exercises

They consist of training the child to go increasesndo the retention time of urine gradually. The child should notify the parents when he feels the urge to urinate, and the volume of fluid retained in the bladder should be measured and recorded periodically on each occasion prior to urination.

5. Pharmacological treatments

Pharmacological treatments, such as Desmopressin (antidiuretic) or Oxybutin and Imipramine (relaxants muscle to increase bladder capacity), have moderate efficacy in the treatment of enuresis, as get lost improvements as soon as treatment is stopped and they have considerable side effects (anxiety, sleep disturbances, constipation, vertigo, etc.).

6.Multimodal treatments

These intervention packages combine different techniques exposed in previous lines and present a higher efficacy since they address the alterations produced in the cognitive (psychoeducation of the disorder), affective (coping with anxiety, fears and concerns generated), somatic (drug prescription), interpersonal (coping with family stressors) and behavioral (the intervention of enuretic behavior in a direct).

Stop wetting the bed

As has been observed, enuresis is a complex psychopathology that requires a set of interventions that involve the entire family system.

The application of behavior modification techniques, specifically the "Pee-Stop" and Cleaning Training, although it is equally essential to deepen and determine what emotional factors are causing such symptoms.

Bibliographic references:

• Belloch, A., Sandín, B. and Ramos, F. (1995). Psychopathology Manual (Vol. 2, Part VI. Developmental psychopathology). Madrid: McGraw-Hill.
• Horse, V. and Simón, M. TO. (Eds.) (2002). Manual of clinical psychology of childhood and adolescence, 2 volumes. Madrid: Pyramid.
• Ollendick, T. H. and Hersen, M. (1993). Child psychopathology. Barcelona: Martínez Roca.
• Mendez, F.J. and Maciá, D. (1990). Behavior modification with children and adolescents. Case book. Madrid: Pyramid.