Enuresis: Problems with Bedwetting?

Enuresis: Problems with Bedwetting?

                Do you or someone you love have problems with wetting the bed?

                Do you have issues with urinating in your clothes throughout the day?

                Do you feel that you have an issue with bedwetting but too scared to tell anyone?               

Enuresis: What Does it Mean?

                Enuresis is an elimination disorder which involves repeated urination into the bed or clothes.  There are a few different types of enuresis.  The first type is nocturnal enuresis.  This type is wetting that occurs in the night while asleep.  The second type is diurnal enuresis. This type is wetting that occurs when the individual is awake.  The third type is mixed enuresis.  This type is wetting that takes place both when asleep and also during the awake hours.  Enuresis is a disorder that occurs voluntary or involuntary.  Enuresis is a disorder that occurs after an individual has been successfully potty trained.  If a child wets the bed during the potty training development this would not be an accurate diagnosis.

Stats: How Many Suffer from this Disorder?

    Enuresis is a disorder that is prevalent throughout children and adolescents.  Studies have shown that between 13-20% of five-year-old children, 10% of seven-year-olds, 5% of ten-year-old children, and around 2% of individuals 15 years or older still struggle with wetting the bed.  Throughout the country, between five to seven million children still wet the bed.  This equivalates to 10% of the United States population of children. 

What Causes Enuresis?

                There is no single cause of this disorder.  This can be an embarrassing situation for children especially if they experience ridicule from siblings, friends, or family.  One theory is that this is due to laziness but this disorder has not been linked to an individual being lazy.  It has been found that there may be a bedwetting gene that an individual may have inherited from a first-degree relative.  If a parent experienced bedwetting their children may have a higher risk of being bedwetters.   Some children may have a delay in the maturation of their bladder, which makes them wet the bed at night.  If a child has a low anti-diuretic hormone or ADH, he or she may be more at risk to experience bedwetting.  Sometimes when a child experiences deeper sleep than others they may be more at risk for bed wetting.  Constipation is a condition which can cause bedwetting because when there is increased pressure on the bladder.   

Signs and Symptoms of Enuresis

                Accidents happen and it is important that if an individual experiences periodic accidents they talk to loved ones and possible medical provider to address this topic.  Most people that wet themselves experience this at night and tend not to have any other symptoms but wetting the bed.  Some other symptoms that can be present when an individual experiences this disorder is wetting themselves throughout the day; frequency, urgency, or burning on urination; straining, dribbling, or other unusual symptoms with urination; cloudy or pinkish urine, or blood stains on underwear or pajamas; soiling or inability to control bowel movements, and constipation. 

Testing: What are the Diagnostic Criteria Per the DSM 5?

                For an individual to be diagnosed using the Diagnostic and Statistical Manual of Mental Disorders: Fifth Edition (DSM-5) with Enuresis they have to meet the following criteria:

  • Repeated voiding of urine into bed or clothes, whether voluntary or intentional
  • The behavior is clinically significant as manifested by either a frequency of at least twice a week for at least three consecutive months or the presence of clinically significant distress or impairment in social, academic (occupational), or other important areas of functioning
  • Chronological age is at least five years (or equivalent developmental level)
  • The behavior is not attributable to the physiological effects of a substance (e.g. a diuretic, an antipsychotic medication) or another medical condition (e.g. diabetes, spina bifida, a seizure disorder)

Specifications:

                                Nocturnal only: Urination only during nighttime sleep

                                Diurnal only: Urination during waking others

                                Nocturnal and diurnal: a combination of the two subtypes
               

  • (American Psychiatric Association, 2013)

Enuresis and Other Conditions

Enuresis vs Encopresis.  If an individual experiences enuresis this means that they have issues with urination that occurs when at asleep in the bed and also during awake others in their clothes.  For an individual to experience encopresis they experience defecation into inappropriate places.  This can include clothes, the floor, or hidden areas.  One of these disorders involves urination and the other involves defecation. 

Enuresis vs Neurogenic Bladder and Other Medical Conditions. A neurogenic bladder is a bladder that is controlled by the nervous system or “nerves.”  If an individual experiences this type of bladder their bladder could become overactive and also underactive.  There are also a few birth defects that can cause a neurogenic bladder: spina bifida, sacral agenesis, and cerebral palsy.  These birth defects cause issues to the spine which directly relates to the nervous system.  These disorders rule out enuresis because there are other conditions which would be more appropriately causing the urination.  There are other medical conditions which can cause neurogenic bladder: stroke, Parkinson’s disease, Multiple sclerosis, spinal cord injuries, spinal surgeries, Erectile dysfunction, trauma/accidents, central nervous system tumors, and heavy metal poisoning.

Related Conditions.  Some of the other related conditions of enuresis are other elimination disorders.  It is important that providers rule out all possibility of other disorders and medical doctors determine if there are other medical conditions which can cause this behavior.

Enuresis in Adults/Children

                Enuresis is a disorder that occurs primarily in children.  Adults that wet the bed normally have another condition which is causing this behavior.  For adults this is an extremely embarrassing condition but most often it is a sign of a medical condition.  Some of these conditions could be urinary incontinence, Urinary tract infection (UTI), small bladder, Diabetes, kidney disease, enlarged prostate gland, Prostate cancer, Bladder cancer, side effects of medications, neurological disorders, Sleep apnea, an imbalance of the antidiuretic hormone (ADH), stress, anxiety, fear, or other psychological issues.  If an adult is experiencing this condition, reach out to your medical provider and talk to them about possible medical conditions.

                This disorder is more prevalent in male children than female children.  It depends on the development of the child and also the progression in his or her potty training, and it relies on the physical and emotional health of the child.  If the individual experiences a chronic illness or emotional/physical abuse they may be more predisposed to bedwetting and this disorder. 

Example Case of Enuresis

                When working with a child or adolescent that has experienced past trauma, abuse (physical, emotional, verbal, or sexual, and/or trauma enuresis is a condition that may be addressed throughout the treatment process.  If a child or adolescent begins to urinate his or her clothes when awake, or bed when asleep they may be experiencing negative reactions to the past issues.  When entering treatment for this issue, it is important that the child or adolescent is treated and also the guardians are educated on the importance of not shaming the individual and not negatively responding to them.  Using Cognitive Behavioral Therapy (CBT) will allow the client to overcome negative feelings when can improve the negative behavior.  Also setting a schedule for when the last time a beverage will be consumed and possibly scheduling a restroom wake up in the night can help with retraining the bladder.  It is important that the client and also his or her guardian are actively in the treatment process so that it can be effective and the disorder can be improved.

How to Deal/Coping with Enuresis

                Enuresis is a condition that can be embarrassing for an individual to discuss.  There are many different ways to deal and cope with this condition.  One way is to get treatment from a medical doctor.  It is important that this is done to rule out any other medical issues which can cause this disorder.  If an individual works to restrict fluid intake one to two hours before bedtime it can reduce the risk of bedwetting.  Also cutting back food late at night can assist with the reduction of bed wetting.

                Look out for These Complications/Risk Factors. There are many risk factors that are present for bed wetting.  Some of these are the male gender and family history; medical conditions such as abnormal anatomy or function of the kidneys, bladder, or neurologic system; sleep apnea; chronic constipation; sexual abuse; excessive fluid intake before bedtime; urinary tract infection; and some medications. 

Enuresis Treatment

                This disorder is typically seen as a more social issue than a medical issue.  It can cause embarrassment, anxiety, and other negative feelings which may need further treatment.  So it can be hard to treat bedwetting if the other negative feelings outweigh the bedwetting.  But if these are treated simultaneously it can be effective in reducing both of these issues and work to increase self-confidence and also positive behaviors.  Medical appointments are needed to rule out if other medical conditions can be treated to reduce the bedwetting. 

Possible Medications for Enuresis.  There are a few medications that can be used to reduce bedwetting.  Three medication regimens have been found to be effective:

  • Desmopression acetate: This medication helps to increase the level of ADH that is present for a child throughout the night.  This helps the bladder to function appropriately throughout the night to help with urination that is involuntary.
  • Anticholinergic medications: These medications help the bladder hold more urine.  This medication helps the bladder not to become full and need to be released.
  • Imipramine:  This medication is a medication that decreases bladder contractility and increases the outlet resistance. It also inhibits the reuptake of norepinephrine or serotonin at the presynaptic neuron due to being an antidepressant medication.

Home Remedies to help Enuresis. There are many home remedies to help in the reduction of bed wetting.  Reducing the evening fluid intake is important and doing this by not drinking an hour or two before bedtime.  There needs to be toilet time before the child goes to bed and being strict with this guideline.   There can be a time that the child is woken up each night to go to the bathroom so that if they are training their bladder they are doing this consistently.  A token economy or a sticker and reward system for each night of not wetting the bed can increase motivation for the child not to want to wet the bed and change this behavior.  It is important that the guardians focus on the problem of bedwetting and not blaming or punishing them if they wet the bed.  If they are ridiculing it can increase negative feelings which can hinder the child not to want to talk about what is going on and hide sheets and clothes.  The guardian also needs to work to be more patient and supportive and in doing this it can increase the success of the reduction of bed wetting.

Living with Enuresis.  This is a condition that will take time to reduce the behavior so it is important that all of the individuals involved are patient and active in the treatment process. Making sure that shame and guilt do not occur to the child is important so that they will feel open to discuss issues that they may be experiencing.  Setting guidelines and developing a process can help with the reduction of this behavior and help form more cohesion in the household.

Insurance Coverage for Enuresis.  Most all insurance providers should cover this disorder.  If you are experiencing symptoms that affect your daily activities, social, relationship, and occupational functioning it is important you reach out and seek assistance.  If you have insurance, you can contact your insurance provider and locate clinicians in your area that are covered.  It is also important that your primary care physician is included throughout the treatment plan and this should be covered by insurance.

How to Find a Therapist?

                There are many local resources to find counseling.  Psychology Today has a list of providers in local areas and also identifies the modalities of the providers.  Word of mouth is a great way to seek a counselor.  More people are getting help and asking a trusted friend could assist you in finding the provider that is right for you.  Your primary care physician could assist in a referral to a provider that could help with this disorder.

                What Should I be Looking for in an LMHP? Looking for a counselor with experience with cognitive behavioral therapy, behavior modification, and trauma therapy to assist with the reduction of negative feelings and also psychological issues that can occur due to bed wetting behaviors.    

                Questions to ask for Potential Therapist? Do you have experience treating elimination disorders, past trauma, and positive healthy lifestyle changes?  Do you utilize Cognitive Behavioral Therapy?  Do you utilize homework and assist in the development of skills to assist in reshaping negative thinking and behaviors?   

Enuresis Resources and Support Helpline

                There are many local support groups for childhood disorders and behaviors. There is not a support group hotline for this topic but one way to locate something is to reach out to your primary care physician to see if there is anything in your area.

               

                Enuresis is an elimination disorder that involves urination on a voluntary or involuntary manner both at night when asleep and also when awake.  It is more common with male children than female.  It affects children that are between the ages of five and fifteen and is prevalent for a child that comes from a parent of a bedwetter, a person with a history of physical/emotional/sexual abuse, have other medical issues, and can cause stress and other negative feelings which can hinder a person’s self esteem.  This is a condition that is treatable via medication and counseling.  It is a condition that causes an individual to be embarrassed and shamed but it is so important to seek treatment because it can cause other negative consequences.  The first step is reaching out to a primary care physician to determine an appropriate course of treatment.

               

Resources

American Psychiatric Association. (2013).  Diagnostic and statistical mental of mental disorders (5th ed.). Washington, DC: Author

author avatar
Angel Rivera
I am a Bilingual (Spanish) Psychiatrist with a mixture of strong clinical skills including Emergency Psychiatry, Consultation Liaison, Forensic Psychiatry, Telepsychiatry and Geriatric Psychiatry training in treatment of the elderly. I have training in EMR records thus very comfortable in working with computers. I served the difficult to treat patients in challenging environments in outpatient and inpatient settings
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