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Reflection: Enuresis
Shannon N. Phifer
Moraine Park Technical College
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Enuresis (bed-wetting) is defined as involuntary urination at least twice a month for
children between five and six, and once a month for those whom are older (Seligman, Walker, &
Rosenhan, 2001). 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 (Staff, 2013). It is said that an estimate between three and seven million school-aged
children in the United States suffer from enuresis (Seligman, Walker, & Rosenhan, 2001).
Nocturnal enuresis, or bed-wetting only at night, is the most common form of enuresis. Diurnal
enuresis, or daytime wetting, is less common and most children may experience one or the other
or even a mix of both (Goldberg, 2012).
Enuresis is more commonly seen in males than females, and those individuals that
experience enuresis into adulthood are typically males. Enuresis typically decreases significantly
with age and by age twelve, only eight percent of males and four percent of females suffer from
enuresis. According to Dr. Joseph Barone, a pediatric urologist at the Bristol-Myers Squibb
Children's Hospital in New Brunswick, N.J., the reason why boys tend to wet the bed more often
than girls is because sometimes the link between the bladder and the brain is not fully developed.
Girls tend to mature faster than boys, hence making the prevalence of boys with enuresis a bit
higher (Sammons, 2011). After reading the information from this study, I suppose that I can see
how these findings relate, even to my own children. My daughter was potty-trained significantly
earlier then my son, and with much more ease. My son, who will be four in August, still needs
to wear a pull-up diaper during the night because of not being able to control his urine while
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sleeping. In contrast, as soon as my daughter was potty-trained during the day, she was
immediately able to hold her urine through the night. She was fully potty-trained at two. The
findings make sense and I even see the differences in the cognitive and behavioral aspects
between my girls and my boy. My girls developed much faster as a whole. It is noted however,
that there is a distinction between primary enuresis, where the child never attains bladder control,
and secondary enuresis, which occurs after the child has achieved bladder control (Seligman,
Walker, & Rosenhan, 2001).
Experts now believe that enuresis in most cases is caused by combinations of the
following three mechanisms:
1. Failure to arouse – the child does not wake up when the bladder is full or contracts
spontaneously. In the majority of cases this is the primary cause, but one or both of the
mechanisms listed below can also play a role.
2. Increased production of urine while asleep – the child’s kidneys make more urine during
the night than can be stored within the child’s bladder. Sometimes this extra urine
production is caused by a relative night-time lack of the hormone vasopressin, which tells
the kidneys to decrease urine production.
3. Overactive bladder – the bladder tends to contract without being full leading to a smaller
than normal capacity. This is the same mechanism as that for daytime incontinence.
Furthermore, it should be noted that enuresis (and/or daytime incontinence) is very often
inherited. It commonly "goes in the family" although this may not always be evident since it may
skip generations and not all grandparents remember (or want to remember) that they were
bedwetters when they were younger. Research has even revealed a specific gene that, if passed
on to the next generation, causes enuresis through the mechanisms described above (Staff,
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Bedwetting (Enuresis), 2011). Voluntary, or intentional, enuresis may be associated with other
mental disorders, including behavior disorders or emotional disorders such as anxiety.
Researchers have also found that voluntary 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. Medications can also contribute to enuresis; some of the side effects of
certain medications can alter a child’s ability to control his/her bladder. These medications
include Alpha-Baclofen, Atrofen, Baclo, Baclofen, Clofen and Lioresal. It makes sense to me
personally that stressful events can subsequently contribute to enuresis. I can particularly see
how the birth of a new sibling or the divorce of parents could contribute. My best friend’s stepson is nine and has enuresis. He began after his parents had split up and his father married my
friend. He was six years old at the time. The physicians ran multiple tests on him and found no
medical findings for his bedwetting. It was later determined by his child psychologist that he
was suffering from enuresis due to the split of his parents and the new family dynamics of his
step-mom. The psychologist explained to them that this was a reaction to the change. I
remember him coming over to our home for sleepovers and he would consistently urinate in his
bed throughout the evening. It went as far as he would even wake up while urinating and just
continue because he didn’t want to get out of bed to go to the restroom. In the mornings, he
would be so embarrassed that he would remain in his urine soaked clothing and wrap himself in
a blanket so that no one would see that he had urinated his bed and clothes. This went on for
three years before he was able to stop. It required lots of time, attention and patience for the
bedwetting to discontinue.
There are numerous treatments for enuresis. Some of the more common treatments
include behavior modification, medication, alternative remedies and psychotherapy. Behavior
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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. 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
This is the method that my friend used for her step-son. It took approximately three weeks
for him to “retrain” his brain to recognize the full feeling of his bladder and get himself up to the
restroom. He still has occasional accidents with bedwetting but they have found that these
usually occur after he returns from a weekend with his biological mother. She does not enforce
him using the restroom and allows him to wear pull-up diapers (even at nine!) to bed.
Another treatment is the use of medication. There are two main drugs for treating enuresis.
Imipramine, a tricyclic antidepressant, has been used since the early 1960s. It is not clear why
this antidepressant is effective in treating enuresis when other antidepressants are not.
Desmopressin acetate (DDAVP) has been widely used to treat enuresis since the 1990s. It is
available as a nasal spray or tablet. Both imipramine and DDAVP are very effective in
preventing bed-wetting, but have high relapse rates if medication is stopped. Alternative
methods include hypnosis, massage and acupuncture. Hypnosis has had some success in
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successful results, but the results are not typically seen until after six weeks of hypnosis.
Massage and acupuncture have produced inconclusive results in their effectiveness.
Psychotherapy is not used for primary enuresis but is used for secondary enuresis because it
tends to have underlying issues associated with the enuresis. Therapy is used to treat any
stressors or traumas that are the primary reason for the voluntary enuresis. Fortunately, most
cases of primary enuresis are resolved on their own as the child gets older. Behavioral
modification has been the most effective treatment for cases that do not resolve by themselves.
It is important to remember though the side effects that enuresis can have on a child. They may
become embarrassed of their disorder and avoid social settings, especially those that require
them to sleepover. These can include sleepovers at friends’ homes, camps and other activities
where their bedwetting is obvious. It is crucial to be empathetic, supportive and patient when
your child is suffering from enuresis, so that the child can avoid any further shame or
embarrassment (Staff, Encyclopedia of Mental Disorders: Enuresis, 2013).
In closing, I found this early onset disorder extremely interesting and one that I had never
really look into further then thinking that it was normal for children to wet the bed. After having
personal experiences with enuresis involving my best friend’s son, and with my further research,
I now realize how real this disorder actually is and how it can affect a child far beyond just
waking up in wet pajamas. Patience, education and empathy are the foundations for assisting a
child in overcoming this disorder.
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References
Goldberg, J. M. (2012, June 4). Enuresis in Children. Retrieved March 28, 2013, from
Webmd.com: http://www.webmd.com/mental-health/enuresis?page=2
Sammons, M. B. (2011, March 28). Bed Wetting More Common in Boys Than Girls, Study
Shows. Retrieved March 29, 2013, from Parentdish.com:
http://www.parentdish.com/2011/03/28/bedwetting/
Seligman, M. E., Walker, E. F., & Rosenhan, D. L. (2001). Elimination Disorders. In Abnormal
Psychology (4th ed., pp. 343-45). New York: W. W. Norton & Company, Inc. Retrieved
March 25, 2013
Staff. (2011, January). Bedwetting (Enuresis). Retrieved March 29, 2013, from Urology Care
Foundation: http://www.urologyhealth.org/urology/index.cfm?article=125
Staff. (2013). Encyclopedia of Mental Disorders: Enuresis. Retrieved March 28, 2013, from
Minddisorders.com: http://www.minddisorders.com/Del-Fi/Enuresis.html