Enuresis

Contributors:
Nicole A. Stargell, The University of North Carolina at Pembroke

Enuresis, also colloquially called bedwetting, is diagnosed when individuals inappropriately eliminate urine although they have the developmental capacity to otherwise use a toilet or comparable facility. Instead of using a toilet, individuals with enuresis eliminate urine into bedding or clothing; to meet diagnostic criteria, this wetting must occur at least twice per week for 3 months, or cause significant difficulty in social, work, or school settings. Individuals must be at least five years old to be diagnosed with enuresis, and the behavior must not be due to a general medical condition (APA, 2013).

Three specifiers for enuresis are included in the 5th edition of the Diagnostic and Statistical Manual for Mental Disorders (DSM) to indicate the time of day during which the behaviors occur (APA, 2013). Nocturnal only is used to indicate that the difficulty is experienced during the nighttime, and Diurnal only is used to indicate daytime occurrences of inappropriate elimination of urine. Nocturnal and diurnal is a specifier used to denote that symptoms occur during both the day and night.

Males and females experience enuresis at similar rates, and it is one of the most commonly- diagnosed disorders in young people (Shapira & Dahlen, 2010). Enuresis can be found in up to 19% of children ages 5-12 (Hodgkinson, Josephs, & Hegney, 2010). Although it is prevalent among young people, enuresis typically subsides with age, affecting only about 1% of people aged 15 years and older (APA, 2013).

Psychological, genetic, and biological factors are known contributors to enuresis. Professional counselors should take care to address the possibility of emotional or physical abuse when assessing for enuresis (APA, 2013). Unstable parenting or other stressful events might also contribute to enuresis, but genetic and biological factors are primary contributors to the development of the disorder (Shapira & Dahlen, 2010). Approximately two thirds of individuals diagnosed with enuresis have a biological relative who also had elimination difficulties (APA, 2013). Biological contributors are various, and might include reduced ability to wake from sleep, low levels of antidiuretic hormones, reduced bladder size, or delayed connection between brain and body (Shapira & Dahlen, 2010).

Identification/Assessment Strategies

As previously mentioned, enuresis is commonly associated with genetic and biological factors. As such, a referral to a medical professional should be made so that possible physiological etiologies can be assessed. These etiologies may include reduced sleep arousal, below normal hormone levels, limited bladder capacity, or delayed brain and body connections (Adamson, Campbell, & Kress, 2015). Even if professional counselors suspect that enuresis is related to psychological factors, a medical referral should still be made to identify any co-occurring contributors.

Psychological factors that have been associated with enuresis include emotional or physical abuse, unstable parenting, or other stressful life events (APA, 2013). Children who have been abused often become emotionally inhibited or act out the behaviors in exaggerated ways (e.g., asking to perform sexual acts, becoming violent with peers; Kellogg, 2010). Professional counselors who suspect abuse should provide a thorough assessment for such (Adamson et al., 2015). Information about stable parenting and other life stressors can also be gathered through intentional interviewing strategies.

Overall, assessment for enuresis can be completed by a professional counselor using the DSM criteria. Assessment for biological or genetic contributors to enuresis should be completed by a medical professional. Additionally, professional counselors should gather information about psychological stressors to identify if any further assessment and additional diagnoses should be made.

Intervention Strategies

Enuresis is commonly associated with biological and genetic factors. Behaviorally-based interventions are highly supported for use in treating those who have this disorder. Interventions can also focus on the emotional consequences experienced by individuals with enuresis.

Enuresis Alarm
An enuresis alarm is currently regarded as the primary intervention for nocturnal (nighttime) enuresis (Hodgkinson et al., 2010; Shapira & Dahlen, 2010). Bedwetting that occurs while the child is sleeping is almost always involuntary and unintentional.  As such, an enuresis alarm can address an individual’s difficulty with sleep arousal and help the person strengthen connections between the brain and body. This intervention can be helpful for individuals who also experience diurnal enuresis, as the learning can carry over into the daytime.

Those who have enuresis are often under the age of 12 (Hodgkinson et al., 2010). As such, caregivers must be engaged in treatment and should assist in purchasing the alarm and supporting the intervention; family commitment is critical to success (Perrin, Sayer, & While, 2013). Enuresis alarms can be found in most pharmacies or ordered online (the search term would be “enuresis alarm” or bedwetting alarm”). These alarms start at just $30, and each alarm is slightly different depending upon the specific brand.  The two main components are a sensor and an alarm (Adamson et al., 2015). The sensor clips to the outside of the individual’s undergarments and measures the moisture level. If the sensor detects moisture, a signal is sent for the alarm to ring or vibrate.

Two behavioral principles are behind the effectiveness of the enuresis alarm. First, classical conditioning pairs an unconditioned stimulus (the alarm) and a conditioned stimulus (the urge to urinate) with an unconditioned response (waking up).  Soon, the individual begins to associate the urge to urinate with waking up to go to the bathroom (Adamson et al., 2015). Thus, the individual no longer urinates in the bed. Although awaking from the urge to urinate is technically a conditioned response, it is hoped that feelings of satisfaction and intrinsic motivation will support the permanency of this behavior across time. As such, it is especially effective to incorporate the second kind of behavioral principle, operant conditioning.

Operant conditioning can be used to reward successive approximations toward a desired behavior, and it has been found to significantly reduce symptoms of enuresis (Hodgkinson et al., 2010). Praise is an especially effective reinforcer, and this can be used by clients’ loved ones to support the effectiveness of the enuresis alarm and transfer the skills to daytime difficulties (Adamson et al., 2015). Reinforcers should be given generously at the beginning of intervention, and can be reduced as the client independently associates the desired behavior with intrinsic motivation and personal satisfaction.

To watch a video and learn about one example of an enuresis alarm, go to: http://www.drybuddy.com/our-products/drybuddy-ez
To review another alarm and additional information, go to: http://www.sleepdryalarm.com/

Pharmacotherapy
Although behavioral interventions are highly recommended for enuresis, medication can be used in addition to these interventions.  Medication is especially relevant if a medical professional identifies a link between the unwanted behavior and a biological contributor (Adamson et al., 2015). Antidepressants and stimulants have been found to support interventions for enuresis (Shapira & Dahlen, 2010). Both medications have been found to potentially stimulate the individual’s body and increase responsiveness to the urge to urinate.  If small bladder size or excessive urine production is found to be a contributor to enuresis, Vasopressin can be used to increase water retention (Adamson et al., 2015).

It is imperative that any medication is used in conjunction with behavioral interventions.  There is a significant risk of relapse if medication is used on its own to treat enuresis (Hodgkinson et al., 2010). It is important that desirable behaviors become habitual and clients learn how to maintain their progress independently.

To learn more about the use of medication with enuresis, visit: http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0014856/

REFERENCES

Adamson, N. A., Campbell, E. C., & Kress, V. E., (2015). Disruptive, impulse-control, and conduct disorders, and elimination disorders. In V. E. Kress & M. J. Paylo (Eds.), Treating those with mental disorders: A comprehensive approach to case conceptualization and treatment (pp. 384-420). New York, NY: Pearson.

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

Hodgkinson, B., Josephs, K., & Hegney, D. (2010) Best practice in the management of primary nocturnal enuresis in children: A systematic review. JBI Library of Systematic Reviews 8(5), 173–254. Retrieved from: http://www.joannabriggslibrary.org/index.php/jbisrir/article/view/111

Kellogg, N. (2010). The evaluation of sexual abuse in children. Pediatrics: Official Journal of the American Academy of Pediatrics, 116, 506-512. doi: 10.1542/peds.2005-1336

Perrin, N., Sayer, L., & While, A. (2013). The efficacy of alarm therapy versus desmopressin therapy in the treatment of primary mono-symptomatic nocturnal enuresis: a systematic review. Primary Health Care Research & Development, 19, 1-11. Retrieved from http://journals.cambridge.org/action/ displayJournal?jid=PHC

Shapira, B. E., & Dahlen, P. (2010). Therapeutic treatment protocol for enuresis using an enuresis alarm. Journal of Counseling and Development, 88, 246-252. doi: 0.1002/j.1556-6678.2010.tb00017.x

Published: March 2015
Updated: August 2016