Bedwetting (enuresis), a complete approach

 

 

Introduction

Enuresis is the common  occurrence of  voidings during sleep after the age of 6. One boy out of 20 continues to wet the bed after 6 years of age, and one girl out of  20 after the age of 5. It is a frequent  problem, often distressing for the family. Sometimes, the enuretic child is viewed as sick, rebellious or in need of  psychiatric treatment. Actually,  enuresis is basically an isolated developmental delay. In some families, children normally  become dry at night at about age 12. A genetic or organic component may be present, justifying a medical approach.  On the other hand, psychotherapeutic interventions are  seldom justifiable. Which does not mean that psychological mistakes are without consequences. It is sometimes said that  the  attainment of  night dryness can be delayed  by the family, but never  hastened. In general for simple enuresis, psychotherapy is  ineffective, if not  counterproductive. 

Proposed approach

  1. Perform a urinalysis to rule out  infection, at least with an  urine paper strip test.

  2.  Measure the bladder  functional capacity : this is the  urine volume produced when the child feels an urge to void.  About 5-10  measurements are usually enough. They allow an accurate estimate of  the bladder's functional size, but also detect an unstable bladder if  values  vary markedly. Normally the bladder capacity is about  85 ml around two years of age. At 4 years and 1/2  it should  reach  200 ml, allowing night dryness. At 7 years and    it is about 225 ml, having  increased less. 

  3.  In doubt, an ultrasound study of the urinary tract is obtained to observe bladder volume, shape, wall thickness, and rule out  stones or localized dilations. 

  4.  Voiding exercises during the day : train the pelvic floor muscles by stopping  the urinary stream approximately half-way and then resume to empty the bladder completely. This is important, a bladder residue can cause infection. 

  5.  Always  empty the bladder when leaving the house.

  6.  "Paradoxical injunction" : pretend to pay no attention or grant no importance to a wet bed. Since psychological factors often play a decisive role (which does not imply any psychological anomaly or disease)  the least parents or guardians worry about the child's problem the better. A glass of water on the night table is a useful  symbolic tool, providing  evidence of  adult tolerance or perhaps even better, lack or concern.  This method is  effective in reducing night "accidents" in children's homes. On the other hand, a child who feels under pressure  and wakes up wet,  inevitably feels frustrated, with an impression of failure or guilt, of disappointing adults and the feeling of not being up to their expectations. More or less consciously he or she will fear the following night. And we know that even slight, diffuse anxiety increases urine  pressure within the bladder and the risk of sleep incontinence during sleep.

  7.  Night self-reliance : if  napkins  have been abandoned, the child must be in charge of changing wet linen and clothing. .

  8.  Active measures : 

  • A small or unstable bladder can  respond to a medical treatement (usually oxybutynin) and resume its growth. 

  • If the bladder is  stable and of normal size :   

    • A motivated child can keep a night diary,  which must remain private.  Left pages are divided in 7 lines for weekdays. Every dry night is rewarded by a coloured sticky label. Nothing  marks wet nights. Several dry nights in a row give the right to stick a  star and if the whole week has been dry, the child may draw a picture on the opposing page. This approach is based on the positive reinforcement psychological technique : successes are emphasized, failures are ignored. 

    • Medications are less  and less prescribed. Antidiuretic hormone at bedtime by nasal inhalations (Minirin) reduces nightime  urine production and the risk of bed incontinence. This treatment allows handling of special  situations (night out of the home, at a friend's house, week-end trips, sports camps...) but no lasting benefit can be expected. .

    •  A  completely different method is the night alarm, ringing when the child wets the bed. It is an application of Pavlovian conditioned reflexes. Soon the child wakes up before voiding. Failures are commonly  the result of  deep sleep  : "everyone wakes up but not him/her". Overall  the technique is quite  effective, with a success  rate approaching 100 percent in girls. When night  dryness is obtained, it is sometimes advised to offer fluids before bedtime, aiming at  triggering  "accidents", and alarms, useful to  stabilize the cure. 

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