Enuresis (bedwetting): causes, symptoms and treatment

This elimination disorder is attributed to learning, emotional and Biological factors.

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

Although bed-wetting is a very common phenomenon in in childhood, this disorder is relatively poorly understood. Far from maintaining the unfounded belief that this type of behavior is a voluntary and malicious act on the part of the child, we will now explain the main characteristics that define this disorder.

What is enuresis?

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

Among the diagnostic criteria, it is emphasized that the child must perform such elimination behavior in inappropriate situations involuntarily with a frequency equal to or more than twice a week for at least three years. twice a week for at least three consecutive months. consecutive months.

Usually, the following are associated with the diagnosis of enuresis sleepwalking, night terrors and, above all, sleep problems. deterioration of self-esteem, misunderstanding and parental criticism.. As a consequence of these circumstances, the child becomes isolated 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 children and older girls, although the general proportion oscillates around 10% of the child population. The enuresis can be classified according to three different criteria: of the moment in which the episodes of sphincter episodes of sphincter dyscontrolThe type of enuresis depends on whether it preceded a period in which the child was able to control the pee and whether it is accompanied by other concomitant symptomatologies.

According to these criteria we can establish the following typologies of enuresis.

1. Daytime, nocturnal or mixed enuresis.

Daytime enuresis occurs during the day and is associated with anxious symptomatology, more frequent in girls. The nocturnal type is more frequent and is linked to images referring to the act of urinating during REM sleep. Cases of mixed enuresis are those in which episodes occur both during the day and at night.

2. Primary or secondary enuresis

The term "primary" applies if the child has not previously experienced a stage of sphincteric control. In the case of secondary enuresis a stage of control has been observed in the past of at least of at least six months' duration has been observed in the past.

3. Monosymptomatic or polysymptomatic enuresis

As its name suggests, monosymptomatic enuresis is not accompanied by any other kind of symptomatology, while polysymptomatic enuresis is accompanied by other micturitional manifestations such as pollakiuria (increase in the number of daily micturitions).

Causes

Although there is no general consensus to date on the factors that cause enuresis, there seems to be some agreement on establishing an interaction between biological and psychological causes..

There are three types 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 in which both parents had enuresis. both parents presented this alteration during their childhood during childhood, compared to 15% of children from families with no history of enuresis.

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

3. Psychological theories

These theories advocate the presence of emotional or anxiogenic conflicts that derive in the loss of sphincter control, although some authors indicate that it is the enuresis itself that motivates these emotional alterations.

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

The behaviorist current proposes an inadequate There are several treatments that have proven efficacy in bedwetting intervention in the intervention in enuresis, although it is certain that the multimodal therapies that combine several of the components that are exposed next have a more acceptable percentage of success.

The following is a description of the most commonly used intervention techniques and procedures in the treatment of enuresis.

1. Motivational Therapy

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

2. The Pee-Stop Technique

The "Pee-Stop" technique is based on the operant technique of Token Economy.. Once the anamnesis has been carried out and the functional analysis of the case has been elaborated by means of interviews with the parents and the child, a self-recording of the evolution of the enuretic episodes during each night is prescribed. At the end of the week, a tally of points is made and, if a certain goal is reached, the child receives a reward for the achievement.

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

3. Dry Bed Training

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

In the first phase, together with the installation of a Pee-Stop device (audible alarm), the child is instructed in the so-called "Positive Practice", in which the subject must the subject must get out of bed to go to the toilet, repeatedly repeatedly, ingest a limited amount of liquid, then return to bed and go to sleep. After one hour, the child is awakened to see if he/she is able to hold the need to urinate for a longer period of time. This procedure is repeated every hour that night.

In case of bedwetting, Cleanliness Training is applied, whereby the child has to change both his/her own clothes and the soiled bed linen before going back to sleep.

In a second phase, the child is woken up every three hours until he/she achieves seven consecutive nights without wetting. seven consecutive nights without wetting the bed.. At that point, the child is moved to a final phase in which the alarm device is removed and the child is allowed to sleep through the night without being woken up. This final phase ends when the child has achieved a total of seven consecutive nights without bedwetting.

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

4. Bladder distension exercises

They consist of training the child to increasingthe time of urine retention in a gradual gradually. The child should tell the parents when he/she 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 (muscle relaxants to increase bladder capacity), have a moderate efficacy in the treatment of enuresis, since improvements are lost improvements are lost as soon as treatment is discontinued and have considerable side effects (anxiety, sleep disturbances, constipation, vertigo, etc.).

Multimodal treatments

These intervention packages combine the various techniques described in the preceding sections and present superior efficacy since they address the alterations produced in the cognitive (psychoeducation of the disorder), affective (coping with anxiety, fears and worries generated), somatic (pharmacological prescription), interpersonal (coping with family stressors) and behavioral (direct intervention of enuretic behavior) areas.

Stopping bedwetting

As it has been observed, enuresis is a complex psychopathology that requires a set of interventions involving the whole family system.

It is very relevant the application of behavior modification techniques, specifically "Pee-pee-pee", is very important.specifically the "Pee-Stop" and Cleanliness Training, although it is equally fundamental to deepen and determine which factors of emotional character are causing such symptomatology.

Bibliographical references:

• Belloch, A., Sandín, B. and Ramos, F. (1995). Manual of psychopathology (Vol. 2, Part VI. Developmental psychopathology). Madrid: McGraw-Hill.
• Caballo, V. and Simón, M. A. (Eds.) (2002). Manual de psicología clínica de la infancia y de la adolescencia, 2 volumes. Madrid: Pirámide.
• Ollendick, T. H. and Hersen, M. (1993). Psicopatología infantil. Barcelona: Martínez Roca.
• Méndez, F.J. and Maciá, D. (1990). Behavior modification with children and adolescents. Case book. Madrid: Pirámide.