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Elimination Disorders: Enuresis

Andrea Barkoukis, M.A., Natalie Staats Reiss, Ph.D., and Mark Dombeck, Ph.D.

Elimination disorders occur when children who are otherwise old enough to eliminate waste appropriately repeatedly void feces or urine in inappropriate places or at inappropriate times. The two disorders that fall under this category are Enuresis and Encopresis.

Enuresis

upset childEnuresis is diagnosed when children repeatedly urinate in inappropriate places, such as clothing (during the day) or the bed (during the night). In most cases, the child's urination problem is involuntary in nature, and is perceived by the child as an unavoidable loss of urinary control.

There are three subtypes of Enuresis: Nocturnal (night-time) Only, Diurnal (day-time) Only, and Nocturnal and Diurnal. The DSM criteria for diagnosis state that the urination problem (whether involuntary or intentional) must occur with regularity, at least twice a week, for three consecutive months before the diagnosis applies. The diagnosis cannot be made unless there is evidence that the urination problem causes distress or impairment in the child's social or academic functioning.

In Nocturnal Only Enuresis, the most common form of enuresis, children wet themselves during nighttime sleep. Typically, wetting occurs during the first third of the night, but it is not uncommon for wetting to occur later, during REM sleep. In this latter case, children may recall having a dream that they were urinating.

Diurnal Only Enuresis, where children wet themselves only during waking hours, is less common than nighttime bedwetting. This type of enuresis is more common in females than in males, and is uncommon altogether after age 9. Children who are affected by this type of disorder will typically either have urge incontinence (i.e., they feel a sudden overwhelming urge to urinate) or voiding postponement (i.e., they know they need to urinate, but put off actually going to the bathroom until it is too late).

As the name suggests, children with Nocturnal and Diurnal Enuresis suffer from a combination of the two scenarios described above.

Predisposing factors that contribute to increased risk of developing enuresis include: delayed or lax toilet training, psychosocial issues (e.g., social anxiety), abnormal urinary functioning, reduced bladder capacity, or unstable bladder syndrome, a condition wherein the child's bladder contracts involuntarily, resulting in sudden urine leakage.

Enuresis is most frequent in younger children, and becomes less common as children mature. According to the DSM, while as many as 10% of five year olds qualify for the diagnosis, by age fifteen, only 1% of children have enuresis.

Enuresis is typically experienced as an embarrassing and shameful condition, particularly if the affected child is older. Children with enuresis may be ostracized, teased and bullied by peers. In addition, they may face caregivers' anger, rejection and punishment for not meeting developmental expectations. Prompt treatment for enuresis can help to head off potential self-esteem problems associated with the condition.