Nocturnal enuresis is often diagnosed and treated by a paediatrician in Primary Care. However, many cases are treated directly by a clinical psychologist specialising in children and adolescents or referred to psychologists/situational analysts when the doctor fails in his first intervention. The evaluation must be medical and psychological since it is a psychophysiological problem. Therefore the presence of possible radiological or neurological anomalies responsible for the disorder must be ruled out as a priority. The environmental circumstances that may be maintaining the condition must be determined.
First, a detailed anamnesis is made on the possible existence of organic pathology and infections. Next, they carry out a physical examination where they examine different parts of the body, such as the lower back, to exclude signs of spinal cord disease (changes in skin colour, fistulas, and the abdominal part to rule out kidney masses that can obstruct the urinary tract or genitalia to evaluate the presence of phimosis or synechiae in the among other conditions that may be causing the problem. In a complementary manner, urine cultures and analyses are performed to determine possible changes in urine density or the presence of Urinary tract infections.
Once the medical tests have been carried out, and the existence of organic problems has been ruled out, a behavioural evaluation is carried out by the psychologist, whose objective is to determine the antecedent and consequent factors functionally associated with the problem to design individualised treatment—and adjusted to the case. This exploration includes the clinical interview, behavioural records and questionnaires.
The clinical interview is carried out with the parents and the child, and where possible, areas related to the nature of the problem are explored.
It is about determining if it is primary or secondary enuresis. It is considered primary if the child has never been dry and secondary if the child has never been dry for six or more months. In the case of secondary enuresis, possible stressful events or factors related to the onset of the problem are investigated:
- Separation from parents
- Death of a relative
- Starting or changing schools (especially at the beginning of preschool)
, the birth of siblings, and hospitalisation, among others. The presence of affective and behavioural disorders, as well as the experience of stressful situations, is significantly related to the appearance of secondary enuresis. Likewise, exposure to stressful events before age four is related to frequent enuresis.
These data point to the importance of carrying out a detailed evaluation of the psychosocial factors that may play an essential role in the appearance and course of the disorder, as well as the importance of directing the intervention not only to treat the enuretic problem per se but also to address the psychological, cognitive and emotional consequences derived from it and from exposure to possible stressful events or experiences that occurred in the child’s life course. Although some research indicates that the psychological repercussions (emotional, cognitive or behavioural) subside spontaneously when urinary continence is achieved, this does not happen in all cases.
Nocturnal and diurnal enuresis:
In the evaluation of enuretic behaviour, it is also essential to know if there is control of urination during the day and if they have acquired skills related to bladder control (ability to discriminate the level of bladder filling, urine retention and delay of urination by time) and if they also have adequate bowel control (constipation or encopresis). In addition, it is essential to evaluate the consequences (reinforcements or punishments) of wetting or keeping the litter dry.
Other factors that the psychologist takes into account in his evaluation are:
Family history of enuresis.
Find out if other family members have had the same problem. It allows them to determine their attitudes and expectations regarding the possible solution of enuresis and correct those erroneous ideas that interfere with the intervention.
Treatments and other means used to solve bedwetting:
Exploring the previously used pharmacological or behavioural treatments allows us to know why they have failed and thus program the intervention more appropriately and adjust, avoiding making the same mistakes. Likewise, it is beneficial to identify what strategies parents have used to help their children deal with the problem to analyse why they have not worked and to be able to correct some guidelines so that they can be effective.
Existence of other psychological problems:
Evaluate coexistence with other disorders, such as fear of noise, the dark, night terrors, anxiety or depression, since they can precipitate or appear simultaneously and consequently interfere with the problem. The presence of enuresis not only has high psychopathological comorbidity but also increases the presence of emotional discomfort (stress, anger, frustration, insecurity, disgust and rejection of one’s own body, shame) and stigmatisation by others. In addition, bedwetting can be a source of embarrassment and provoke peer ridicule or punishment from adults (parents and teachers). Consequently, feelings of low self-esteem and subclinical symptoms of anxiety and depression may appear.
Evaluate what the affective environment is like, the type of relationship between the different members of the family, the time that parents spend with their children, as well as the degree of concord between them
Know the conditions of the home (location of the bathroom concerning the room, access to the light switch from the bed, single bedroom or shared with siblings) to determine if they interfere with appropriate behaviour and, in that case, proceed with its modification.
Know the motivation of both the parents and the child to manage enuresis and what the child’s attitude is towards these episodes of incontinence: if they want to stop peeing or are indifferent to it if they feel ashamed or sad.
Record of activities and results:
On the other hand, behavioural records are made to obtain a baseline and thus study the evolution of the child’s enuretic behaviour during treatment. Information is collected on the frequency of wet nights and urination performed during the night. The functional capacity of the bladder is also measured, examining the maximum and average amount of urine evacuated and the frequency of urination during the day. In addition, it is of great interest to record the response of spontaneous awakenings during the night.
It is necessary to carry out a multimodal intervention aimed not only at covering the enuretic problem but also at addressing cognitive, emotional and psychological aspects derived from the enuretic situation or due to the experience of traumatic or stressful experiences. In this sense, cognitive behavioural treatment is indicated to cover this type of repercussions or psychological sequelae.
Medical treatment of nocturnal enuresis
Primary Care paediatricians initially apply the diagnosis and treatment. However, these interventions are based on pharmacological prescriptions, although it is common for doctors to prescribe behavioural therapies such as those discussed in the next section.
Among the most widely used drugs is desmopressin, frequently administered in cases of nocturnal enuresis, which has a reducing effect on urine output at night and intravesical pressure. Despite its effectiveness in reducing the frequency of wet nights, the suspension of treatment produces a relapse rate of between 80 and 100% of cases. In addition, different studies have shown that behavioural therapy through the alarm method is more effective on its own than when it is complemented with this drug. Other medications used are oxybutynin, which is an anticholinergic that relaxes the detrusor muscle (a muscle that produces urination when it contracts), indicated in children with overactive bladders or small bladder capacity,
Behavioural treatments for nocturnal enuresis:
The psychologist’s intervention is indicated when physical pathology has been ruled out and in cases where contextual factors are determining factors.
The alarm method:
It consists of placing a pipi-stop device in the child’s bed. The device is sensitive to humidity and is activated with an intense sound at the first drops of urine. This sound causes the urine to stop and the child to wake up. The repetition of this sequence causes the child to associate the body signals of the beginning of urine with the action of waking up. After several nights, the child will wake up before the device sounds, thus avoiding wetting the bed and acquiring the control habit of the micturition reflex.
Two variants are included to reduce the relapse rate: overlearning and intermittent reinforcement. When the child reaches the initial success criterion, it is understood that she has learned to control the urination reflex. However, to reinforce this learning, over-learning tests are carried out where fluid intake is increased one hour before bedtime (gradual increase in fluid consumption adjusted to age and the characteristics of the case), allowing a certain margin of error against extinction and relapse. Overlearning increases the functional capacity of the bladder and improves the child’s confidence in realising that he can stay dry despite drinking more.
On the other hand, intermittent reinforcement strengthens learning (sphincter contraction responses or interruption of micturition-wake-up). It consists of intermittently reinforcing the enuretic episodes, programming the alarm so that it sounds every other night, or activating it randomly only for 70% of the nights or any other percentage considered convenient.
Dry bed training
It has been considered an effective and well-established treatment by the Group for the Promotion and Dissemination of Psychological Treatments. The average success rate is 75.3%, which has been considered a faster procedure to achieve effective results and with a lower relapse rate than the alarm.
It is a multi-component program that includes the alarm device, wake-up training (programmed wake-up), extra fluid intake (over-learning), retention training, positive consequences of staying dry (exceptionally social reinforcement), positive practice (training in the habit of getting out of bed quickly to go to the bathroom to urinate) and training in cleanliness (changing pyjamas, sheets, cleaning the detectors of the alarm device) that refer to the establishment of good habits.
Training in voluntary retention:
This procedure teaches the child to withhold urination when faced with an urgent need to urinate, intentionally postponing the evacuation for extended periods. This method includes positive reinforcement of the retention response, progressive extra fluid intake, and exercise and strengthening of the sphincter muscles that control urine retention.
However, it is also the least effective, given that the success rate is even lower than spontaneous remission (healing with the simple passage of time, without any intervention), so it is not the most indicated technique to solve enuresis nocturnally.
This type of intervention requires active involvement by children, parents and professionals, which requires more significant effort than in other treatments, such as pharmacological. The type of treatment chosen will depend on the disposition of the parents and the child towards the method, the child’s age, and the case’s characteristics.