Nocturnal enuresis means bedwetting during the night, for most children enuresis resolves by around age 5, some children can take a little longer. There are the few for which extra help is needed to treat bed wetting.
Enuresis is taken from the Greek word (enourein) meaning ‘to void urine’. The International Children’s Continence Society (ICCS) divides the enuresis into two types, primary enuresis (PE) and secondary enuresis (SE).
Primary vs secondary enuresis
Primary enuresis is when a child has always been wet. As the child develops they learn naturally about their normal bladder capacity and as their bladder control improves, daytime wetting should become a thing of the past. The next developmental challenge for children is to go to sleep and awaken with a dry bed.
Primary nocturnal enuresis
For younger children staying dry during the day is more manageable because they are awake, therefore more conscious of daytime symptoms and of course a full bladder. Primary nocturnal enuresis points to a child who has never had a dry night and awakens each day in a wet bed. Nocturnal urine production is not the problem, the problem is getting the child to use the toilet instead of sleeping through.
Bedwetting is defined by the Diagnostic and Statistical Manual of Mental Disorders, fifth Edition (DSM 5) as an involuntary wetting during sleep, at least twice a week, in children older than 5 years of age with no congenital or acquired defects of the central nervous system.
Secondary enuresis is when older children return to urinary incontinence after a period of successfully staying dry. This need not be night time bed wetting, daytime incontinence can be triggered as the child finds new things to distract their thoughts, becoming more involved in the game of life and forgetting their bladder capacity.
Secondary nocturnal enuresis
This is probably the most frustrating and disappointing condition because most children have already left the bed wetting stage and now they are back. There may be a family history, or other family members may have suffered with secondary nocturnal enuresis, which may bring a little comfort to the child. This knowledge can help older children to see it as a phase that will go away before they know it.
Checking that your child doesn’t have a urinary tract infection, which may be causing the relapse, can be a very easy and quick solution. See diabetes insipidus below, which can present after age 4.
Enuresis causes in children
If after a few weeks there has been no change you might want to consult your doctor about having enuresis diagnosed. The child can be given a physical examination to assess the bladder and bowel are functioning correctly. Urinalysis, urine culture tests for signs of disease and ruling out any physical causes of enuresis such as:
Urinary tract infection – Urinary tract infections (UTIs) in children are fairly common, but not usually serious. They can be effectively treated with antibiotics.
Lower urinary tract infection – lower urinary tract function in children and adolescents: lower urinary tract symptoms can be cystitis and urethra, lower abdominal or suprapubic pain, dysuria, urinary frequency and urgency. Older children may present with signs and symptoms suggesting the site of infection.
Overactive bladder – Bladder overactivity can cause urinary incontinence and dysfunctional voiding. Small functional bladder capacity may mean poor bladder control as the full bladder needs to be emptied more frequently. Usually bladder dysfunction corrects itself by age 5, as the bladder capacity increases or the child learns to empty the bladder more frequently.
Neurogenic bladder – Neurogenic bladder is the name given to the neurologic symptoms that can cause poor bladder control. Congenital anomalies such as meningomyelocele and diseases/damage of the central, peripheral, or autonomic nervous systems may produce neurogenic bladder dysfunction.
Diabetes insipidus – Diabetes insipidus or “water diabetes” means that the child will urinate more frequently and in small amounts. This is because there’s not enough antidiuretic hormone (ADH) in the body. ADH is also known as vasopressin and helps the kidneys keep the correct amount of water in the body.
Diabetes mellitus – At presentation, the child with diabetes mellitus will have an increased thirst, usually have a history of bedwetting, poor bladder control, polyuria, polydipsia and weight loss for days to months. Diabetes mellitus may be diagnosed at nearly any age, though peaks in presentation occur between ages 5 to 7 and around puberty.
Nocturnal polyuria – Nocturnal polyuria is defined as the excessive over production of urine at night time. International Children’s Continence Society (ICCS) highlight nocturnal polyuria, as being 130% of expected or maximum bladder capacity.
The child has been at school all day and arrives home hungry and thirsty, this is usually their main nutritional and fluid intake of the day.
Sleep Apnea – Sleep apnea is when breathing stops and starts whilst you sleep. This can be a very serious condition as your brain is deprived of oxygen during sleep. Loud snoring, coughing or choking whilst asleep, breathing through the mouth, sleep terrors and bed-wetting are symptoms of obstructive sleep apnea. There are 2 types of sleep apnea :
Central sleep apnea: causes obstructive sleep as the brain fails to signal the muscles to breathe, due to instability in the respiratory control center.
Obstructive sleep apnea – Obstructive sleep apnea is when the airway is physically blocked during sleep. Obstructive sleep apnea is caused by a blockage of the airway, usually when the soft tissue in the back of the throat collapses during sleep.
Sickle cell disease – A hereditary condition that affects red blood cells. The child is encouraged to drink lots of fluids in an attempt to reduce the onset of pain. Sleep disturbance and depression are commonly encountered in children with this recessive genetic disorder, caused by mutations in the β-hemoglobin gene on chromosome 11. Bed-wetting is a symptom of sickle cell disease.
Urinary incontinence – The International Children’s Continence Society (ICCS) defines urinary incontinence as ‘involuntary leakage of urine’.
Psychophysiological causes of enuresis in children
Psychophysiological (mind impacting body) dis-ease is caused by the brain responding to a perceived threat within the immediate environment. This ‘threat’ (real or imagined) affects the limbic system, which triggers the fight, flight, freeze – stress response.
The information about the threat is held as an emotional memory image (EMI) inside the mind, creating a barrier to learning. This explains why it is so difficult for the child to consciously overcome involuntary urination whether monosymptomatic enuresis or nonmonosymptomatic enuresis. The limbic system, which is involved with motivation, emotion, learning, memory and behaviour is driven subconsciously, outside of the child’s awareness.
What contributes to emotional memory images?
Emotional memory images (EMI) are created after negative or positive learning experiences, from which the brain derives the best strategy to survive the current and future contexts.
The CDC-Kaiser Permanente Adverse Childhood Experiences (ACE) Study showed that 61% of adults had experienced at least one adverse childhood experience and (16%) 1 in 6 adults reported they had experienced four or more types of ACEs.
That’s an awful lot of EMI’s, which can attribute to long term health problems, of which primary monosymptomatic nocturnal enuresis can be a marker.
Psychophysiological causes of enuresis in children and adults:
Sexual abuse, physical/psychological harm from family members, arrival of a new sibling, growing up in a family that has mental disorders, toxic stress, the loss of a loved one, divorce, social and financial worries from family members passed on to the child.
Traditional talking therapy for these presenting problems often take years to bring about results, as many children have no conscious access to the experience, therefore can’t talk through it. Behavioral Therapy or any approach that targets the limbic system can bring about faster results. As the intersection between body and mind, the limbic system holds the key to many psychophysiological disorders.
The EMI remains stored inside the mind, activated only when something similar to the original context/experience comes along, triggering the original enuresis. This may account for secondary enuresis when the urinary symptoms return to be a problem many years later. More research is needed.
Enuresis treatment for children
Enuresis in children refers to the involuntary loss of urine during sleep, occurring at least twice a week in a child 5 years of age or older, for at least 3 months.
Enuresis in children is a normal condition that young children go through, but if your child has primary enuresis and shows no signs of stopping, then a treatment plan may be necessary.
Breaking non monosymptomatic enuresis
Enuresis in children is nocturnal enuresis (whilst asleep) and nonmonosymptomatic nocturnal enuresis means that the child has other symptoms contributing to enuresis.
To begin helping your child to be free of primary enuresis you must allow him/her to feel uncomfortable for a while with the cold wet bedding or clothes. Discomfort helps them to learn from a sensory basis. This can take a little time but it is worth the week or so that it might take.
Breaking primary nocturnal enuresis
When the daytime symptoms have gone, nocturnal enuresis becomes the final challenge. Remember the rule of uncomfortable at this stage, use cheap nappies/diapers for bedtime. Modern diapers are designed to keep baby dry for long periods of time, so if you use these during this stage it will make it difficult for the child to notice urinary symptoms.
What about Fluid intake?
Nocturnal enuresis in children is hardly impacted by normal fluid intake. Some parents reduce the fluid intake of the child to almost zero and still all of the bladder training, and bladder control fly out the window as the child falls asleep and nocturnal secretion occurs.
The child needs to have good hydration, keeping his fluid intake regular can help to prevent chronic constipation, which can cause an overactive bladder.
Nocturnal polyuria can develop too as a result of the child dehydrating during the day and drinking large quantities of fluids in the evening.
Nocturnal enuresis alarm therapy
Alarm therapy shows good results in children aged 7 and older but not so good for children younger. The enuresis alarms or bedwetting alarms have a moisture sensor, which buzzes or rings if the child begins to urinate. Enuresis alarm therapy has been used successfully over 30 years for the treatment of primary monosymptomatic nocturnal enuresis.
Each time the child’s bladder capacity creates dysfunctional voiding, the child is awoken by the bedwetting alarms signal. The brain is learning bladder training and associating this with a positive feeling of success. The parents then compound this success, which steadily supports the child to being able to maintain bladder control over an overactive bladder, nocturnal polyuria and monosymptomatic nocturnal enuresis.
Enuresis treated with Tricyclic antidepressants or Alarm therapy?
Desmopressin therapy, tricyclic and related drugs are first-line medications most commonly used in children with nocturnal polyuria and normal bladder range. Tricyclic antidepressants also goes by the name of imipramine [Tofranil]) and anticholinergics. Desmopressin is an analogue of antidiuretic hormone.
Studies with randomized controlled trials show a small but not significant change in nocturnal enuresis in children vs enuresis alarms or doing nothing at all.
A recent study was carried out to measure the effectiveness of alarm interventions vs tricyclic to resolve nocturnal enuresis in children Cochrane Database of Systematic Reviews. The research concluded that alarm therapy may be more effective than no treatment in reducing enuresis in children.
Considering there were 74 trials with a total of 5983 children, the researchers are uncertain if alarm therapy is more effective to treat bedwetting than desmopressin therapy. The study concluded there were no risk factors with alarm therapy.
The authors concluded
Although tricyclics and desmopressin are effective in reducing the number of wet nights while taking the drugs, most children relapse after stopping active treatment. In contrast, only half the children relapse after alarm treatment. Parents should be warned of the potentially serious adverse effects of tricyclic overdose when choosing treatment. Further research is needed into comparisons between drug and behavioural or complementary treatments, and should include relapse rates after treatment is finished.
Common risk factors of Tricyclic antidepressants (TCA’s) can include:
- dry mouth
- slight blurring of vision
- problems passing urine
- weight gain
- excessive sweating (especially at night)
- heart rhythm problems, such as noticeable palpitations or a fast heartbeat (tachycardia)
The side effects should ease after a couple of weeks as your body begins to get used to the medicine.
For more information on enuresis in children Cochrane database is a useful resource
Psychophysiological treatment for enuresis
Using the lens of psychophysiological dis-ease we may be able to have a positive affect on both primary monosymptomatic enuresis and nonmonosymptomatic enuresis, which opens the door to what western medicine describes as complementary and miscellaneous interventions.
As you have read earlier, the anti-depressant drugs are a front-line treatment for enuresis. Hopefully that will cause you to search for another way to help your child and it’s probably the reason you have read this far.
Enuresis in children is a natural process that each of us has been through on our journey to adulthood. For some, there maybe a troublesome EMI that creates a psychological barrier to learning, which continually prevents the next step in development.
Urinary incontinence presents with larger social and psychological stigmatism as the child grows older, therefore a fast solution to enuresis in children is called for.
Using the psychophysiological model to treat enuresis creates a therapeutic experience for the child’s subconscious mind to use. This intervention aims to clear the negative EMI, which may help to relieve behavioral disorders that have developed as a result of the EMI firing overtime.
Interestingly, bladder capacity, neurogenic bladder, overactive bladder, dysfunctional voiding and behavioural disorders may all be improved with a psychophysiological approach to helping your child.
What is a psychophysiological treatment for enuresis?
A psychophysiological treatment can be defined as a therapy or intervention that utilises the mind to create a change in the body. The limbic system holds the key to automatic responses that have happened as a result of adverse experiences. Interacting with this perceived reality can allow the emotional brain to upgrade.
The limbic system contains
The amygdala is at the core of a neural system for processing fearful and threatening stimuli. This includes detection of threat and activation of appropriate fear-related behaviours in response to threatening or dangerous stimuli.
The hippocampus, is essentially the memory centre of our brain. Connections made in the hippocampus also help us associate memories with various senses (the association between Christmas and the scent of gingerbread would be created here). The hippocampus is also important for spatial orientation and our ability to navigate the world.
Think of behavioural change as experiential learning, this includes Hypnotherapy, EMDR, Yin Yoga, Qigong, Tai Chi and even Salsa dancing. They can all create change in the stored emotional memory images. Opening up of the mind and body to listen and learn will influence the amygdala and hippocampus, allowing your system to take on new learning.
Hypnosis can be achieved via audio downloads or digitally via the internet.
MindReset app combines the strategies of limbic system learning and accelerates the intervention process via state of the art eye-tracking. The whole process works outside of the users conscious awareness, which can initially create confusion, as the user struggles to understand what has happened outside of their awareness.
The key to gaining the best results in any of the psychophysiological treatments is curiosity. The state of curiosity gives you the ability to overcome previous learning and upgrade your life.
Is a psychophysiological treatment for enuresis harmful?
A psychophysiological treatment for enuresis is usually done outside of conscious awareness, to create a change in the limbic system. There are no harmful effects associated with its use. Unlike the potentially serious adverse effects of tricyclic and other antidepressant drugs that are prescribed for children.
Antidepressant drugs and psychophysiological treatments have the same intention – to adjust the way a person perceives their reality. The latter is noninvasive whilst the former has a list of side effects.
A better way…
The good news is there is a better way to help with certain types of enuresis, more research is needed in this area.