Mental Health: Enuresis What is Enuresis?

Enuresis is when a child has repeated passage of urine in places other than the toilet. Enuresis that occurs at night, or bed-wetting, is the most common type of elimination disorder. This behavior may or may not be purposeful. The condition is not diagnosed unless the child is 5 years or older. Nocturnal enuresis is the passage of urine during nighttime sleep, while diurnal enuresis is daytime wetting. Children with enuresis may experience either nocturnal or diurnal wetting, or they may experience a combination of both. What Are the Symptoms of Enuresis? The main symptoms of enuresis include:

Repeated bed-wetting. Wetting in the clothes. Wetting at least twice a week for approximately 3 months.

What Causes Enuresis? Many factors may be involved in the development of enuresis. Involuntary, or non-intentional, release of urine may result from:

A small bladder. Persistent urinary tract infections. Severe stress. Developmental delays that interfere with toilet training.

Voluntary, or intentional, enuresis may be associated with other mental disorders, including behavior disorders or emotional disorders including anxiety. Enuresis also appears

to run in families, which suggests that a tendency for the disorder may be inherited (passed on from parent to child). In addition, toilet training that was forced or started when the child was too young may be a factor in the development of the disorder. Currently, however, there is little research to make firm conclusions about the role of firm or lax toilet training regimens in the development of enuresis. Children with enuresis are often described as heavy sleepers who fail to awaken at the urinary urge to void or when their bladders are full. How Common Is Enuresis? Enuresis is a common childhood problem. Estimates suggest that 7% of boys and 3% of girls age 5 have enuresis. These numbers drop to 3% of boys and 2% of girls by age 10. Most children outgrow this problem by the time they become teens, with only about 1% of males and less than 1% of females having the disorder at age 18. How Is Enuresis Diagnosed? First, the doctor will take a medical history and perform a physical exam to rule out any medical disorder that may be causing the release of urine, which is called incontinence. Physical conditions that could result in incontinence include diabetes, an infection, or a functional or structural defect causing a blockage in the urinary tract. Enuresis also may be associated with certain medicines that can cause confusion or changes in behavior as a side effect. If no physical cause is found, the doctor will base his or her diagnosis of enuresis on the child's symptoms and current behaviors. How Is Enuresis Treated? Treatment may not be needed for mild cases of enuresis, because most children with this condition outgrow it (usually by the time they become teens). Knowing when to begin

treatment is difficult because it is impossible to predict the course of symptoms and when the child will simply outgrow the condition. Some factors to consider when deciding to begin treatment are whether the child's self esteem is affected by the wetting and whether enuresis is causing impairment in functioning, such as causing the child to avoid attending sleepovers with friends. When treatment is used, therapy aimed at changing behavior is most often recommended. Behavior therapy is effective in more than 75% of patients and may include:

Alarms: Using an alarm system that rings when the bed gets wet can help the child learn to respond to bladder sensations at night. The majority of the research on enuresis supports the use of urine alarms as the most effective treatment. Urine alarms are currently the only treatment associated with persistent improvement. The relapse rate is low, generally 5-10%, so that once a child's wetting improves, it almost always remains improved. Bladder training: This technique uses regularly scheduled trips to the bathroom timed at increasing intervals to help the child become use to "holding" urine for longer periods. This also helps to stretch the size of the bladder, which is a muscle that responds to exercise. Bladder training is typically used as part of a larger treatment package Rewards: This may include providing a series of small rewards as the child achieves bladder control.

Medications are available to treat enuresis, but they generally are only used if the disorder interferes with the

child's functioning and usually are not recommended for children under 6 years of age. Medications may be used to decrease the amount of urine produced by the kidneys or to help increase the capacity of the bladder or. Drugs commonly used include desmopressin acetate (DDAVP), which affects the kidneys' urine production, and imipramine (Tofranil), an antidepressant which has also been found useful for treating enuresis. While medications can be useful for managing the symptoms of enuresis, typically once medications are stopped, the child begins wetting again. When choosing medications for children, the side effect profile and the costs of medications need to be considered. The best uses of medication for treating enuresis tend to be to improve child functioning until the behavior treatments are effective. What Is the Outlook for Children With Enuresis? Most children with enuresis outgrow the disorder by the time they reach their teen years, with a spontaneous cure rate of 12-15% per year. Only a small number, about 1%, continue to have a problem as adults. Can Enuresis Be Prevented? It may not be possible to prevent all cases of enuresis -particularly those that are related to problems with the child's anatomy -- but getting treatment as soon as symptoms appear may help reduce the problems associated with the condition. Being positive and patient with a child during toilet training may help prevent the development of negative attitudes about using the toilet. Reviewed by the doctors in the Section of Behavior Medicine at the Children's Hospital at the Cleveland Clinic (2005).

What Are Elimination Disorders? Elimination disorders occur in children who have problems going to the bathroomboth defecating and urinating. Although it is not uncommon for young children to have occasional "accidents," there may be a problem if this behavior occurs repeatedly for longer than 3 months, particularly in children older than 5 years. There are two types of elimination disorders, encopresis and enuresis.

Encopresis is the repeated passing of feces into places other than the toilet, such as in underwear or on the floor. This behavior may or may not be done on purpose. Enuresis is the repeated passing of urine in places other than the toilet. Enuresis that occurs at night, or bed-wetting, is the most common type of elimination disorder. As with encopresis, this behavior may or may not be done on purpose.

What Are the Symptoms of Encopresis? In addition to the behavior of releasing waste in improper places, a child with encopresis may have other symptoms, including:

Loss of appetite Abdominal pain Loose, watery stools (bowel movements)

Scratching or rubbing the anal area due to irritation from watery stools Decreased interest in physical activity Withdrawal from friends and family Secretive behavior associated with bowel movements.

What Causes Encopresis? The most common cause of encopresis is chronic (longterm) constipation, the inability to release stools from the bowel. This may occur for several reasons, including stress, not drinking enough water (which makes the stools hard and difficult to pass) and pain caused by a sore in or near the anus (the opening of the rectum in the fold between the buttocks, where waste is expelled). When a child is constipated, a large mass of feces develops, which stretches the rectum. This stretching dulls the nerve endings in the rectum, and the child may not feel the need to go to the bathroom or know that waste is coming out. The mass of feces also can become impactedtoo large or too hard to pass without pain. Eventually, the muscles that keep stool in the rectum can no longer hold it back. Although the large, hard mass of feces cannot pass, loose or liquid stool may leak around the impacted mass and onto the child's clothing. Factors that may contribute to constipation include:

A diet low in fiber Lack of exercise Fear or reluctance to use unfamiliar bathrooms, such as public restrooms

Not taking the time to use the bathroom Changes in bathroom routines; for example, when going to school and there are scheduled bathroom breaks

Another possible cause of encopresis is a physical problem related to the intestine's ability to move stool. The child also may develop encopresis because of fear or frustration related to toilet training. Stressful events in the child's life, such as a family illness or the arrival of a new sibling, may contribute to the disorder. In some cases, the child simply refuses to use the toilet.

How Common Is Encopresis? Encopresis is fairly common, even though many cases are not reported due to the child's and/or the parents' embarrassment. It is estimated that anywhere from 1.5% to 10% of children have encopresis. It is more common in boys than in girls. How Is Encopresis Diagnosed? If symptoms are present, the doctor will begin an evaluation by performing a complete medical history and physical examination. The doctor may use certain testssuch as Xraysto rule out other possible causes for the constipation, such as a disorder of the intestines. If no physical disorder is found, the doctor will base his or her diagnosis on the child's symptoms and current bowel habits. How Is Encopresis Treated?

The goal of treatment is to prevent constipation and encourage good bowel habits. Educating the child and family about the disorder is another important part of treatment. Treatment often begins by clearing any feces that has become impacted in the colon, also called the large intestine. The next step is to try to keep the child's bowel movements soft and easy to pass. In most cases, this can be accomplished by changing the child's diet, using scheduled trips to the bathroom and encouraging or rewarding positive changes in the child's bathroom habits. In more severe cases, the doctor may recommend using stool softeners or laxatives to help reduce constipation. Psychotherapy (a type of counseling) may be used to help the child cope with the shame, guilt or loss of self-esteem associated with the disorder. What Other Problems Are Associated with Encopresis? A child with encopresis is at risk for emotional and social problems related to the condition. They may develop selfesteem problems, become depressed, do poorly in school and refuse to socialize with other children, including not wanting to go to parties or to attend events requiring them to stay overnight. Teasing by friends and scolding by family members can add to the child's self-esteem problems and contribute to the child's social isolation. If the child does not develop good bowel habits, he or she may suffer from chronic constipation. What Is the Outlook for Children with Encopresis? Encopresis tends to get better as the child gets older, although the problem can come and go for years. The best results occur when all educational, behavioral and emotional issues are addressed. A child may still have an occasional

accident until he or she regains muscle tone and control over his or her bowel movements. Can Encopresis Be Prevented? Although it may not be possible to prevent encopresis, getting treatment as soon as symptoms appear may help reduce the frustration and distress, as well as the potential complications related to the disorder. In addition, being positive and patient with a child during toilet training may help prevent any fear or negative feelings about using the toilet. Reviewed by the doctors at The Cleveland Clinic Department of Psychiatry and Psychology. Edited by Cynthia Dennison Haines, MD, on July 1, 2005.