Enuresis (urinating on): causes, symptoms and treatment
Enuresis is part of elimination disorders , corresponding to the group of psychopathologies related to the stage of childhood and development. Its manifestation is often the external sample of some kind of internal and intense emotional discomfort of the child.
Even though wetting the bed is a very common phenomenon in childhood, this disorder is relatively poorly understood. Far from maintaining the unfounded belief in the commission of this type of behavior as voluntary and malicious acts 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 the clinically significant difficulty in exercising adequate control of the sphincters in the absence of a cause, either organic or derived from the consumption of certain substances, clearly observable.
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 greater than twice a week for at least three months Consecutive
In addition, this type of behavior must generate a significant emotional discomfort in different areas of the child's life and can not be diagnosed before the age of five.
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Comorbidity and prevalence
In the usual way, the diagnosis of enuresis is associated with sleepwalking, night terrors and, above all, problems with sleep. deterioration of self-esteem, incomprehension and paternal criticism . As a result of these circumstances, the isolation of the child is derived 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 varies around 10% of the child population . Night enuresis is the most frequent. In most cases there is a spontaneous remission, mainly of secondary type, but it can also be maintained until adolescence.
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Types of enuresis
Enuresis can be classified according to three different criteria: moment when the episodes of sphincter decontrol , if it has preceded a time in which the child was able to control the pee and if it is accompanied by other concomitant symptoms.
Based on these criteria we can establish the following types of enuresis.
1. Diurnal, nocturnal or mixed enuresis
Diurnal enuresis occurs during the day and is related to anxious symptoms, more frequent in girls. The night type is more frequent and it is linked to images referring to the act of urinating during REM sleep. Cases of mixed enuresis are those in which the episodes occur both by day and by night.
2. Primary or secondary enuresis
The qualifier "primary" applies if the child has not previously experienced a sphincter control stage. In the case of enuresis secondary if a control stage has been observed in the past of a minimum duration of six months.
3. Monosymptomatic or polysymptomatic enuresis
As the name suggests, monosymptomatic enuresis is not accompanied by any other type of symptomatology, while polysymptomatic enuresis is accompanied by other voiding manifestations such as pollakiuria (increase in the number of daily urinations).
Causes
Without being able to count today with a general consensus on what are the factors that cause enuresis, there seems to be some agreement in establishing an interaction between causes of biological type and psychological type .
There are three kinds 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 presented said alteration during his childhood, compared to 15% of the children of families with no history.
In addition, greater correspondence has been found between monozygotic twins than between dizygotic twins, which indicates a significant degree of genetic determination and heritability.
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2. Physiological theories
Physiological theories defend the existence of altered bladder function , as well as insufficient capacity in the bladder.On the other hand, there has been a deficit in the secretion of the hormone vasopressin or antidiuretic, predominantly during the night.
3. Psychological theories
These theories argue for the presence of emotional or anxiogenic conflicts that result in the loss of sphincter control, although some authors indicate that it is enuresis itself that motivates these emotional alterations.
It seems that the experience of stressful experiences like the birth of a brother , the separation of the parents, the death of a significant person, the change of school, etc. they can be associated with the development of the disorder.
The behavioral current proposes a process inadequate learning of hygienic habits as a possible explanation of enuresis, further affirming that certain parental patterns can negatively reinforce the acquisition of sphincter control.
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Intervention and treatment
Various are the treatments that have a proven efficacy in the intervention in enuresis, although it is true that multimodal therapies that combine several of the components listed below have a more acceptable success rate.
Next, we will describe the intervention techniques and procedures currently used in the treatment of enuresis.
1. Motivational therapy
In enuresis, Motivational Therapy focuses on the decreased anxiety and emotional disturbances comorbid with the disorder, as well as working to enhance self-esteem and improve the family relationship.
2. The Pipe-Stop Technique
The "Pipí-Stop" is based on the operating technique of Token Economics . Once the anamnesis was made and the functional analysis of the case was elaborated by means of the interviews with the parents and the child, it is prescribed to carry out an autoregistration on the evolution of the enuretic episodes during each night. At the end of the week a count of points is made and, in case of having reached a certain goal, the child receives a reward for the achievement obtained.
At the same time follow-up interviews with the family are carried out, tips are given to increase the effectiveness of the bladder function and progressively more advanced objectives are being proposed.
3. Training in Dry Bed
This intervention program proposes a series of tasks divided into three differentiated phases in which fundamental principles of operant conditioning are applied: positive reinforcement, positive punishment and overcorrection of behavior.
At first, together with the installation of a Pipi-Stop device (sound alarm), the child is instructed in the so-called "Positive Practice", in which the subject must get out of bed to go to the bathroom Repeatedly, ingest a limited amount of fluid and go back to bed and start the dream. After an hour he is awakened to see if he is able to endure the need to urinate for longer. This procedure is repeated every hour that same night.
In case of wetting the bed, the Cleaning Training is applied, by which the child must change both his own clothes and those of the bed that has been soiled before going back to sleep.
In a second phase, the child is awakened every three hours until he gets add seven consecutive nights without wetting the bed . At that moment, we move on to a final phase in which the alarm device is removed and we allow it to sleep through the night without waking it up. This last phase ends when the child has achieved a total of seven nights in a row without wetting the bed.
For each successful night it is positively reinforced to the child and for each night of non-control, Positive Practice should be applied immediately.
4. Bladder distension exercises
They consist of training the child to go increases all the time of urine retention Gradually The child should notify the parents when they feel like urinating and in addition, 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 Oxybutyn and Imipramine (muscle relaxants for increased bladder capacity), have a moderate efficacy in the treatment of enuresis, since they get lost the improvements as soon as the treatment is abandoned and have considerable side effects (anxiety, sleep disturbances, constipation, vertigo, etc.).
6. Multimodal treatments
These intervention packages combine different techniques exposed in previous lines and present a higher efficacy since they address the alterations produced in the cognitive (psychoeducation of the disorder), affective (coping with anxiety, fears and concerns generated), somatic (pharmacological prescription), interpersonal (coping with family stressors) areas. and behavioral (the intervention of enuretic behavior directly).
Leaving the bed wet
As has been observed, enuresis is a complex psychopathology that requires a set of interventions that involve the entire family system.
It is very relevant the application of behavior modification techniques , concretely the "Pipí-Stop" and the Training in cleaning, although equally fundamental it becomes to deepen and to determine what factors of emotional character are causing such symptomatology.
Bibliographic references:
- Belloch, A., Sandín, B. and Ramos, F. (1995). Manual of psychopathology (Vol.2, Part VI, Psychopathology of development). Madrid: McGraw-Hill.
- Caballo, V. and Simón, M. A. (Eds.) (2002). Manual of clinical psychology of childhood and adolescence, 2 volumes. Madrid: Pyramid.
- Ollendick, T. H. and Hersen, M. (1993). Psychopathology for children. Barcelona: Martinez Roca.
- Méndez, F.J. and Maciá, D. (1990). Behavior modification with children and adolescents. Book of cases. Madrid: Pyramid.
