Enuresis can occur only at night (nocturnal), which is more common, or only in health problems (such as urine infections, diabetes, kidney or bladder disorders) …
Bedwetting and Its Treatment
The diagnosis of Enuresis, or Bedwetting, requires accidental or voluntary
urination into clothes, bedclothes, or bedding at least twice a week for at
least three months after the age of five Enuresis can occur only at night
nocturnal, which is more common, or only in the day diurnal, or both
Enuresis can be primary or secondary In primary enuresis the child was
never successfully toilet trained for bladder control while secondary
enuresis means that wetting has resumed after having been free of wetting
for at least several months, and sometimes years Bedwetting frequently
runs in families and is often inherited It is also more common in boys
Encopresis refers to fecal staining or lack of bowel control and is covered
in the article below although it may occur along with enuresis, especially
in more severe cases This article does not address the incontinence that
may occur with older age, multiple childbirths, or certain health problems
in some adults
Fortunately, the prognosis of bedwetting is usually good Most youth
outgrow bedwetting during their elementary school years or teens probably
due to the natural course of brain
maturation which comes with development
However; less than 1 of 18 year olds, especially males, still wet the bed
at least once a week
The first step in treating enuresis is determining whether or not it
happens only at night, whether or not it occurs after a prior period of
bladder control, and whether or not there may be some other associated or
causal medical or psychiatric problems If neurologic problems such as
seizures or paralysis, etc, health problems such as urine infections,
diabetes, kidney or bladder disorders, or psychiatric problems such as
sexual abuse, developmental delays, sleep disorders, or ADHD, exist, they
are usually treated first Medications that overly sedate the child
antihistamines, sleep aides, etc or increase urine flow diuretics,
aminophylline, caffeine, lithium, etc can cause bedwetting to occur or
increase
The second step is to next decide whether the bedwetting or day wetting
even needs any additional treatment If the wetting does not lead to
social, self esteem, family, or other problems or if it is mild, it may be
left untreated Frequently however, the result of bedwetting is
embarrassment, avoidance of sleep-overs, lessened self esteem, and
or
family conflict Wetting during the day is often even more of a concern
Once the decision to explore treatment has been made there are several
possible approaches The first is to provide the family with basic toilet
training guidance emphasizing routine toileting scheduling and rewarding
the child for success This helps the primary enuretic never successfully
toilet trained child learn to read and act appropriately on the body
signals that urination is needed Restricting fluids after supper and
ensuring voiding just before sleep is advisable This broad approach along
with helping the family provide supportive understanding to the child who
has resumed wetting secondary due to a move, birth of a sibling, parental
separation, divorce, new parental relationship, or traumatic event; is
often all that is necessary These steps are what is called standard
pediatric management and is often effective Daytime wetting occurs most
often because the youth fails to recognize the body signals that going to
the bathroom is needed or is just too busy and doesnt want to stop for a
bathroom break and waits too long Both of these can be helped by
scheduling bathroom breaks regardless of perceived
need and rewarding
success
Some cases need more in-depth treatment The two most common treatments at
this stage are psychotherapy, especially using specialized behavioral
techniques, or medications These approaches can also be used together
Lets explore the special behavioral techniques first These can be broken
into two categories; bladder training and the bell or alarm pad method
Both are highly effective 60 to 80 for people able and willing to stick
through the treatment and may even cure but require sustained intensive
effort and compliance by the child and parents This approach is most
effective with a dedicated family and child working with a skilled
behavioral therapist I refer the family to an expert for this
Medications have a lower rate of success and primarily suppress the problem
until maturation and training kick in, but are generally easier to use The
three most reliable options are Imipramine Tofranil and cousins,
oxybutinin Ditropan, Ditropan XL and DDAVP Imipramine has been around
for many years, is well known and studied, is very cheap, and has many
other uses such as for depression, sleep, attention deficit, chronic pain,
and preventing migraines See my
medicine chart on the tricyclic
antidepressants The dosage for bedwetting is on the low end of the range,
usually 25 to 100 mgs, and may require some monitoring of blood and heart
rhythm EKG Response is generally partial and helps a lot about 40 to 60
of the time Oxybutinin or its brand Ditropan is often used by general
doctors or urologists for overactive bladder and can be used for enuresis
as well I usually prefer DDAVP DDAVP is a synthetic version of the body
hormone Vasopressin which is also known as anti-diuretic hormone DDAVP was
invented to treat Diabetes Insipidus not sugar diabetes which is known
as Diabetes Mellitus in which people dont produce enough Vasopressin We
dont fully understand how Imipramine or DDAVP work but the theory on DDAVP
is that it boosts the apparently inadequate nighttime body production of
Vasopressin in uncomplicated enuretic patients DDAVP may rarely unbalance
electrolytes sodium, potassium, chloride, etc in the blood and thus a
check of a blood test after being on it awhile may make sense, especially
if negative effects occur This is probably not routinely necessary I have
not seen a single side effect with this medicine DDAVP comes in both
a
nose spray and a pill form The success rate of DDAVP is higher than
Imipramine but may not be as high as with behavioral treatment DDAVP is
easy to use Both medicines are generally given at night and are most
effective given every night They can be given morning and night if wetting
also occurs in the day The medicine is generally taken for about six
months and then stopped to see if wetting recurs If it recurs the medicine
may be restarted for another six months and the cycle repeated The
medicine success rates may appear lower at least partly because the
treatment dropouts or refusers are typically subtracted before calculating
the success rates with behavior treatment and may not be with the medicine
treatments
In summary, enuresis may affect day and or night; may be primary or
secondary; may be mild or complicated; may be caused by genetic,
psychiatric, or other medical reasons; and is often successfully treatable
by more than one technique
What Is Encopresis? soiling
Encopresis is the repeated accidental or intentional soiling of clothes or
other places floor, etc by the passage of partial or full bowel
movements beyond the age, or developmental level of, at least 4 or 5
The
diagnosis is usually not given unless the problem occurs at least weekly
for at least 3 months The diagnosis of encopresis is not given if some
other medical condition, except constipation, causes the problem Such
causes may include laxative misuse, dietary causes like lactose
intolerance, problems with absorption, low thyroid, bowel or rectal
structural abnormality, sexual abuse, etc The diagnosis generally refers
to children and adolescents and does not include the incontinence that may
occur in previously soiling free adults who have the symptom start but is
caused by some other health problem
Encopresis may occur either with or without constipation and overflow
incontinence A recurrent alternating pattern of constipation and loose
diarrhea-like stools is not unusual Encopresis is 4 times more common in
boys than girls It occurs in about 15 of children, lessens with age and
is rare in teens It may run in the family Higher rates are seen in people
who are mentally retarded, developmentally delayed, sexually abused, or
have seizures Soiling can occur up to multiple times daily and may involve
the hiding of dirty underwear by a youth who may seem unaware or not caring
about
the problem
The very young child often naturally experiences his or her bowel movements
as a production to be proud of, even to play with - this may linger in some
kids who have encopresis The encopretic child has typically lost
sensitivity to the gastro-colic reflex see below as well as to the smell,
and to the rectal and anal areas remarkable ability to distinguish between
and control the release of gas, liquid, and solid It is natural to wonder
if this is some neurologic disorder The mechanism of this seeming loss of
sensation and smell is best understood if you think about what happens if
you spend the next month full time with an oily smelly moist rag wrapped
around your hand or if your hand was immersed in a bucket of liquid for a
month Your body would adjust to this now constant condition and the
sensory messages would fade into the background as more important changing
stimuli would register instead
Encopresis, like enuresis, can be primary or secondary Primary means that
the youth has never had a significant period of full bowel control, such as
at least 3 months Secondary means the soiling returns after a significant
period of bowel control
Treatment: The first step is
to make sure there is no other medical cause
of the problem A visit to the pediatrician or family doctor for a physical
examination is advised strongly The physical will often include a rectal
examand simultaneous feeling palpation of the abdomen belly to ensure
there is no impaction An impaction is a large hard mass of fecal material
which often will not pass on its own without laxatives or enemas as advised
by the doctor Such cases are often marked by daily leakage of liquid or
very soft stool with a formed stool being rare or nonexistent The later
steps in treatment will often be unsuccessful unless this is cleared up and
kept clear The doctor will also assess whether any other factors may be
causing the problem This is generally done by listening to the history and
doing the physical and may occasionally include other tests or referral to
a gastrointestinal specialist or neurologist
The second step is standard pediatric behavior therapy which takes
advantage of the natural body rhythm of the gastro-colic reflex When food
goes into the stomach gastro the bowels colic soon move The key is re-
training the childs body to do what comes naturally This is done by
having the youth
sit on the toilet for 10-15 minutes after, at least,
breakfast and supper lunch too, if feasible for which he or she is
rewarded whether he produces a bowel movement or not An extra reward is
earned for production of a BM; there is no punishment for failing to
produce The rewards chosen will depend on the child and his or her
interests - nintendo time, a goody grab bag, points toward a pokemon card,
etc This is the key to the treatment; the child who never learned or
resisted and lost touch with the body rhythm will be re-trained and become
able to read and will be rewarded for responding to the body cues to
defecate Once normal control has been gained, this same basic at least
twice daily toileting and reward system should be maintained for at least 2
months for mild cases, 4 months for moderate, and 6 months for severe cases
in order to lessen the very high relapse rates
Stool softeners, not laxatives, are used as part of the on-going behavior
plan for all moderate to severe cases and anytime there has been an
impaction or recurrent constipation, or tendency for the child to hold in
the stool The most powerful softeners are the forms of mineral oil which
prevent constipation
when given daily as directed by the physician Medical
involvement is key to ensure no laxative is given they can damage the
future bowel function and to ensure the tendency of mineral oil to deplete
the body of fat soluble vitamins E,A,D does not occur The generic
prescription of Miralax or Glycolax is often the best choice This or an
over the counter softener such as Colace DSS can be advised by the
physician and adjusted just right and weaned off with time
If the youth or family cannot follow through with the above plan,
psychotherapy is advisable or may be necessary There are no psychiatric
medicines for encopresis Sometimes a medication may be useful for an
accompanying depression, anxiety disorder, ADHD, etc Treatment is made
more difficult by a high frequency of soiling or a long duration of the
problem, resistance to the treatment plan or inability to follow the plan,
and by accompanying medical, emotional, or family problems Generally,
frequent long standing soiling is much tougher to successfully treat than
bedwetting and tougher than many other childhood behavioral problems
Severe cases may also be marked by a very angry withholding child and a
very frustrated angry
parent wherein the parent child relationship may seem
poisoned by the longstanding control and power conflicts In these
situations the childs character formation may be at risk Fortunately, as
even these youth progress through middle school and into high school peer
pressure and increasing awareness of the social costs often lead to the
resolution of the encopresis
When primary never been successfully bowel trained encopresis has been
present for a short period of time and is uncomplicated by serious
psychiatric problems like attachment disorder, serious developmental
delays, or abuse and molest, the treatment is often a matter of improving
the basic toilet training routine as outlined above Inadequate,
inconsistent, or punitive toilet training is the usual cause and can be
addressed by working with the parents primarily The same is true for brief
duration mild to moderate secondary encopresis soiling has returned
Frequently some stressful event is the trigger and needs addressing These
events may include a move, starting or changing schools, parental
separation, divorce or conflict, birth of a sibling, or a traumatic event
Complications and severe cases usually indicate the need
for counseling,
psychotherapy, and/or behavior management therapy for the family
———————–
Kevin Leehey, MD
Child, Adolescent and Adult Psychiatry
Find this issue of Medical Memo, past issues, and other helpful information
at Dr Leeheys web site:
wwwleeheymdcom
This newsletter is for information only and does not substitute for talking
with your psychiatrist, medical doctor, and/or therapist
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