Enuresis Assessment and Treatment
Assessment of Enuresis
A diagnosis of enuresis cannot be made until it is clear that there is no medical problem that accounts for the behavior. Accordingly, the child be examined medically to rule out possible medical conditions (e.g., urinary tract infections, birth defects, and traumatic injury) that can be creating the problem. A physical medical examination is supplemented with lab tests (including a urinalysis) and a detailed clinical history of the problem (including questions about emotional problems, as well as the onset and course of the wetting behavior) to help establish the appropriate diagnosis. Standardized tests such as the Child Behavior Checklist and the Conners Parent and/Teacher Rating Scales may also be administered to help round out the information. Both scales are useful ways to determine if any other problems (e.g., anxiety, depression, anger, ADHD, etc.) are contributing to or exacerbating the Enuresis behavior and can be used with children (depending on their ages), parents, and teachers.
Treatment of Enuresis
A number of options are presently available for treating Enuresis. One very well-known behavioral treatment known as the "bell-and-pad" procedure dates back to the 1930s. The bell-and-pad procedure utilizes a urine-sensitive pad that is placed under the child's buttocks. The pad is connected to a loud bell or buzzer. If a child starts to urinate in the bed, the urine activates an alarm that wakes the child up. Across time, sleeping children learn to identify the sensation of having a full bladder, because doing so helps them predict and avoid the loud, jarring alarm. Eventually, trainees wake up when their bladders are full and are then able to use the bathroom appropriately. The bell and pad procedure eliminates nighttime Enuresis in about 75% of cases, although relapse rates thereafter are generally high. However, most of the time, repeated use of the treatment generally leads to a complete cure.
Another well-known type of behavioral treatment for Enuresis was developed in 1974 by Arzin, Sneed, & Foxx. This technique involved a range of strategies including:
- positive reinforcement (rewards or praise) for urinating appropriately
- urine retention control training (strategies to promote better bladder control)
- positive practice (parents help their child to develop the habit of going to the bathroom at regular intervals during the day, just before sleep, and during the nighttime in order to avoid accidents)
- nighttime waking (children learn to wake themselves in the night to use the restroom)
- cleanliness training (children help thoroughly clean the bedding and mattress when accidents occur)
- mild punishment (primarily disapproval when accidents occur)
- family encouragement of good toilet habits and successful progress.
Success rates associated with this Enuresis treatment appear to be around 85%, with relapse rates falling between 7%-29%. Some people view this strategy as a kinder, gentler and more effective approach than the bell and pad procedure described previously.
Arousal training is another technique useful for treating Enuresis. This approach combines the use of a urine alarm and a reward system. The urinary alarm sensor is typically attached to the crotch area of the child's underpants (like a panty liner), and connects to a watch bracelet worn on the child's wrist. Children must turn off the alarm, use the restroom, and then return to bed and reset their alarm within three minutes in order to receive a reward. Parents reward and punish the child's performance with stickers. Two stickers are handed out on nights where all the required toilet activities occur within the three minute window. One sticker is taken away from the child on nights when performance is slow. This treatment is designed to be self-contained and can be implemented without the aid of a child health professional. Parents purchase the urine alarm system, read the accompanying instructions, and implement the treatment on their own. Urine alarms are available through Nytone Medical Products, (801-973-4090), or Palco Laboratories, (831-476-3151).
Some physicians may suggest a pharmacological treatment for Enuresis. The most commonly prescribed drug is imipramine (Tofranil) which is an old-style tricyclic antidepressant. Imipramine treatment is often a successful treatment in the short term, with between 40 and 50 % of children showing improvement. However, when the drug is discontinued, about 2/3 of children show a relapse and begin enuresis behavior again.
Though generally quite safe when taken as prescribed, Imipramine is not without its side effects (e.g., tremors, dizziness, confusion, weight gain, and nausea) and cautions. Additionally, children are more sensitive to overdose with Imipramine than are adults, so the dose used to treat childhood enuresis must be tightly-controlled by a child psychiatrist who has experience treating this disorder. In addition, antidepressants have a black box warning because some children who have been prescribed antidepressants have shown suicidal behavior. Though the actual risk of suicidal symptoms is small, the possibility of suicidal impulses remains a danger that must be closely monitored by parents and (ideally) by an experienced mental health clinician. It's a good idea to talk with your doctor about the risks and benefits associated with antidepressant treatment for children before that treatment begins.
Alternatives to antidepressant therapy for enuresis exist. Desmopressin (DDAVP) is a synthetic form of a natural pituitary antidiuretic hormone which reduces urinary production by instructing the kidneys to retain water inside the body rather than excreting it. Administering Desmopressin to children reduces their urine output dramatically, making it easier for them to maintain continence. Between 10 and 60 percent of children with enuresis taking DDAVP show improvements. However, as is the case with Imipramine, relapses back into enuresis are common when the drug is discontinued.
Due to their better side effect profiles and longer lasting effects, behavioral treatments for enuresis are usually recommended over medical ones with rare exception.