The elimination of bodily waste is a fundamental function that occurs instinctively from birth. A large development is initiated in the first years of life, which will lead the child from total dependence to complete autonomy. In this evolutionary process, which generally extends until the fourth or fifth year of life, the child must acquire a series of learnings. These learnings eventually consolidate as self-care habits.
Sphincter control generally follows a sequence that is common to most children. The first thing that is acquired is nocturnal fecal continence. In other words, the control of bowel emptying during sleep. The second thing that is acquired is the daytime fecal control. Usually acquired soon after daytime urinary continence. Finally, nighttime urine control is obtained, which is usually the sequence that takes the longest to acquire.
Gender is a variable that also influences the age of sphincter control. Normally, girls gain control before boys, with a lag that can range from a few months to 2 or 3 years. Despite this variability, control begins in principle to be performed after 18 months and is acquired between 3 and 5 years. When the child exceeds these times of development, the lack of urinary or fecal control is considered problematic.
There are many children who, after 5 years, still pee on them either during their sleep or during the day. This is a source of discomfort, both for children and for parents.
What is enuresis?
Bedwetting has traditionally been defined as an involuntary and persistent discharge of urine. This discharge occurs during the day, at night, or both, after the age of 4-5 years. In other words, the term enuresis refers to the repeated and involuntary emission of urine in inappropriate places, such as the bed or clothes, in children over 5 years of age. Age at which we assume that the child should have already acquired urinary control, and since there is no organic pathology motivating incontinence.
Bedwetting is one of the most common problems in children and refers to the fact that urination takes place during sleep. Between 10 and 20% of 5-year-olds usually have this problem overnight.
The causes of enuresis
Different hypotheses have been formulated to explain the origin of enuresis, but none of the variables studied could explain the phenomenon on its own. This is why the most accepted hypothesis is that of multicausal etiology.
Multicausal etiology refers to the existence of various physiological, maturation, genetic and learning factors. Interacting with each other, this set of factors would help explain, to a greater or lesser extent, each case of bedwetting.
In order to gain urinary control, a child needs to learn to identify detrusor contractions as a sign that his bladder is full. Therefore, the child should go to the required place to urinate.
It is normal for the bladder to be relaxed during the filling phase and for the detrusor to contract only when the latter is completely full. However, some enuretics show a high detrusor hyperactivity. This causes uncontrolled contractions before the bladder is full.
This is the reason why the child shows a great urgency to urinate, which can lead to nocturnal incontinence. Overactivity of the detrusor during sleep could be responsible for about a third of cases of bedwetting.
The existence of a familiar pattern is a known fact in enuresis. In about 75% of bedwetting cases, there is a first-degree relative with a family history of bedwetting.
In addition, several genes have been identified which seem to be involved in the problems of nocturnal enuresis. However, the results are not entirely conclusive.
The voluntary control of urination is a complex phenomenon which supposes that the child sequentially acquires a series of specific skills:
- Recognize the signs of bladder distension, that is, their bladder is full and be able to communicate it to others.
- Awake and with a full bladder, learn to contract the muscles of the pelvis to hold urine until it reaches the right place.
- Relax said muscles to start urinating.
- Control the emptying of urine with different filling levels, being able to stop and restart it.
If this sequence is not learned correctly, it will not be automated, so it will be difficult to apply at night to achieve control of nighttime urination.
Symptoms of bedwetting
As we have seen previously, the main symptom of bedwetting is the loss of urine, unintentional or intentional. It occurs with a frequency of 2 episodes per week, for a period of at least 3 consecutive months.
Bedwetting causes clinically significant discomfort or deterioration in social, academic or other important areas of activity in the child. Some children with bedwetting may have difficulty waking up and have constipation.
Treatment of enuresis
There are several treatment options for bedwetting, which range from pharmacological treatment to behavioral treatment. Regarding pharmacological treatment, one of the most widely used drugs has been imipramine, a tricyclic antidepressant.
In recent years, the use of imipramine has been replaced by desmopressin, an analogue of the antidiuretic hormone (vasopressin). It facilitates the reabsorption of water by the kidneys, so that the volume of urine is reduced.
Regarding behavioral treatment, we can say that it is consolidated in psychological intervention. This treatment was developed from three basic procedures: the alarm method, urine retention training and dry bed training.
Therefore, if one of your children suffers from enuresis, it is recommended to consult a specialized psychologist. Let us not lose sight of the fact that the behavioral treatment is effective and that the side effects of the drugs will thus be avoided.
Comeche Vallejo, I., Vallejo Pareja, MA Manual of Behavioral Therapy in Childhood. Dykinson-Psychology. Madrid, 2012.
Bragado Álvarez, C. Enuresis infantil. Pyramid Madrid, 2006