Enuresis is included among the disorders of elimination , corresponding to the group of psychopathologies related to the stage of childhood and development. Its manifestation is often the external sign of some kind of internal and intense emotional discomfort of the child.

Although bed-wetting is a very common phenomenon in childhood, this disorder is relatively poorly understood.Far from maintaining the unfounded belief that this type of behaviour is voluntary and malicious 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 adequately exercising sphincter control in the absence of a clearly observable cause, either organic or derived from the consumption of certain substances.

Among the diagnostic criteria, 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 consecutive months

In addition, this type of behavior must generate significant emotional distress in different areas of the child’s life and cannot be diagnosed before the age of five.

Comorbidity and prevalence

Usually, associated with the diagnosis of enuresis is the presence of
sleepwalking, night terrors and, above all, problems of deterioration of self-esteem, incomprehension and parental criticism . As a consequence of these circumstances, the child becomes isolated in terms of participation in activities that involve outings such as excursions or camping.

Prevalence in each sex varies with age, being higher in younger children and older girls, although the overall proportion varies
. Nocturnal enuresis is the most frequent. In most cases, spontaneous remission occurs, mainly from the secondary type, but it can also be maintained until adolescence.

Types of Enuresis

Enuresis can be classified according to three different criteria
when the episodes of lack of sphincter control occur, whether it has preceded a time when the child was able to control the pee and whether it is accompanied by other concomitant symptoms.

According to these criteria we can establish the following typologies of enuresis.

1. Daytime, nighttime or mixed enuresis

Daytime enuresis occurs during the day and is related to
anxious symptomatology, more frequent in girls. The nocturnal type is more frequent and 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 during the day and at night.

2. Primary or secondary enuresis

The term “primary” applies if the child has not previously experienced a stage of sphincter control. In the case of enuresis
secondary if a control stage has been observed in the past lasting at least six months.

3. Monosymptomatic or polysymptomatic enuresis

As its name suggests, monosymptomatic enuresis is not accompanied by any other kind of symptomatology, while polysymptomatic enuresis is accompanied by
other manifestations of urination such as pollakiuria (increased number of daily urinations).


Without being able to count today on a general consensus about which are the factors that cause enuresis, there seems to be some agreement in establishing an interaction between
biological and psychological causes .

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 bedwetting belong to families in which
both parents presented this alteration during their childhood, compared to 15% of the children from families with no previous history.

In addition, a greater correspondence has been found between monozygotic twins than between dizygotic twins, indicating a significant degree of genetic determination and heritability.

2. Physiological theories

Physiological theories defend the
existence of altered bladder function , as well as insufficient bladder capacity. On the other hand, a deficient action has been observed in the secretion of the hormone vasopressin or antidiuretic, predominantly during the night.

3. Psychological theories

These theories advocate the presence of emotional or anxiety-related conflicts that result in the loss of sphincter control, although some authors indicate that it is the enuresis itself that motivates such emotional alterations.

It seems that the experience of
Stressful experiences such as the birth of a sibling , the separation of parents, the death of a significant person, the change of school, etc. may be associated with the development of the disorder.

The conductive current proposes a process
inadequate learning of hygienic habits as a possible explanation of enuresis, also stating that certain parental patterns may negatively reinforce the acquisition of sphincter control.

Intervention and treatment

Diverse are the
treatments that have a proven efficacy in intervening in enuresis, although it is true that multimodal therapies that combine several of the components below have a more acceptable success rate.

Next, we will describe the most currently used intervention techniques and procedures in the treatment of enuresis.

1. Motivational Therapy

In enuresis, Motivational Therapy focuses on
decrease in anxiety and emotional disturbances comorbid with the disorder, as well as in working on enhancing self-esteem and improving family relationships.

2. The Pipi-Stop Technique

The “Pee-Stop”
is based on the operating technique of Token Economy . Once the anamnesis has been made and the functional analysis of the case has been carried out by means of interviews with the parents and the child, a self-registration of the evolution of the enuretic episodes during each night is prescribed. At the end of the week, a count of points is made and, in case a certain goal has been reached, the child is rewarded for the achievement.

At the same time, follow-up interviews are held with the family, advice is given to increase the effectiveness of bladder function and increasingly advanced objectives are proposed.

3. Dry Bed Training

This intervention programme proposes a series of tasks divided into three distinct phases in which the principles of
operant conditioning: positive reinforcement, positive punishment and over-correction of behaviour.

At first, in conjunction with the installation of a Peei-Stop device (sound alarm), the child is instructed in the so-called “Positive Practice”, in which the subject
should get out of bed to go to the bathroom repeatedly, ingest a limited amount of fluid and return to bed and begin sleeping. After one hour, you will be woken up to check whether you can hold in the need to urinate for longer. This procedure is repeated every hour that night.

In case of bed-wetting, the Cleaning Training is applied, by which the child must change both his own clothes and the clothes of the bed that has been dirtied before going back to sleep.

In a second phase, the child is awakened every three hours until he or she achieves
add seven consecutive nights without bed-wetting . At this point you move on to a final phase in which the alarm device is removed and you are allowed to sleep through the night without waking you up. This last phase ends when the child has achieved a total of seven consecutive nights without wetting the bed.

For every successful night the child is positively reinforced and for every night of non-control, Positive Practice should be applied immediately.

4. Bladder distension exercises

They consist of training the child to
go increase ndo the urine retention time gradually. The child must tell the parents when he or she feels the urge to urinate and the volume of liquid retained in the bladder must be measured and recorded regularly on each occasion before urination.

5. Pharmacological treatments

Pharmacological treatments, such as Desmopressin (antidiuretic) or Oxybutin and Imipramine (muscle relaxants to increase bladder capacity), are moderately effective in the treatment of bedwetting, since
improvements are lost as soon as the treatment is abandoned and present considerable side effects (anxiety, sleep disturbances, constipation, vertigo, etc.).

6.Multimodal treatments

These intervention packages
combines different techniques exposed in previous lines and presents a superior efficacy since it addresses the alterations produced in the cognitive (psychoeducation of the disorder), affective (coping with anxiety, fears and worries generated), somatic (pharmacological prescription), interpersonal (coping with family stressors) and behavioural areas (the intervention of enuretic behaviour in a direct way).

Stopping bed-wetting

As it has been observed, enuresis is a complex psychopathology that requires a set of interventions involving the whole family system.

It is very relevant the
application of the techniques of behavior modification , specifically the “Pee-Stop” and the Cleaning Training, although it is equally fundamental to go deeper and determine which factors of an emotional nature are causing such symptoms.

Bibliographic references:

  • Belloch, A., Sandín, B. and Ramos, F. (1995). Manual de psicopatología (Vol. 2, Part VI. Psychopathology of development). Madrid: McGraw-Hill.
  • Caballo, V. and Simón, M. A. (Eds.) (2002). Manual de psicología clínica de la infancia y de la adolescencia, 2 volumes. Madrid: Pirámide.
  • Ollendick, T. H. and Hersen, M. (1993). Child psychopathology. Barcelona: Martínez Roca.
  • Méndez, F.J. and Maciá, D. (1990). Behavior modification with children and adolescents. Case book. Madrid: Pirámide.