It is understood by enuresis repeated emission of urine during the day or night, in bed or on clothing, involuntarily or sometimes intentionally, that has occurred at least twice a week for a minimum of three months or that being the lower frequency, causes clinically significant discomfort to the subject, with a chronological age equal to or greater than five years or, in the case of children with Cognitive Deficit, with an equivalent mental age. If you take into account the diversity of causes that may be at the base of a enuretic problem (neurological, anatomical, incorrect learning patterns, etc.) it is not strange that it is usually used different methods to evaluate and intervene. We usually resort to a medical exam, interview with the parents, the child, behavioral observation and records.
- 1 Physiology of urination
- 2 Acquisition of bladder control
- 3 Bedwetting Epidemiology
- 4 Types of Bedwetting
- 5 Bedwetting Evaluation
- 6 Enuresis Treatment
Urine is made in the kidneys and reaches the bladder through the ureters. The bladder flows into the urethra that pours urine directly outside. The muscular bundles of the bladder that are located in the vicinity of the urethra extend through the bladder neck and the proximal fragment of the urethra constituting the internal sphincter, which opens and closes the urine exit pathway at this level. Since the muscles are smooth, there can be no voluntary control. The muscular area that extends through the bladder neck and the mouths of the ureters constitutes the trigone. Surrounding the urethra and immediately after the internal sphincter is located the external sphincter, consisting of striated muscle fibers that are subject to voluntary control.
In order for bladder filling to occur normally, the bladder must be relaxed, adapting your muscle tone to the progressive amounts of urine that are constantly reaching it.
Voluntary emptying is more complex. Habitually voluntary urination begins after experiencing the urge to urinate. These desires correspond to the perception of certain sensations that start mainly from the bladder organ. When urine pressure reaches a certain intensity, the detrusor contracts intermittently, these contractions in turn increase intravesical pressure. The feeling of urination depends on the stimulation of different sensory receptors. Thus, the desire increases with detrusor contraction in response to bladder distention caused by increased urine pressure. This desire can be endured with the voluntary activation of the external sphincter and part of the pelvic musculature. When you decide to urinate, the external sphincter voluntarily relaxes. Voluntary control is also manifested through acts such as starting urination without wanting to or interrupting the emission of urine.
Acquisition of bladder control
Any acquisition or learning requires two conditions: a biological, somatic substrate, capable of acquisition and experiences or interactions with the environment that are capable of promoting the learning in question.
At three years the average child usually goes alone to the sink, and usually announce it before. Many times he does not "arrive on time" especially if he is playing. At age four you can go to any sink without problems, and start closing the door. Around five peeing is a private activity, at this age it is able to start emptying the bladder regardless of the amount of urine it contains. This is an activity limited to dogs and men exclusively.
In both sexes, to at 18 months of age about 60% of the population has already acquired bowel control during sleep. Almost half controls urination during the day. About 20% controls defecation during the day and 10% keeps the bed dry at night. By two years night and daytime control over the anal sphincter has been achieved by almost the entire population. There are no similar rates of bladder control at three and a half years, but only during the day.
The first thing acquired is nighttime rectal control, after day, then the daytime bladder and finally the nighttime.
Rutter et al. (1973) found that the prevalence of enuresis in males and females of five and seven years of age increased from 13.4% to 21.9% in boys and from 13.9% to 15.5% in girls. These increases are explained by the appearance around seven years of a certain number of relapses, that is, secondary enuresis.
The decrease experienced between the ages of four and six is 71% in girls and only 16% in boys. Up to eight years of age, boys do not reach the approximate level that girls have at five. These data reaffirm the greater general frequency of bedwetting in children, but the specific prevalence changes of sex and age that they describe (Verhulst et al., 1985) do not appear in the remaining reviewed works. Even so, all this is important since we should surely delay the age for the diagnosis of enuresis being eight years for boys and five for girls.
Daytime bedwetting is much less frequent than nocturnal (1-2 versus 7-8), it occurs much less in adolescence than in childhood, it usually accompanies nocturnal enuresis with some frequency (between 2% and 17% of the cases).
Types of Bedwetting
When the child is shown incontinent from birth, without significant periods of bladder control, there is talk of primary enuresis, continuous or persistent. The enuretic disorder that appears after a significant control season (six months-one year), according to different criteria is called is called secondary enuresis, regressive, beginning or acquired.
The increase in nocturnal enuresis between five and seven years of age makes us think that it is due to the appearance of secondary enuresis during that period of time. It also seems established that after eleven years of age secondary enuresis is extremely rare.
The characteristics of daytime bedwetting are very different from nighttime. It has a higher prevalence in females, it is usually accompanied by greater urological changes, worse results are obtained with conventional treatments.
We understand by enuresis the repeated emission of urine during the day or night, in bed or on clothes, involuntarily or occasionally, intentionally; that has occurred at least twice a week for a minimum of three months or that being the lowest frequency, causes a clinically significant discomfort to the subject; with a chronological age equal to or greater than five years or, when it comes to children with Cognitive Deficit. With an equivalent mental age.
When we receive a child who responds to the possible enuretic characteristics, the first thing we should do is rule out a possible functional failure. For this we usually refer the pediatrician to the child to discard any medical pathology.
Once the child returns to consultation with a medical diagnosis, we will see what we can do based on the medical conclusions. Thus, the diagnosis of enuresis would only be correct (on our part) if the organic component were not so important as to explain the existence of the disorder alone. That is, it would be diagnosed as such only if the incontinence was present before the onset of the disease or persisted after the application of the appropriate treatment.
Anyway, the normal thing is that the organic pathology is not present but you always have to rule out because there are times that it does appear.
Usually and unless there are indications for a more rigorous examination, a general medical examination of the urinary tract will suffice. Sometimes very invasive techniques are used that if possible it is better to avoid them to the child, they can be: pyelography, cystourethrography, sphincter electromyography and cystoscopy.
Once we have all the medical data and we have seen that it is a case that we can address, we will conduct the clinical interview, which in these cases is absolutely essential.
Historical evolution and current state of the enuretic problem: when the episodes occur (day, night, both). Children who only have it at night have a better prognosis as do those who only have daytime bedwetting. We also need to know if the child had previously controlled, at least for six months, or if control was always absent. In the first case we have to investigate the circumstances that have surrounded the appearance of the episodes such as school changes, separation from parents, birth of a brother, death of a relative ... Also We are interested to know if the child has been able to control outside the home like when he goes on vacation or sleeps at a friend's house, or if control is totally absent. We also want to know if bedwetting is continuous or occasional, as it may only occur before certain events such as exams or vacations.
As for the current state of the problem we have to collect different information according to the type of enuresis.
If you have nocturnal enuresis:
- If you get to detect the onset of urination at night but do not get up to go to the bathroom.
- Intensity of the episodes, we can measure it through the urine stain.
- Frequency of nights that wet the bed, as well as if there is more than one episode on the same night.
If you have daytime bedwetting:
- If you have only a small loss of urine before doing so in the bathroom or if you wet all your clothes without giving it time.
- If you completely empty your bladder when you urinate or if only partially.
In both cases:
- The number of episodes per day / week.
- The child's ability to delay his visit to the bathroom.
- If you feel the need to go to the bathroom.
- The urgency with which he feels this need.
- If you experience pain when you urinate.
- What kind of dream the child presents.
We cannot forget in this part of the interview that if the child has difficulty waking at night, it can influence in the case of using night alarm in the intervention.
We will also take note of the self-care skills presented by the child dressing and undressing alone, going to the bathroom without being accompanied.
Possible presence of other problems in the child: enuresis may be accompanied by the existence of other problems in the child such as: sleep disorders, anxiety, impulsivity, attention deficit, hyperactivity, low self-esteem, social imbalance, etc.. In the event that another disorder is associated, it should also be treated as the effectiveness of the treatment would be reduced and the possibility of relapse would increase.
Family history of bedwetting: Around 75% of enuretic children have a first-degree relative who suffered the problem. From the behavioral orientation we think that this is produced by the facilitation of poor learning patterns by parents.
The enuresis history is long and the methods used To correct it are many, but as a curiosity we will see some of the "methods" that both parents and doctors used in their fight against bedwetting.
Hitting and hitting children, forcing them to drink their own urine, ridiculing them before their classmates, tying their penis, making them wear wet pajamas around their neck, exposing wet sheets in public, inflicting burns, making them sleep outdoors; this parents, and in medicine the interventions were the following: potions of pig urine and carcomas, hedgehog cooking, cock tracheas and goat hooves, sleeping on uncomfortable surfaces, applying a steel pin on the child's back to avoid sleeping on it, stick hypodermic needles in the sacrum, saline or paraffin injections, real or simulated surgical interventions (cauterize the bladder neck or circumcise), chemically neutralize urine, seal the urinary opening, put ice on the external genitalia.
It is important to note before carrying out strange and macabre methods, which Bedwetting tends to subside over time, both primary and secondary; therefore, in order for our treatment to be successful it has to "cure more" than Over time.
A) The alarm
Currently we can find a PIPÍ-STOP with a 3 x 1 '5 grid, which is introduced in a safe slip between cellulose and cotton avoiding direct contact with the skin. It is the smallest moisture detector.
There is also for sale the WET-STOP that has a sensor that is inserted in a cotton sheath and placed on the outside of the underwear. The sound stops drying the sensor.
When we use these methods we rely on the achievement of a number of consecutive dry nights, the normal is about 14 consecutive nights without bedwetting. The use of the alarm achieves success (14 consecutive dry nights) in 70% of cases, to prevent relapses it is best to use the alarm intermittently by keeping the system on some nights and others not. Also, once the success is achieved, we ask that the children ingest increasing amounts of liquid before bedtime to achieve an increase in bladder control with larger amounts of fluid.
- After 14 consecutive nights without peeing the alarm is maintained.
- The child should drink two, three or four glasses of water during the hour before bedtime.
- This is repeated every night.
B) Dry bed training
Here we will use the alarm first and then a systematic wake-up program consisting of:
The first night an intensive training is done, so the night before a holiday is chosen. We wake up the child after an hour sleeping, insisting as little as possible. Then they take him to the bathroom where he practices voluntary retention, which means that the child drinks two to four glasses of his favorite drink before bedtime, when they wake him up to go to the bathroom they have to ask him if he thinks he could take another hour more, if he says If he is praised and put to bed again, if he says no, he is asked to endure a few minutes and be praised for it, then he is returned to bed and drinks another glass of liquid. This procedure is repeated every hour during that first night. On the following night they only have to wake up the child three hours after falling asleep or before their parents go to bed. After each night without enuresis, the parents wake the child half an hour earlier than the previous night; if you pee in bed the next night you wake up at the same time, and we will stop waking you when the interval between going to bed and waking is half an hour. This training can be done during the day, the child has to be reinforced as he leaves longer periods of time between the desire to pee and the time to go to the bathroom. In principle you are asked to delay voluntary urination for five minutes. Each day we increase the waiting time by two or three minutes. In 15 or 20 days usually reaches 45 minutes of delay and from there the training ends.
Also on this first night we talked about before, we will do positive practice in wake up quickly and pee. We do this one hour before going to sleep during the first night of training. The child lying down and with the light off, counts to 50, gets up, goes to the bathroom and tries to pee, and returns to his bed. This is repeated 20 times. If the alarm sounds at night, after changing clothes, the child has to do positive practice 20 times more. After the second night, you will only do positive practice for one hour before bedtime if the bed was wet the night before.
And of course we will use overcorrection after each enuretic episode, the child will have to get up, go to the bathroom, finish peeing, change pajamas, change the sheets, dry the alarm mats, leave the wet clothes in the laundry basket Dirty and redo your bed.
The Dry bed training is suspended after seven consecutive nights without wetting the bed. Since then, if two or more accidents occur in one week, the procedure is reinstated, omitting the first intensive night.
While we do all this we will incorporate positive reinforcement that will simply consist of keeping a weekly record in which the child must stick stickers of his or her taste every day that the bed has not been wet.
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