Childhood Enuresis Nocturna Psychological or Developmental/Genetic?

Short Communication

Misconceptions sadly continue to be undisturbed perpetuated among doctors despite recent revival of ‘Evidence Based Medicine’ - age old concept widely “preached” lately.

Admittedly the cause of enuresis is not fully understood sleep arousal difficulties, volume of urine, bladder dysfunction, behavioural/emotional triggers, family/social issues, maltreatment, learning difficulties, attention deficit disorder (ADHD), autistic spectrum disorder are widely quoted. For treatment NICE recommends a variety of measures including support in managing anger and negativity among parents/carers, reward system for the child engaging in management, alarm as first line treatment, drug treatment by desmopressin - all admittedly only partially effective if at all [1].

The negative effect of bedwetting on the affected child and the family is often emphasised with varying degree of commiseration.

The concept of persisting bedwetting being a genetically determined developmental delay was first published eight decades ago by Danny Brown and Robertson in Brain [2]. Despite its importance it is never quoted. This work was followed seven to four decades later by several important publications including Gesell [3] Baldwin [4] Harbour et al [5] Klackenberg [6]. These authors emphasised that the delay is the result of developmental variations.

Their work is equally and completely disregarded.

A study of 100 Israeli bedwetters revealed positive family history - in 83%. There was a remarkable intra familial consistency regarding time: as various family members over several generations stopped bedwetting at the same age - Elian et al [7] rein forcing the maturational concept – not dissimilar to familial consistency in language development or onset of menarche.

Exploring family history considerable difficulty is caused by fathers: they rarely attend outpatient clinics with their child; mothers are usually reluctant to ask their husbands; men who were bedwetters often claim not to remember it; fathers need considerable pressure to activate their memory. On the other hand their mothers – if available for interview – as a rule do remember.

Managing bedwetting by regulating fluid intake, by interfering with the child’s sleep, waking children with alarm clock or electrical devices are harsh measures bordering on cruel. Drug therapy and psychotherapy are ineffective, annoying for child and carers and usually resented.

One may suspect that the psychological symptoms accompanying nocturnal enuresis may not be the cause but rather the result of the often cruel attempt of cure.

Perhaps doctors should exchange their “treating hat” with “teaching hat”. After all Doctor means Teacher - Elian M [8]. Explaining to the child and family the genetic/maturational concept is freeing them of guilt and worry and is more effective without cruel waking methods and without side effects as with drugs.

Quality of life of the entire family is considerably improved by teaching.

Conclusion

Enuresis Nocturna should be urgently removed from its current attachment to the psychiatric domain. It should have been replaced a long time ago by explaining the concept of genetics and of maturational delay, evidence available and neglected for eight decades. With the teaching and subsequent reassurance of child and family the psychological symptoms remain negligible.

References

1. Wright, Ann. Childhood Nocturnal Enuresis: Assessment and Management in Primary Care. British Journal of Family Medicine. 2014; 14-18.
2. Denny Brown D, Robertson EG. On the Physiology of Micturition. Brain. 1933; 56: 149-190.
3. Gesell AL. The Infant in the Culture of Today. New York Harper. 1944; 322.
4. Baldwin H. Enuresis in Children. J. Paediatric. 1961; 58: 806-819.
5. Barbour rf, borland em, boyd mm, miller a, oppe te. Enuresis as a disorder of development. Br Med J. 1963; 2: 787-790.
6. Klackenberg G. Nocturnal enuresis in a longitudinal perspective. A primary problem of maturity and/or a secondary environmental reaction? Acta Paediatr Scand. 1981; 70: 453-457.
7. Elian M, Elian E, Kaushansky A . Nocturnal enuresis: a familial condition. J R Soc Med. 1984; 77: 529-530.
8. Elian M . Treating bed wetting. BMJ. 1991; 302: 729.