Enuresis is a relatively common problem among children. There are two types: diurnal enuresis, which occurs during the day, and nocturnal enuresis, which occurs at night. This disorder can be continuous (primary) or discontinuous (secondary). The secondary enuretic child has at least six months of continence and during that time has been able to control the function of their sphincter (Ollendick and Hersen, 1988).
The importance of evaluation in this disorder is becoming increasingly evident. Therefore, this evaluation is based on a clinical interview in which a history and description of the problem, family and medical history, knowledge about the existence of problems in the family or in the child, an impression of the home environment, and information about previously received treatments are obtained (Ollendick and Hersen, 1988). This is how the specialized psychologist works with the Master in Child and Adolescent Clinical Psychology.
On the other hand, it is also very useful to examine the child’s enuretic behavior pattern by collecting relevant data on nocturnal and diurnal patterns, which are obtained through continuous parental observation during the day and intermittent observation during the night. Generally, a general physical examination, a urine analysis, and a urine culture are sufficient to rule out renal pathology and infection (Ollendick and Hersen, 1988).
Years ago, several intervention techniques were used in the treatment of enuresis. One of them was the administration of tricyclic antidepressants with the aim of improving mood, decreasing sleep depth, relaxing the detrusor muscle and dilating bladder capacity, and increasing involuntary control over the urethral sphincter. Likewise, bladder expansion was used, through which attempts were made to get the child to hold the urge to urinate for progressively longer periods and subsequently, after increasingly larger fluid intakes (Ollendick and Hersen, 1988).
However, the most researched procedure in the treatment of nocturnal enuresis is the alarm system (Pipi-Stop). This technique uses a urine-sensitive device that is placed on the child’s wrist or between the sheet and the mattress. This device will sound an alarm when it detects any amount of urine. The alarm’s sound intensity will be adjusted to the child’s susceptibility to waking up. Once awake, the child will clean themselves and return to bed. In this technique, conditioning theoretically occurs as follows: a) the child achieves an inhibitory response to emptying during sleep throughout the night, or b) bladder distension acquires sufficiently strong discriminative properties to wake the child from sleep and prevent wetting (Ollendick and Hersen, 1988).
For its part, dry bed training applies social contingencies as an alternative to urinary alarm conditioning. This program incorporates positive practice, positive reinforcement, retention control techniques, waking the child at night, negative reinforcement techniques, and teaching hygiene habits (Ollendick and Hersen, 1988). It is based on programmed awakenings where care will be taken not to overstimulate the child so they don’t lose sleep, but they will be instructed to always go to urinate at a predetermined time after having ingested large amounts of water. While in the bathroom, they are asked if they think they can hold their urine for another hour; if so, they are positively reinforced and returned to bed until the next programmed awakening.
In this treatment, fluid intake is increased to promote learning. The first night of treatment is intensive (the child is woken every hour), then the next day they are only woken three hours after falling asleep, and this is advanced by half an hour each day. When only half an hour remains between bedtime and waking up, the child is no longer woken. If they wet the bed on any occasion, we must continue waking them at the same time (without advancing it until they manage not to wet themselves). Likewise, they are told that they must clean their bed when they wet it and change their pajamas (restitutive overcorrection).
Positive practice is recommended, that is, learning to lie in bed and get up and go to the bathroom and try to urinate, as this is the response they must learn to emit when the alarm sounds.
Despite the various therapeutic approaches, what has been agreed upon regarding enuresis is that the child must acquire some fundamental habits, which are:
1. Have a voiding schedule: the child should urinate an average of six times a day, and attempts should be made for these voidings to be at similar times.
2. The child should have frequent fluid intake and distribute it throughout the day, drinking more in the morning, less in the afternoon, and little at night before bed.
3. Fill out a voiding calendar, where the child should mark dry nights and wet nights, in order to observe their progress and encourage them to continue treatment.
4. Avoid very abundant, salty dinners that involve drinking a lot of liquid. In fact, the child should not drink more than 200 ml of liquid (soups, yogurt, milk, juice, water) during dinner.
The most appropriate therapeutic approach for each child will be chosen by the psychotherapist, together with the parents, as their intervention is indispensable. Adequate training in child and adolescent clinical psychology is essential to successfully address this type of treatment.