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Understanding and Managing Psychogenic Enuresis in Children

  • Post category:Disorders
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Psychogenic Disorders in the Function of Urinary Organs in Children

Psychogenic disorders in the function of the urinary organs are manifested in the fact that the child can not fully control the emptying of the bladder. It is a neurotic sphincter dysfunction on that organ. A child urinates in bed in his sleep (nocturnal enuresis). Sometimes, in addition to nocturnal enuresis, waking occurs. It rarely happens that a child only gets wet on the floor during the day, when awake, and not at night. The baby sometimes has a frequent urge to urinate, but does not let the urine under itself. These are all variants of bedwetting in sleep that dominate psychogenic bladder dysfunction. Psychogenic enuresis should be distinguished from difficult or completely impossible control of the sphincter in some anomalies or diseases of the spinal cord, in inflammation of the bladder or in diabetes. But in these cases, enuresis is a side effect along with other major symptoms of the underlying disease. Such diseases are relatively rare in childhood.

Enuresis: The Most Common Childhood Neurosis

Enuresis is very common, with psychogenic inpetence probably the most common childhood neurosis. Various authors agree that in the average population, 15-20% of children (Thorne F. C.: “Incidence of nocturnal enuresis after age 5″, American Journal of Psychiatry”, 1944.) urinate in bed after the age of five. Among neurotic children who went through the dispensary for two years, they suffered from enuresis:

  • Boys 145 or 47.2%
  • Girl 66 or 42.6%

This difference in the frequency of enuresis in males and females is not statistically significant, so it seems that – unlike stuttering – both sexes are equally prone to enuresis. Perhaps the function of the urinary bladder in sleep is so often susceptible to neurotic disorder precisely because then that function is not subject to control of consciousness, so unconscious mechanisms in the child’s psyche can disrupt it more easily than other functions of the young organism.

Primary and Secondary Enuresis

The intensity and course of enuresis are very different. In some cases, the child wet the floor at intervals of several days; in other cases it urinates in bed every night and several times in the same night. It happens that the enuresis stops spontaneously for a month or two, and then reappears. Once the child urinates more often, in the second period less often, so the frequency increases again. Sometimes enuresis disappears spontaneously as early as childhood; it disappears more often at the beginning of puberty, although it sometimes continues into adolescence. It usually stops earlier in girls than in boys. There are adults who have relapses, for example during their stay in the army. Many former enuretics, even when they grow up, are sensitive to the bladder.

Bedwetting is a pathological phenomenon only if it occurs after the third year of life. The second and third years are the period in life when a child learns to automatically monitor the function of the bladder in sleep, if he develops mentally normally. According to the way it occurs, pathological enuresis is divided into two groups:

  • Primary or continuous enuresis
  • Secondary enuresis.

With primary enuresis, the child does not automatically gain control of the bladder in his sleep by the end of the third year, and even after that period he continues to urinate in bed. Physiological enuresis imperceptibly, continuously turns into pathological. This can last for years, even until the end of childhood. Secondary enuresis is when a child normally begins to monitor his or her bladder during sleep. After a certain period of “dry regime”, which can last for several years, the child suddenly starts urinating in bed again, and thus continues for a longer or shorter period of time, often until puberty and even adolescence. Secondary enuresis is much rarer than primary. Among our patients (211) suffered from:

  • Primary enuresis 169 or 80.1%
  • Secondary enuresis 42 or 19.9%

In more than half of the cases, secondary enuresis occurs between 4 and 6 years of age. It becomes somewhat more common again in the first year of schooling, and sometimes occurs only at the beginning of puberty.

Familial Predisposition and Underlying Factors in Enuresis

In some enuretics, a familial predisposition to this neurosis may be established. In our cases, these closest relatives of small patients suffered from childhood enuresis:

We found a familial predisposition to enuresis in 74 or 35.2% of our cases. Examining enuresis in identical twins, Hallgren found that out of 10 pairs of such twins, in 7 cases, both twins urinated in bed. Kanner L.: “Child psychiatry”, Springfield, 1957, found a familial disposition for enuresis in 47% of his cases.

In 9 (4.3%) cases, the child was born prematurely. In 46 or 21.8% of cases, the small enuretic was mentally underdeveloped in various intensities, from mild dullness to marked dementia. The authors, however, claim (Addis, Ackerson) that average enuretics do not differ in the degree of intellectual development from average non-euretics. However, it is likely that mental retardation makes it difficult for a child to acquire an automatic controls the bladder in his sleep, though it is possible for him to achieve this. Only in severe forms of mental retardation (imbecile, idiot) is it very difficult or impossible to achieve control of the sphincter in sleep. Due to these factors, the nervous system is less able to develop automatic control of bladder function in sleep during the physiological period. In such cases, it is to be expected that this control will be more difficult and slower to establish than in the average child. Then the child stops urinating in bed at night only at the end of the third year or even during the fourth year. It usually urinates more often during the day than other children and is more sensitive to various stimuli, such as cold, which can impair bladder function.

In any case of pathological enuresis, one should also think about whether it is not nocturnal epilepsy, because a child in a large epileptic seizure usually urinates on the floor. But fortunately such cases are rare. Of our 211 enuretics, only one boy suffered from nocturnal epilepsy.

The Pathology of Enuresis in Children: Causes and Consequences

Usually, the impatience of the educator is the reason that the disposition for enuresis manifests itself as pathological bedwetting. When a child urinates on the floor longer than educators think is normal or “allowed,” then they begin to “wean” him from enuresis in the ways we described in the chapter on the child’s biological needs (“body emptying”). We have seen that everything that is done in this regard causes negative emotions regarding bladder function, so the nervous system does not develop an automatic control of the sphincter in sleep, but pathological enuresis occurs. This is the most common way in which primary enuresis occurs.

The Harmful Effects of Educator Impatience on Childhood Bedwetting

When educators, with their methods of weaning from bedwetting, do not keep the child dry at night, they regularly tighten these measures, and at the same time begin to insult, punish and abuse them physically and mentally. In doing so, they drag the child’s neurosis into a vicious circle: the child’s emotional tension intensifies, and the enuresis becomes even more stubborn; educators are then even stricter, even more impatient, and the child becomes more and more neurotic. Then enuresis becomes a central problem in relation to which educators and the child increasingly clash. This causes new disorders and neurotic reactions in behavior, the child suffers more and more, his personality becomes more and more deformed, and all this reflects his enuresis.

The Role of Upbringing in Primary and Secondary Enuresis

It happens, unfortunately, that doctors sometimes advise parents to mistreat a child who urinates in bed, turning him into a long-term enuretic. In the press, we read these tips from the pen of a doctor:

“First of all, the child should be observed and notice exactly what time of night he urinates in bed, because that time is usually quite accurate. A little before that, he should be woken up every night and made to urinate, so that he will get used to just waking up at that time of night and doing his duty. Before going to bed, all pillows should be removed from the bed, so that the child sleeps in a horizontal position. Such a position is very important because less blood collects in the lower parts of the body and the urinary tract is less supplied with blood. In some cases, it is good to even lift the lower body so that blood accumulates more in the upper body.

As arousal also plays a very important role in involuntary nocturnal urination, the child should calm down before going to bed and turn off any arousal. When a child is more nervous, one should not avoid mild sedatives, which cannot harm him when taken in precisely determined quantities according to the doctor’s instructions.

It is necessary to pay attention to the diet, especially at dinner. She should be easy. The child should not overload the stomach, should not take too much fluid and liquid food that will increase the amount of urine excreted during the night. “

We have already noticed that waking up a child at night is gross violence against his body. The same goes for that advice on the position of the child in bed. Sedatives deepen sleep, and very deep sleep makes it difficult to control the sphincter. The child’s diet is secondary to enuresis, because bedwetting does not occur because the bladder is too full, but is the result of psychogenic sphincter dysfunction. When this one is not functioning properly, it is quite secondary how much urine there is in the bladder.

Psychological Factors in Enuresis: Behavior, Personality, and Emotional Conflicts

Sometimes completely wrong opinions are heard from doctors’ mouths about the cause of a child’s urination in bed even after the age of three. Too much importance is attached to various small anomalies in the spine that can be detected on X-rays in many enuretics. But such anomalies are equally common in children who have never suffered from enuresis, so there is no place for claims that they are a causative factor in bedwetting (Bakwin). They may possibly only be a disposition for the occurrence of enuresis in a neurotic child. The same is true for abnormalities in the development of the male genitalia, such as phimosis, and for various nonspecific changes on the electroencephalogram, which can sometimes be found in enuretics.

If the doctor overemphasizes the existence of such anomalies, it is very difficult for parents to turn away from the belief that their child’s enuresis is an organic disease. He will be even more fixed with this opinion if any unnecessary physical examinations are performed on the enuretic or he is even hospitalized due to enuresis. Then parents expect various medications to relieve the child of bedwetting, and neglect to correct their upbringing procedures, so anything taken against enuresis has no effect.

Enuresis is a completely psychogenic disease. Therefore, it is unnecessary and harmful for a child to undergo medication. It can only have a transient effect, due to the suggestive effect on the child. But sooner or later, as soon as the effect of the suggestion subsides, the neurosis will reappear. Such treatment also strengthens the child’s belief that he is physically ill, and passivates him, depriving him of the motivation to do something in terms of eliminating his deficiency. Enuresis is quite an educational, psychological problem, so it can only be treated by proper upbringing and understanding the motivation of his neurosis. All other procedures are just a line of least resistance. They support bad educators in their neurotic belief that they are “doing everything” for the child and do not let them see that they are to blame for their child still urinating in bed.

Secondary Enuresis: Emotional Shock and Personality Deformation

A parent’s wrong response to a lack of bladder control in sleep is usually only part of a generally malfunctioning procedure. In our young patients, in only 12 of 211 cases did we not find any significant errors in the educational procedure with the child. All other children were brought up extremely poorly, even before enuresis appeared, and even worse when it manifested itself.

Here, too, neurotic children are spoiled in half of the cases, and sooner or later austerity and even abuse are combined with that. In three-quarters of cases, children are exposed to violent treatment by educators at some point in their lives. There is a relatively high percentage of educationally neglected children. In poorly brought up children, enuresis occurs partly due to a wrong reaction to the child’s urination in bed, and partly due to a generally incorrect upbringing procedure. Both bring the child into conflict with the environment, into a state of emotional tension manifested in enuresis. Depending on the way the child treats himself and his environment, the motivation for this neurosis varies from case to case. We will understand it best if we look at what behavioral disorders occur in enuretics. Such children always behave in an unhealthy way. Among our patients, we did not find anyone who would behave in a completely orderly manner.

Defiance and aggression prevail in the behavior of enuretics. It is not difficult to guess that this enuresis is most motivated by resistance to educators, the struggle for supremacy with them and even the need for revenge. In timid and withdrawn children, the main driver of enuresis is their fear, the constant anxiety in which such children live, their insecurity and the expectation of failure to control the sphincter, or fear of the consequences of enuresis. Independent and careless children rely on their environment in everything, they do not consider themselves responsible for anything, and they even unconsciously leave the control of the bladder to someone else’s care, without developing any initiative in that regard. Since the same child often combines active and passive forms of behavioral disorders, the motivation for his enuresis can be intertwined with aggression and fear, defiance and lack of independence, or the desire to draw the educator’s attention to himself, to employ them more with himself.

Enuretics often suffer from other neurotic disorders. In our material, these neuroses were the most common: lack of appetite, stuttering, restless sleep, night terrors, neurotic masturbation.

The frequency of other neuroses in enuretics further confirms the assumption that these children live in a state of intense emotional conflicts, which create so much tension in the child that it is converted into a psychogenic disorder of a number of somatic functions.

Sequential enuresis occurs when educational errors are so amplified that emotional tension reaches the intensity needed to turn into a neurotic disorder. Therefore, in many cases, a specific event in the child’s life cannot be found that would be responsible for the occurrence of enuresis. We have seen that it most commonly occurs between 4-6 years of age. This is a time when the position of the child in the family has already become quite fixed, when it has been given a certain form and content that is unlikely to change significantly. And the actions of educators have taken their final form – if at the beginning of life they caressed a child, now they have probably already moved on to strict upbringing and abuse; if they have always acted in an authoritative manner, they have probably remained with that method of upbringing

In other cases, secondary enuresis occurs as a reaction to some emotional shock that the child has experienced or is still experiencing. In our patients, we found such an onset of secondary enuresis in 33 of 42 cases. The causes of emotional shock were:

Enuresis in Foster Children

Jealousy seems to be the most common of these factors. In our material, we met 21 children (11 boys and 10 girls) who showed intense jealousy of their brother or sister. They were mostly older than two children. There were relatively more girls (15.2%) than boys (7.6%). This agrees with the well-known fact that jealousy occurs more often in female than in male children. Jealousy caused secondary enuresis in our patients in part and was in part the reason why the already existing primary enuresis continued and persisted.

Bedwetting is a particularly common problem in foster children. When visiting one orphanage, we found that of the 64 wards aged 6-10, 14 or 21.9% of them urinated in bed. Data from the literature suggest that an incidence of enuresis of up to 40% can be expected among foster children. This phenomenon should come as no surprise given the fact that foster children are very often severely impaired in emotional development, whether they have already come to the home, or that staying in an institution and raising without emotional warmth seriously deforms their personalities. In emotionally neglected children, enuresis is usually an expression of their general mental underdevelopment, or is a symptom of a child’s regression to a lower level of development, if he or she has become jealous at home, if he or she feels neglected toward other residents.


Enuresis is a psychogenic disorder that is caused by a combination of emotional conflicts, negative upbringing procedures, and various environmental factors. It is not a result of a physical abnormality or organic disease, and it should not be treated with medication or physical procedures. Rather, it should be addressed by understanding the motivation of the neurosis and correcting the upbringing procedures that led to its development. Educators and parents must be patient, understanding, and supportive in helping children overcome enuresis.