IACAPAP Textbook of Child and Adolescent Mental Health

DEVELOPMENTAL DISORDERS

Chapter

C.4

ENURESIS
Alexander von Gontard

Alexander von Gontard
Department of child andadolescent psychiatry, Saarland
University Hospital, Homburg,
Germany
Conflict of interest: none
disclosed

Manneken Pis, Brussels
This publication is intended for professionals training or practising in mental health and not for the general public. The opinions
expressed are those of the authors and do not necessarily represent the views of the Editor or IACAPAP. This publication seeks todescribe the best treatments and practices based on the scientific evidence available at the time of writing as evaluated by the authorsand may change as a result of new research. Readers need to apply this knowledge to patients in accordance with the guidelines andlaws of their country of practice. Some medications may not be available in some countries and readers should consult the specific drug
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©IACAPAP 2012. This is an open-access publication under the Creative Commons Attribution Non-commercial License. Use,
distribution and reproduction in any medium are allowed without prior permission provided the original work is properly cited andthe use is non-commercial. Send comments about this book or chapter to jmreyATbigpond.net.au
Suggested citation: von Gontard A. Enuresis. In Rey JM (ed), IACAPAP e-Textbook of Child and Adolescent Mental Health. Geneva:
International Association for Child and Adolescent Psychiatry and Allied Professions 2012.

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IACAPAP Textbook of Child and Adolescent Mental HealthEnuresis constitutes a very common group of disorders in childhood that
occur world-wide at approximately the same rate. 10% of all 7-yearolds, wet the bed at night and 2% to 3% during the day. Despite a highremission rate, still 1% to 2% of all adolescents are affected by nocturnal enuresisand less than 1% by daytime wetting. The vast majority of elimination disorders
are functional, i.e., not due to neurological, structural or medical causes (vonGontard & Neveus, 2006).
Enuresis is associated with emotional distress in both children and parents,
which is reversible once children become dry. Achieving continence is therefore
the main goal of treatment and will lead to an improvement of self-worth andself-confidence (Longstaffe et al, 2000). On the other hand, 20%-40% of allchildren with enuresis have additional, comorbid psychological disorders, not only
externalising conditions such as attention deficit hyperactivity disorder (ADHD)
and oppositional defiant disorder (ODD) but also internalising disorders such as
depression. These comorbid conditions require separate assessment and treatment –in addition to the symptom-oriented treatment of the child’s elimination disorder.
Most types of enuresis can be treated effectively with counselling andcognitive-behavioural approaches but some may require additional medication.
These therapies can in most cases be provided in primary care outpatient settings– provided that they are based on a correct diagnosis and that child and parents
are given adequate professional care with sufficient time. The aim of this chapter isto provide a practical approach to the assessment and treatment of children withenuresis that can be implemented in different settings even in those with limited
resources.

DEFINITION AND CLASSIFICATION
Enuresis is defined by both ICD-10 (World Health Organisation, 2008)
and DSM-IV-TR (American Psychiatric Association, 2000) as involuntary (oreven intentional) wetting in children 5 years of age or older after organic causes
have been ruled out. The wetting must have persisted for at least three months to
be considered a disorder. According to ICD-10, enuresis is diagnosed if wetting
occurs two times a month in children under 7 years of age and once a month inchildren 7 years and older. The criteria according to DSM-IV is less precise: thevoiding must occur at least twice per week or else must cause clinically significant
distress or impairment in social, academic (occupational) or other important areasof functioning. Both ICD-10 and DSM-IV-TR describe nocturnal, diurnal or
combined enuresis – no other subtypes are included. Also, ICD-10 excludes adiagnosis of enuresis if other psychiatric disorders are present. Both ICD-10 and
DSM-IV-TR are outdated and do not reflect newer research findings in this field.
Unfortunately, the proposed DSM-5 criteria are not very useful and may evenconstitute a step back from DSM-IV. The Children’s Continence Society (ICCS)(Neveus et al., 2006) has proposed newer, more practical suggestions, which arebeing revised in 2012. The aim is to provide simple, descriptive clinical terms thatcan be used in all settings world-wide.
According to the ICCS criteria, enuresis denotes an intermittent (i.e.,
not continuous) wetting during sleep in children after their fifth birthday. The
term nocturnal can be added for clarity (i.e., enuresis and nocturnal enuresis are

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Table C.4.1
Society

Definitions according to the Children’s Continence
Symptom

Disorder••Intermittent wetting during sleep
Age 5 or more

Enuresis or nocturnal enuresis••

Daytime wetting
Age 5 or more

Urinary incontinence or daytime urinary
incontinence (not “diurnal enuresis”). In mostcases functional.

synonyms). Daytime wetting is termed urinary incontinence, which can be organic(structural, neurogenic or due to other physical causes) or functional. As the vast
majority of cases are functional, most children with daytime wetting would beconsidered to have some form of functional urinary incontinence. According
to these criteria, the term diurnal enuresis is obsolete and should be avoided. Ifchildren wet during sleep and during the day, they would receive two diagnoses:
enuresis and urinary incontinence.
The classification of enuresis is simple. Only two aspects need to beconsidered: the longest dry period and if lower urinary tract symptoms are present:•Primary enuresis means that the child has been dry for less than 6 months (ornot at all)
• Secondary enuresis means that a relapse after a dry period of at least 6 months
has occurred.
The dry period can occur at any age; also, it does not matter if it came about
spontaneously or was achieved by treatment. This distinction is important because
children with secondary enuresis have experienced stressful life-events (such as
separation of parents, birth of siblings, etc.) more often and have higher rates ofcomorbid psychiatric disorders (Järvelin et al, 1990; von Gontard et al, 2011b).
These issues have to be considered in assessment and treatment, otherwise thetreatment of primary and secondary enuresis is exactly the same.
The presence of lower urinary tract symptoms is more important as it
carries implications for treatment. Children who wet during sleep and do not havedaytime symptoms suggesting disturbances of bladder function are suffering frommonosymptomatic enuresis. In other words, they wet at night but bladder storageand emptying is completely normal (i.e., children go to the toilet 5-7 times during
the day, do not postpone micturition with the use of holding manoeuvres, do
not experience urge symptoms and can empty their bladders without problems).
In these cases, treatment can focus on the wetting episodes during sleep without
further preliminary procedures.

James Joyce wet his bed.
The first page of Joyce’s

Portrait of the Artist as aYoung Man contains thefollowing: “when you first wet
the bed it is warm and thenit gets cold. His mother put
on the oilsheet. That had thequeer smell” (Gill, 1995).
Portrait by Robert Amoswww.robertamos.com

Children who have lower urinary tract symptoms and may havegastrointestinal symptoms, such as constipation and soiling, have nonmonosymptomatic enuresis. In non-monosymptomatic nocturnal enuresis, daytime
symptoms have to be treated first before addressing the night-time wetting. The
terms monosymptomatic and non-monosymptomatic are based entirely on history
and verified by voiding diaries, i.e., are based on clinical assessment only (vonGontard & Neveus, 2006).

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Figure C.4.1
SocietyClassification of nocturnal enuresis according to the Children’s Continence*Daytime incontinence, increased/decreased day-time voiding frequency, urgency, voiding postponement, holding
manoeuvres, intermittent urine stream, interrupted flow, constipation, encopresis, etc.

The classification of daytime urinary incontinence is more complex. Most
types are functional – organic urinary incontinence is rare and can be due tostructural, neurogenic or other medical causes. The three main syndromes offunctional urinary incontinence are:• Urge incontinence• Voiding postponement, and• Dysfunctional voiding.
Rare types include: stress incontinence, giggle incontinence, detrusor
underactivity and others. Each one of these types of urinary incontinence has
typical symptoms.
Urge incontinence or overactive bladder is characterised by urge symptoms,
increased micturition frequency and small voided volumes. By contrast, low
micturition frequency and postponement of micturition is typical in voiding
postponement. In both cases children employ holding manoeuvres to avoid wetting.

Urge:
The strong, sudden need tourinate.

Dysfunctional voiding is a disorder of the emptying phase: instead of relaxing
the sphincter muscle, it is contracted paradoxically. Straining and an interrupted
urine stream are indicative of this disorder.
Stress incontinence is rare in children – in contrast to adults. Wetting
during coughing, sneezing (i.e., any increase of intra-abdominal pressure) andsmall volumes are typical. Giggle incontinence is characterised by wetting during
laughing, large volumes with apparently complete emptying. Detrusor underactivity,
a decompensation of the detrusor muscle, is marked by an interrupted stream;
consequently, emptying the bladder is possible only by straining.

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Table C.4.2
Classification of daytime wetting (functional urinary
incontinence) and key distinguishing symptoms
Type

Key symptoms

Urge incontinence (overactive
bladder)

•
•
•

Urge
Frequency more than 7 times per day
Small volume voided

Voiding postponement••

Infrequent micturition (< 5 times per day)Postponement

Dysfunctional voiding••

Straining to initiate and during micturition
Interrupted stream of urine

Stress incontinence••

Wetting during coughing, sneezing
Small volumes

Giggle incontinence••

Wetting during laughing
Large volumes with apparently complete
emptying

Detrusor underactivity••

Interrupted stream
Emptying of bladder possible only bystraining

As daytime urinary incontinence (and non-monosymptomatic enuresis)
can be identified by altered rates of micturition frequency and volume, it is helpful
to know the normal values (these are only an approximation), which are shownin Table C.4.2. Normally, children void 5 to 7 times a day. The normal voided
volume in millilitres can be calculated by adding one to the age of the child andmultiplying by 30. For example a normal amount of micturition in an 8 year oldchild would be: 8 + 1 = 9; 9 x 30 = 270 ml.
The aim of treatment is to achieve long-term continued and complete
dryness, not just a reduction of symptoms. Regrettably, this is not achieved in allcases; for some children and families, however, a reduction in the frequency of
episodes can provide relief and has been shown to improve self-esteem (Longstaffe
et al, 2000).

Approximate normal
values in childhood
Micturition frequency•
5-7 times per day
Voided volumes•(age + one) multipliedby 30ml

EPIDEMIOLOGY
Enuresis is 2-3 times more common than daytime urinary incontinence; itis 1.5 to 2 times more common in boys than girls. Prevalence of night wetting
decreases with increasing age: 20% in 4 year olds, 10% in 7 year olds, 1%-2%
in adolescents, and 0.3%-1.7% among adults (von Gontard & Neveus, 2006).
Prevalence depend on how enuresis is defined, especially on the number of wet
nights required. In a large population study of 8151 children aged 7½ years, 15.5%
had nocturnal enuresis (boys 20.2%, girls 10.5%). Frequent enuresis, defined by
two or more wet nights per week, affected only 2.6% of them (boys 3.6%, girls
1.6%) (Butler et al, 2005). Primary is more common than secondary enuresis, withcomparable rates at the age of 7 years (Fergusson et al, 1986). Monosymptomaticenuresis is twice (68.5%) as common as non-monosymptomatic enuresis (31.5%)(Butler et al, 2006).

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Daytime urinary incontinence is 1.5 times more common in girls than boys
(Bower et al, 1996; Hellström et al, 1990); 2%-3% of 7 year olds and less than 1%of adolescents wet during the day (Hellström et al, 1990; Largo et al, 1978). In a
UK population study of 13,973 children, the rates of infrequent (less than 2 times
per week) and frequent (more than 2 times per week) were respectively: 13.6%
and 1.9% at the age of 4½; 7.8% and 1.5% at 5½; 9.7% and 1.0% at 6½; 6.9%
and 1.0% at 7½; 4.4% and 0.5% at 9½ years (Swithinbank et al, 2010). Different
trajectories can be identified:• Children with chronic, persistent incontinence over many years• Children with relapses and• A group with a continuous spontaneous remission rate (Heron et al, 2008).
Urge incontinence is the most common, affecting 4% of 7-year olds,
especially girls (Hellström et al, 1990). Voiding postponement is the second mostcommon type based on clinical studies. Population-based rates for the other types
are lacking.
The prevalence of nocturnal enuresis is comparable world-wide:
•
•
•
•
•
•

4.3% of Chinese children and adolescents aged 6-16 years (Liu et al, 2000)
8% of children aged 6-11 years in Taiwan (Chang et al, 2011)
14.9% of children aged 5-7 years in Turkey (Erdogan et al, 2007)
15% of children and adolescents in Saudi Arabia (Kalo & Bella, 1996)
17.4% of 7 years olds in Sudan (Rahim & Cederblad, 1986)
20.8% of children and adolescents aged 6-15 years in Ethiopia, including
daytime incontinence (Desta et al, 2007).

Click on the picture to hear
two children share theirexperience of bedwetting.

Variation in rates is probably due to different definitions, modes ofassessment and possible underreporting due to social desirability, particularly in
the Chinese and Taiwanese studies.
Only a few studies have reported daytime urinary incontinence. For
example, 16.6% of Korean children aged 5-13 years had overactive bladder, 4.5%
daytime incontinence and 6.4% enuresis (Chung et al, 2009).

CLINICAL PRESENTATIONS
Typical symptoms of monosymptomatic enuresis are: deep sleep and difficult
arousal (Wolfish et al, 1997), increased urine volume at night (polyuria) with large
wetted volumes. The typical presentation is a child who is extremely difficult towake and who wets the bed with large amounts of urine. In contrast, bladderfunction during the day is completely normal.
Children with a non-monosymptomatic enuresis have the same symptoms
but, in addition, have signs similar to those with daytime urinary incontinence(except wetting). This means that some go to the toilet infrequently and postpone
micturition with holding manoeuvres, others have signs of urgency and frequency,
while others have to strain and the urine stream is interrupted. Also, urinary tract
infections (UTI’s), constipation and encopresis are possible.
Children with secondary enuresis have higher rates of comorbid behaviouraland emotional disorders (von Gontard et al, 1999). A relapse can be precipitatedby stressful life-events such as separation or divorce of parents (Järvelin et al, 1990).
Otherwise, they do not differ from those with primary enuresis.

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IACAPAP Textbook of Child and Adolescent Mental HealthChildren with urge incontinence are characterised by:• High micturition frequency (more than 7 times per day with short intervals
in between)• Urge symptoms, sometimes with sudden, intensive urge
• Incontinence with small micturition volumes, increasing with tiredness, e.g.,during the afternoon• Holding manoeuvres such as contracting pelvic floor muscles, pressing thighs
together, holding abdomen, jumping from one leg to the next, sitting on
heel, squatting with the heel pressed against the perineum (curtsey sign)• Vulvovaginitis, perigenital dermatitis• Urinary tract infections
Typical signs of voiding postponement are:• Low micturition frequency (less than 5 times per day)• Postponement of micturition in certain situations (school, play, reading,television). With increasing postponement and fullness of bladder, holding
manoeuvres are instituted (as in urge incontinence) until wetting cannot be
avoided.
• Constipation and encopresis are common.
Voiding postponement is characterised by:• Repeated straining at the beginning and during micturition• Intermittent and fractioned urine flow
• Incomplete bladder emptying with residual urine and UTI’s• Stool retention, constipation and encopresis• Vesico-ureteral reflux.
Clinical symptoms of stress incontinence are wetting during situations that
result in increased intra-abdominal pressure (coughing, sneezing, play and sports).
Giggle incontinence is associated with cataplexy, i.e., motor contractions can bevisible. The incontinence is initiated by laughing and often cannot be stopped
until the bladder is empty. Children with underactive bladder have infrequentmicturitions (less than 5 times per day), a large bladder with incomplete emptying
and large residual volumes.

ETIOLOGY AND RISK FACTORS
Genetic and neurobiological factors interact with environmental influencesin the pathogenesis of elimination disorders. While some have a marked genetic
component (monosymptomatic enuresis and urge incontninence), in others both
genetic and environmental factors are involved (secondary enuresis), while someare mostly environmentally determined (voiding postponement).
Enuresis
Enuresis is a genetically determined maturational disorder of the central
nervous system (von Gontard et al, 2001; 2011a); 70% to 80% of all children withenuresis have affected relatives. The concordance rates are higher among monothan di-zygotic twins (Bakwin, 1973). The recurrence risk for a child to be affectedby enuresis is 40 % if one parent and 70 % if both parents had been enuretic(Bakwin 1973). Most cases are consistent with with an autosomal dominant mode

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The fundamental idea thatchildren willfully control
their thought processes
during sleep and the
proposition that suchcognitive control accounts
for bedwetting are simply
not plausible. If suchpropositions were true,
then why do we have ahistory of 3,500 years ofparents and professionals
talking to children about
stopping bedwetting withlittle or no results? The
one treatment that weknow to work reliably,
the urine alarm, does not
require cognitive control
and most likely works
via a process of active
avoidance conditioning […]It is disturbing enough tothink that talking therapy
for enuresis may makea comeback, but it iseven more disturbing toconsider […] that the mosteffective treatment known
for children's bedwetting israrely promulgated by ourcurrent health care system(Houts, 2000).

7IACAPAP Textbook of Child and Adolescent Mental Healthof inheritance; only one third of cases are sporadic (von Gontard et al, 2001).
Several loci on chromosomes 12, 13 and 22 have been identified in linkage studies– irrespective of the type of enuresis (von Gontard et al, 2001). Candidate genes
have not been identified yet. A genetic predisposition for enuresis remains life-longand can be reactivated by risk factors, even in adulthood (Hublin et al, 1998).
Children with enuresis have more neurological “soft signs” and need longer
to complete motor tasks (von Gontard et al, 2006). In contrast, sleep architecture
is not affected. Enuresis occurs in non-REM sleep phases, i.e. it is not associatedwith dreaming (enuresis during REM sleep is the exception). Enuresis occurs
predominantly in the first third of the night – some children even wet the bed 10
minutes after falling asleep. The mean latency is 3 hours (Neveus et al, 1999). This
explains why some children with enuresis wet even during daytime naps.
The main mechanisms responsible for the development of enuresis include:• Increased urine volume (polyuria) affects some, but not all children. Thisis associated with a circadian variation (but not lack) of the antidiuretic
hormone (Rittig et al, 1989).
• Impaired arousal is another important factor (Wolfish et al, 1997). In
standardised waking schedules with sounds of up to 120 decibels, only
9% of children with enuresis can be woken up – significantly fewer thancontrols. This means that children with enuresis do not wake up when their
bladder is full.
• Finally, children have an inhibition deficit of the pontine micturition centreof the brainstem. When the bladder is full during sleep, they are not able tosufficiently suppress emptying (Koff, 1996).
In addition to local bladder dysfunction, the same factors are responsible forthe development of non-monosymptomatic enuresis.
Psychosocial factors modulate genetic and neurobiological risks in different
ways. The time of initiation and intensity of toilet training, for example, has
no effect on the development of enuresis (Largo et al, 1978; 1996). Psychosocial
factors play a minor role in primary enuresis, as the rate of psychological disorders
and risk factors is not increased (Fergusson et al, 1986; Feehan et al, 1990).
Children with secondary enuresis, however, have both higher rates of emotionaland behavioural disorders as well as stressful life events prior to the relapse (Järvelin
et al, 1990; Feehan et al, 1990). The age of school entry (5-6 years) is the mostcommon age for relapse while parental separation or divorce is the most importantlife event (Järvelin et al, 1990).

In West Africa, children who
wet the bed were “treated” byattaching a large frog to theirwaist, and this apparently
frightened them into being
dry. Among the Navaho tribe,
one preferred treatment wasa ritual that required enuretic
children to stand naked overa burning bird's nest, and thiswas believed to produce acure of bedwetting because
birds did not soil their nests(Houts, 2000).

Urinary incontinence
Genetic factors play a role in daytime urinary incontinence as well. In a
population-based study of 8230 children, the odds ratio for daytime incontinence
increased by 3.28 if the mother and by 10.1 if the father was affected (von Gontard
et al, 2011a). Linkage studies demonstrate a positive linkage to chromosome 17(Eiberg et al, 2001). Urge incontinence is caused by spontaneous contractionsof the detrusor during the filling phase of the bladder, which are not sufficiently
inhibited by the central nervous system (Franco, 2007). Genetic factors also play amajor role in giggle incontinence but not in the other types of incontinence.

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Daytime continence is not influenced by early or intensive toilet training in
general (Largo et al, 1996; 1978). However, psychosocial factors do play a majorrole in daytime incontinence (see section on comorbidity). Voiding postponement
can be due to an acquired habit or as one of many oppositional symptoms as partof ODD (Kuhn et al., 2008).

COMORBIDITY
Enuresis
Overall, psychological disorders are 2 to 5 times more frequent in children
with elimination disorders. In summary, 20%-30% of children with enuresis,
20%-40% of those with urinary incontinence, and 30-50% with encopresis haveclinically relevant comorbid disorders (von Gontard et al, 2011b). Comorbidity
rates are highest in children with secondary enuresis – up to 40% in populationbased and 75% in clinic-based studies (Feehan et al, 1990; von Gontard et al,1999). Children with non-monosymptomatic enuresis have more comorbid
disorders than those with monosymptomatic enuresis (Butler et al, 2006).
ADHD is he most common comorbid disorder in enuresis. In a population
study of 1379 children aged 6 years, 9.4% had clinically relevant ADHD symptoms
compared to 3.4% of non-wetting children (von Gontard et al, 2011c). The rate of
ADHD in enuretic children presented to a paediatric hospital was 28.3%, compared
to 10.3% in a non-selected sample (Baeyens et al, 2006). Enuresis persisted longer
in children with ADHD – 2 years later, 65% were still enuretic compared to 37%
of controls (Baeyens et al, 2005). Enuresis in combination with ADHD is moredifficult to treat due to non-compliance. With alarm treatment, 43% of those withcomorbid ADHD were dry (versus 69% of those with enuresis alone) at 6 months
and only 19% (versus 66%) at 12 months. The rate of non-compliance was 38%
if both enuresis and ADHD co-existed (Crimmins et al, 2003).
Externalising disorders predominate but internalising conditions can also
occur. In a British population-based study of 8242 children at the age of 7½ years,
those with enuresis also suffered from separation anxiety (8.0%), social anxiety(70%), specific phobia (14.1%), generalised anxiety (10.5%), depression (14.2%),
ODD (8.8%), conduct disorders (8.5%) and ADHD (17.6%) (Joinson et al,2007).
Children with enuresis are not only afflicted with more comorbid disorders,
they are also more distressed and show more subclinical symptoms, which often
improve upon attaining dryness. Self-esteem can be affected and can improve under
treatment – irrespective of treatment success (Longstaffe et al, 2000). Also, qualityof life can be reduced by the enuresis (Bachmann et al, 2009). Both children andparents can be distressed by the enuresis.
Daytime urinary incontinence
Comorbidity rates among children with daytime urinary incontinence(30%-40%) are slightly higher than in children with enuresis (20%-40%) (vonGontard et al, 2011b). In a population-based study of 8242 children aged 7 ½
years, externalising disorders were prominent with significantly increased rates of
ADHD (24.8%), ODD (10.9%) and conduct disorders (11.8%) (Joinson et al,2006). In another population study, 36.7% of children with urinary incontinence
had ADHD symptoms, in comparison to 3.4% of dry children (von Gontard

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IACAPAP Textbook of Child and Adolescent Mental Healthet al, 2011c). Adherence to treatment is lower in cases of urinary incontinenceand ADHD: only 68% became dry, compared to 91% of controls with urinary
incontinence without ADHD (Crimmins et al, 2003).
Children with urge incontinence have lower rates of comorbid disorders
than those with voiding postponement (36% vs. 59%) but higher than controls(9%) (Kuhn et al, 2009). Children with urge incontinence predominantly haveinternalising disorders while the most typical disorder in voiding postponement is
ODD (Kuhn et al, 2009). It would appear that comorbid disorders are a consequenceof wetting in urge incontinence while ODD seems to be the underlying problem
in voiding postponement. Much less is known about comorbidity in the othertypes of incontinence.

DIAGNOSIS
Assessment and a careful diagnosis are the bases for successful treatment– each subtype of enuresis and urinary incontinence responds best to its specifictreatment. Assessment also means building a relationship with the child and parents
that will become the foundation for the entire course of therapy. It is therefore
advisable to take plenty of time for the first consultation with child and parents.
More details on the diagnosis and treatment of all elimination disorders can befound in von Gontard and Neveus (2006), which is still the most comprehensive
textbook on the topic, with both background information and practical procedures.
Most of the diagnostic process is based on simple, good clinical practicethat can be delivered in most primary care settings. The most important step isa good and thorough history. The history will lead the clinician towards possible
diagnoses which need to be followed up and enable the exclusion of many otherconditions. An example of a detailed history with pertinent questions can be foundin Appendix C.4.1.
Frequency-volume chart
The second most important step is a 48-hour frequency-volume chart.
Parents are asked to observe, record and measure over 48 hours when and how muchtheir child voids and drinks, as well as associated symptoms such as incontinence,
holding manoeuvres, etc. Parents can be given a simple plastic measuring cup(which they will return at the next visit and that can be used many more times).
This chart gives essential information for the diagnosis. In urge incontinence, forexample, a micturition frequency of over 7 and small volumes (of 20-60ml) are
typical; in voiding postponement, some children void only 2 or 3 times a daywith large volumes of 400ml or more. Also, drinking habits can be assessed: mostchildren with elimination disorders do not drink enough fluids (some only 400600ml), while polydipsia is extremely rare. Most parents are not aware of theirchild’s voiding and drinking habits and will not be able to provide this information
when asked. An example of a chart is presented in Appendix C.4.2.

Assessment inenuresis and urinary
incontinence•
History•
48-hour frequency/
volume chart•
Questionnaires•
Paediatric physicalexamination•
Urinalysis•
Child psychiatricscreening or
assessment•
Sonography (ifavailable).
Only if indicated•
Urine bacteriology•
Uroflowmetry andpelvic-floor EMG•
Other diagnostic
procedures:radiologicalexaminations,invasive urodynamics,
cystoscopy, etc.

Questionnaires
Specific enuresis questionnaires are helpful to confirm and augment the
information children and parents provide (see Appendix C.4.3). The 48-hourvolume/frequency chart, however, is far more important than a questionnaire.

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Physical examination
Each child should be examined physically at least once at the beginningof treatment. It is essential that organic causes of incontinence are ruled out. A
full paediatric and neuorological exam is recommended. Children with daytime
incontinence may require several examinations in the course of treatment,
especially if UTI’s and other complications occur. For most children with enuresis,
especially with monosymptomatic enuresis, one exam will suffice.
Investigations
At least one urinalysis (with a urine stick) is recommended to be surethat no signs of bacteriuria and manifest UTI are present. This is especially
important in daytime urinary incontinence; it is usually negative in children withmonosymptomatic enuresis.
If available, sonography is a very useful, non-invasive tool. In addition to thedetecting structural anomalies of the urinary tract, sonography can give valuable
information regarding three functional changes:• A thickened bladder wall (> 2.5mm) can be indicative of a hypertrophy ofthe bladder wall as a sign of bladder dysfunction or it can be due to UTI’s• Residual urine (>20ml) can be indicative of incomplete bladder emptying;and finally,• An enlarged rectal diameter of more than 25mm can be a sign of stool
retention and constipation.
However, even in Europe, sonography is not easily available in many
countries and thus not routinely performed in children with enuresis and urinary
incontinence. In complicated cases with recurrent UTI’s it is definitely indicated.

Click on the picture to hear
two mothers share theirexperience of bedwetting

All other procedures are not routinely indicated. Uroflowmetry alone or
combined with pelvic floor EMG is required for the diagnosis of dysfunctional
voiding (Chase et al, 2011). So-called staccato (changes in flow rates) or fractioned(complete interruption of flow) are typical, combined with contractions of thepelvic floor. If not available, good clinical practice would be to listen and observea child during the emptying of the bladder: one can hear and observe the straining
as well as the waxing and waning of the urine stream.
All other, especially invasive, procedures should not be performed inchildren with enuresis or functional urinary incontinence unless they are absolutely
indicated medically. Radiological and further urological investigations should be
avoided as they are in most cases not necessary and can harm the child.
Psychiatric assessment
In a child psychiatric setting, a routine assessment regarding comorbid
emotional and behavioural disorders is recommended. In all other settings(paediatric, urologic etc.) at least a screening with a validated and standardisedparental questionnaire is recommended because of the high frequency of comorbid
disorders (von Gontard et al, 2011b). This can be done in one or two stages,
either by using a short screening questionnaire, such as the SSIPPE (Van Hoecke
et al, 2007), first and a long questionnaire next, or by using a long questionnairesuch as the CBCL (Achenbach, 1991). If many problem items are endorsed, afull assessment by a child psychologist or psychiatrist should follow. If comorbid
disorders are present, they should be treated (see Figure C.4.1).

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IACAPAP Textbook of Child and Adolescent Mental Health

Figure C.4.1 Flow chart for assessment of psychological symptoms (subclinical) or
disorders (clinical): specific treatment for enuresis/incontinence is the same for all children;
those with symptoms require counselling, those with disorders need treatment (from von
Gontard et al, 2011b)

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Differential diagnosis
Somatic causes of urinary incontinence must be excluded. These include
structural anomalies (such as epispadias, hypospadias, urethral valves, and othermalformations of the urinary tract), neurologic conditions (such as spina bifida
occulta, tethered-cord-syndrome, etc.) and other paediatric diseases (such as
diabetes insipidus, diabetes mellitus). Comorbid emotional and behaviouraldisorders should be assessed in addition to the type of elimination disorder.

TREATMENT
Again, treatment of enuresis and urinary incontinence is based on simple,
effective steps that can be delivered in many primary care settings. However, it istime-consuming as most interventions require cooperation of the child and parents.
More detailed information is provided in von Gontard and Neveus (2006).
Enuresis

Recommendations
to rate treatment
outcome according
to the Children’sContinence Society(Neveus et al, 2006):
Initial outcome•

Several meta-analyses have shown conclusively that, overall, nonpharmacological interventions are more effective than medication, which also has
its place if indicated (Houts et al, 1994; Lister-Sharp et al, 1997). The classic metaanalysis of Houts et al (1994) shows this quite clearly (Figure C.4.2).
General principles•••

Certain general principles should be followed for treatment:• A child should be at least 5 years of age (the age required to diagnose enuresis
and urinary incontinence), younger children do not require treatment• Treatment should always be symptom-orientated, aimed at achieving
continence (i.e., complete dryness). Primary psychotherapy for enuresis
is not effective and not indicated. Comorbid disorders should be treatedseparately according to evidence-based recommendations• When there are several concurrent disorders, encopresis and constipation
should be treated first because some children will stop wetting once these
problems have been dealt with

Non-response: 0 to
49% reduction
Partial response: 50
to 89% reduction
Response: >90%
reduction
Full response:
100% or less than 1
accident per month.

Long-term outcome•••

Relapse:morethan one episode permonthContinued success:no relapse in
6 months after
treatment
Complete success: norelapse in two years
after treatment• Daytime incontinence should be treated first, as many children will stop
wetting at night once the daytime problems have been treated• In non-monosymptomatic enuresis, all daytime bladder problems should
be tackled first (according to the principles of urinary incontinence) before
starting the specific treatment of enuresis• Primary and secondary enuresis are treated in the same way
The initial treatment steps are simple, non-specific aspects of “good practice”:• Counselling, support and provision of information• Enhancing motivation and alleviating guilt feelings• Educating about drinking and toileting habits: drinking more fluids during
the day, taking time while on the toilet, sitting in a relaxed way, refraining
from holding manoeuvres, etc.
• Discontinuing all ineffective measures such as punishing the child, fluid
restrictions, waking and lifting, ineffective medication, other alternative
medicine treatments

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IACAPAP Textbook of Child and Adolescent Mental Health

Figure C.4.2 Effectiveness of different treatment forms for
nocturnal enuresis (% dry at the end of treatment and at follow-up)(Houts et al, 1994).

• A baseline period is then recommended with a simple observation andrecording of wet and dry nights over a period of 4 weeks. Children are
asked to draw a symbol for wet and dry nights (clouds and suns, stars, etc.)
in a chart and bring it to the next consultation. An example of chart is
depicted in Appendix C.4.4.
These simple measures will achieve dryness in 15-20% of cases without
further intervention and are supported by evidence (Cochrane review of Glazener
and Evans, 2004). If these simple interventions do not suffice, specific treatment
is required.
Two main interventions are available: alarm treatment and pharmacotherapy.
As alarm treatment is more effective and has the best long-term results, this shouldbe the first line treatment if child and parent are motivated. As shown in Figure
C.4.2, 62% of children are dry at the end of treatment and 47% at follow-up.
Houts et al (1994) conclude that “urine alarm treatments should not only beconsidered the treatment of choice, but the evidence from this review suggeststhat cure rather than management is a realistic goal for the majority of children

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IACAPAP Textbook of Child and Adolescent Mental Healthsuffering from nocturnal enuresis.” A Cochrane review of 22 RCT’s involving 1125
children concluded: “Alarm interventions are an effective treatment for nocturnal
enuresis. Desmopressin and tricyclics appeared as effective while on treatment,
but this effect was not sustained after treatment stopped and alarms may be more
effective in the long run” (Glazener et al, 2005).
If alarm treatment cannot be implemented adequately, medication(desmopressin) is the second line treatment. If either method fails, a switch tothe other treatment is recommended (Neveus et al, 2010) and was shown to beeffective (Kwak et al, 2010).
Alarm treatment
An alarm consists of a pad or a metal sensor, which is connected to a bell by
a wire. Once the sensor becomes wet, an electric circuit is closed and the alarm is
set off. Alarms are very simple devices; they can be cleaned and used by different
children many times over. Sterilisation is not required, as urine is per se a sterile
fluid (unless UTI‘s are present), cleaning with a surface disinfectant is enough.
Two different types of alarms exist, body worn and bedside. In body worn
alarms, the bell is attached to the night dress while the sensor is attached to theunderpants. If desired, body worn alarms can be used with diapers. In bedsidealarms, a metal foil or a cloth pad (with integrated wires) is placed under the top
sheet of the bed and connected to an alarm next to the bed. Both alarms are equallyeffective. Therefore, children should decide which alarm they prefer.
The alarm should not just be prescribed but its functions demonstrated andshown directly during the consultation. Children should feel responsible for theirtreatment. Some instructions are extremely important and should be gone throughin detail with parents and child:
1. Children are asked to go to the toilet before going to bed
2. The alarm is attached and switched on
3. In case of a dry night, nothing happens and the child can turn off thealarm the next morning. In case of wetting, the alarm is triggered andthe child should wake up completely, either by themselves or withparental help
4. The child is asked to go to the toilet and urinate
5. The night dress and the bedding are changed and the alarm is reset.
6. The child should be actively involved in this process. If the child wets a
second time during the night, the whole routine is repeated.
7. Parents are asked to record all relevant data in a chart (see Appendix
C.4.5).
To be successful, the alarm must be used every night for a maximum of 16
weeks. Some children become dry in only a few weeks, most will require 8 to 10
weeks and some a little longer. After 14 consecutive dry nights, use of the alarmis discontinued and the child is considered to be dry. Parents are advised to restart
alarm treatment if a relapse (two wet nights per week) happens, this occurs in up
to 30% of cases.
The alarm treatment relies on operant conditioning and should beenhanced with other measures including positive reinforcement with praise andother rewards, as well as aversive consequences such as getting up, going to theEnuresis

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IACAPAP Textbook of Child and Adolescent Mental Health

Figure C4.3 Twomodels of bed-wetting
alarmstoilet and remaking the bed (Butler, 1994). Dryness can be achieved by two basic
mechanisms: either children learn to wake up and go to the toilet (one third) or
they sleep through the night without wetting (two thirds).
Usually, simple alarm treatment is sufficient. It can, however, be reinforcedby additional means. A simple addition to the alarm is the so called “arousal
training” by van Londen et al (1993). In arousal training the alarm is set up before
sleep, the alarm is triggered, children are instructed to turn off the alarm within
three minutes, go to the toilet and reset the alarm. If this is achieved correctly
children are rewarded with two tokens, such as stickers. If this is not achieved, one
token has to be returned. In younger children, we found it advisable to modify thistraining: children receive one token if they are successful but do not have to pay
back a token, which would be too frustrating for them. Arousal training has beenshown to be more successful than alarm alone. A well-known training program is“dry bed training” by Azrin et al (1974). This is a complicated, difficult to perform
program which starts with an intensive night (in which the child is awaken once
every hour until 1 am) followed by maintenance treatment. Meta-analyses haveshown that “dry bed training” is no more effective than alarm treatment alone(Lister-Sharp et al, 1977). Therefore, it is not recommended.
The combination of alarm treatment and desmopressin cannot berecommended due to conflicting results. However, if a child has urge symptoms(i.e., a non-monosymptomatic enuresis) a combination of anticholinergic

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IACAPAP Textbook of Child and Adolescent Mental Healthmedication (for example 2.5mg to 5mg Oxybutinin or Propiverin at night) is
helpful, otherwise the alarm may go off several times per night and the outcome
will be less favourable.
Medication••••

Indications for medication are:
Unwillingness to undertake alarm treatment
Lack of motivation in the children
Family overwhelmed by demands such as a work situation, cramped
housing, infants to care for, i.e., cooperation with alarm treatment is notpossible
Short-term dryness is required, e.g., for school outings.

There are two groups of medication with a clear antienuretic effect:
desmopressin and tricyclic antidepressants (TCAs). Although both are effective,
desmopressin has less side-effects and is therefore the preferred substance.
Desmopressin (1-deamino-8-D-arginine vasopressin, abbreviated DDAVP)
is a synthetic analogue of the antidiuretic hormone (ADH). A reduction of wet
nights or even dryness can be achieved in 70% of cases: 30% of children are full
responders, 40% partial responders, and 30% non-responders (Neveus et al, 2010).
After discontinuing medication most children relapse, so that desmopressin has a
low curative potential (Neveus et al, 2010). According to van Kerrebroeck (2002),
only 18%-38% of children remain dry 6 months after medication is withdrawn.
Compared with the alarm, desmopressin has a distinctly lower curative effect in
the long run.
Desmopressin is taken in tablet form in the evenings only. The oral dosage
is 0.2mg to 0.4mg. It is advisable to titrate the required dosis over 4 weeks, as
shown in the chart in Appendix C.4.6. One starts with the low dosage of 0.2mg in
the evening for two weeks. If the child is dry or a marked reduction of wet nights
is documented one stays with this dosage. Otherwise, medication is increased
40 years of being treated for nocturnal enuresis
In the course of forty years I have consulted a wide range of experts in the hope of finding asolution to my nocturnal enuresis [...] Most of the GPs [family doctors] advised curtailmentof drinking and methods of awakening in the night. The urologists performed various
technical studies that showed no abnormalities. Alarm systems usually gave relief for ashort period. Consultations with a naturopath and a homeopath yielded no benefits, andconsequent disappointment resulted in new mental strain... I consulted a psychologist who,
although unable to find anything abnormal in my personality, advised Pavlov's methodof adaptation: immediately after waking with a wet bed, I was to take a cold shower as
punishment for the “bad” behaviour. A urologist prescribed imipramine, despite its severeside effects including excessive sweating, dizziness, and a dry mouth. The psychiatrist usedsandpit therapy to trace traumatic experiences in childhood: recognition and acceptance of
precipitating experiences might, it was hoped, remove the cause of my enuresis. Two years
of weekly sessions of 45 minutes had a major influence in my personality. Sandpit therapy,
with its focus on the ego, changed me from a sociable to a self-centred individual. Again,
the bedwetting was unaffected [...] Finally, after nearly four decades and many years of
disappointing experiences I consulted Professor Janknegt, who suggested desmopressin(DDAVP)—an analogue of antidiuretic hormone. Used as a nasal spray once a night thisbrought immediate relief. Discontinuation of the spray immediately results in bedwetting. So
far, there have been no side-effects […] Over the years, the intrinsic difficulties of nocturnal
enuresis have been compounded by the effects of unsuccessful treatments.
De Graaf MJ. Lancet 1992, 340:957-958.

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IACAPAP Textbook of Child and Adolescent Mental Health

to 0.4mg in the evening. If children do not become dry with 0.4mg, they are
considered to be non-responders and desmopressin is discontinued. Otherwise,
one can continue with the required dosage for a maximum of 12 weeks, after which
desmopressin should be stopped to check if the child can remain dry without
medication. If a relapse occurs, desmopressin can be given for another 12 weeks
and this regime can be continued for as long as indicated. Adverse effects are rare
and not pronounced, like head and stomach aches, lack of appetite, etc. The mostdramatic, though rare side effect is hyponatremia and water intoxication, which
may require intensive care. Therefore it is important not to overdose and not todrink a large amount of fluids after taking the medication. Laboratory blood tests
are not necessary.
Tricyclic antidepressants such as imipramine have a proven anti-enuretic
effect and similar relapse rates as desmopressin. Due to cardiac arrhythmias
even with therapeutic doses, a detailed family history, ECG before and during
treatment and blood tests are recommended. A low dose of 10mg to 25mg in theevening (1mg per kg of body weight per day or less) is often sufficient. If higher
doses are necessary, imipramine should be give 3 times a day and the medication
slowly increased to a maximum of 3mg per kg of body weight per day. Due to side
effects (and toxic effects in case overdosage), imipramine has become a third line
treatment for severe therapy-resistant cases.

Click on the picture to accessthe NICE guideline for the
management of enuresis

Urinary incontinence
The same basic principles as in the treatment of enuresis should be followed,
e.g., provision of information, counselling, supporting and motivating both childand parent is essential.
The main focus in the treatment of urge incontinence is a symptom-oriented
cognitive-behavioural approach aimed at a conscious control of the urge without
the use of the pelvic floor muscles, i.e., holding manoeuvres (Vijverberg et al,1997). Children are instructed to note when they feel an urge and go to the toilet
right away without using holding manoeuvres. They are asked to document in achart if their pants were dry (with the symbol of a flag, for example) or if they werewet (with the symbol of a cloud, for example). This means, that children should beallowed to go to the toilet in any situation, especially in kindergarten and school.
If adhered to, the number of voidings is typically reduced first, followed by areduction in the number of wet episodes.
This simple approach is sufficient for 1/3 of children; the other 2/3 will
require additional medication. Monitoring – observing and documenting (i.e.,the cognitive-behavioural component) – should continue throughout the therapy.
Anticholinergic medication is indicated. Oxybutine is a well-known preparation
available as generic drug in most countries. It should be introduced slowly to
avoid side-effects up to an initial dosage of 0.3mg per kg of body weight per day
in 3 doses (maximum daily dosage: 15mg). If not effective, it can be increased
to 0.6mg per kg of body weight per day (maximum 15mg/day). Side-effects are
dose-dependent and reversible. They include typical anticholinergic effects such as
flushing, blurred vision, tachycardia, hyperactivity, dryness of the mouth, residual
urine and constipation.

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IACAPAP Textbook of Child and Adolescent Mental HealthAn alternative is propiverin, which unfortunately is not available in many
countries. The dosage is a maximum of 0.8mg of body weight per day in two
doses (with a total maximum of 15mg/day). Side effects are similar but possibly
at a lower rate. If one of these two standard medications is not effective or isaccompanied by too many side effects, a switch-over to the other medication isrecommended. Other anticholinergic medications such as tolterodine, solifenacineand others are used in adults but are not recommended for standard treatment inchildren.
A symptom-oriented approach is indicated in all cases of voiding postponement.
The first step is provision of information and psycho-education. Often, theassociation of voiding postponement, retention of urine and incontinence are notknown to parents and children. Children and parents are instructed to increase thefrequency of micturition. The goal is to go to the toilet seven times a day at regularintervals. Children should sit on the toilet in a relaxed way and take plenty of time.
Micturitions in the toilet as well as wetting episodes are noted in a chart. Often thisrequires parents to send their child to the toilet. To increase motivation, a simple
token system with positive reinforcements can be added. In older children, digital
wrist alarm watches (or cell phones) can be of help. Intervals of 1½ to 3 hours are
set to remind the child to go to the toilet. However, these approaches are often
not sufficient because of the high behavioural comorbidity, especially with ODD,
which requires additional treatment.
Treatment of dysfunctional voiding includes increasing motivation, cognitivebehavioural elements, relaxation and general drinking and toileting advice (Chaseet al, 2010). If necessary, voiding frequency and oral fluids can be increased. Toilet
re-training is initiated. It is recommended that children take a lot of time, sit ina relaxed manner on the toilet seat, spread their legs apart and have contact withthe floor either directly or with a little foot stool. The children are asked to relax
completely, initiate micturition without straining and simply let the urine flow
until they have the feeling that the bladder is empty. The most specific and effective
treatment is biofeedback – either with uroflowmetry or pelvic-floor EMG (Chaseet al, 2010). Signals of the urine stream or pelvic floor contractions are presented
to the child in real time either visually or acoustically. Many child-friendly
programmes and animations are available. EMG-feedback can be performed athome under instruction; otherwise, biofeedback is limited to specialised outpatient
departments and beyond the scope of most primary care services. Coordinationand continence can be achieved in a few sessions in most children. Medication is
not indicated (Chase et al, 2010).

Click on the picture toaccess the website of theInternational Children’sContinence Society (ICCS).
Families and professionals
can find in the website avariety of useful information
and resources.

Giggle incontinence is treated with a classical conditioning paradigm(Elzinga-Plomp et al, 1995) or with high-dose methylphenidate (due to the overlap
with cataplexy and narcolepsy) (Sher & Reinberg, 1996). Stress incontinenceis treated by physiotherapy or imipramine. Children with underactive bladderrequire an intensive training and often intermittent catheterisation. All of theserare disorders do require specialised treatment (see von Gontard & Neveus, 2006).
In therapy-resistant cases, structured group therapies have been successful(Equit et al, 2012). These combine counselling, provision of information, relaxation
techniques, cognitive-behavioural, play and group therapy approaches.

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IACAPAP Textbook of Child and Adolescent Mental Health

COURSE
Enuresis has excellent long-term outcome with a high spontaneous
remission rate – 13% per year – and effective treatments are available; 60% to 80%
become dry with alarm treatment and 50% remain so on the long-term (Houts
et al, 1994). Still, a small group of children have chronic enuresis with 1%-2% of
adolescents affected. Nocturia (waking up at night and voiding) can be a residual
symptom. The prevalence of enuresis overall is 1.7% in adults, with an 8-fold riskfor enuresis if they had wetted as children (Hublin et al, 1998).
Studies of the long-term outcome of daytime incontinence are lacking.
Urge incontinence seems to have the best prognosis, while voiding postponement,
especially combined with ODD is difficult to treat. Daytime incontinence increases
in adulthood with age, especially in women, although these are not necessarily aconsequence of childhood incontinence.

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103:1193-1197.
Nevéus T, von Gontard A, Hoebeke P et al (2006). The
standardisation of terminology of lower urinary tract
function in children and adolescents: Report fromthe Standardisation Committee of the International
Children’s Continence Society (ICCS). Journal of
Urology, 176:314-324.
Nevéus T, Eggert P, Macedo A et al (2010). Evaluation ofand treatment for monosymptomatic enuresis: A
standardization document from the International
Children’s Continence Society. Journal of Urology,
183:441-447.
Sher PK, Reinberg Y (1996). Successful treatment of giggle
incontinence with methylphenidate. Journal of
Urology, 156:656-658.
Rahim SIA, Cederblad M (1986). Epidemiology of nocturnal
enuresis in a part of Khartoum, Sudan. I. The
extensive study. Acta Paediatrica Scandinavica,
75:1017-1020.
Rittig S, Knudsen UB, Norgaard JP et al (1989). Abnormal
diurnal rhythm of plasma vasopressin and urinary
output in patients with enuresis. American Journal of
Physiology, 25:664-671.
Swithinbank LV, Heron J, von Gontard A, Abrams P (2010).
The natural history of daytime urinary incontinencein children: a large British cohort. Acta Paediatrica,
99:1031-1036.
Van Hoecke E, Baeyens D, Vanden Bossche H et al (2007). Early
detection of psychological problems in a populationof children with enuresis: construction and validationof the short screening instrument for psychologicalproblems in enuresis. Journal of Urology, 178:26112615.
van Kerrebroeck PEV (2002). Experience with the long-term useof desmopressin for nocturnal enuresis in children andadolescents. BJU International, 89:420-425.

21

IACAPAP Textbook of Child and Adolescent Mental Healthvan Londen A, van Londen-Barensten M, van Son M et al(1993). Arousal training for children suffering fromnocturnal enuresis: a 2½ year follow-up. Behavior
Research and Therapy, 31:613-615.

von Gontard A, Heron J, Joinson C (2011a). Family history of
nocturnal enuresis and urinary incontinence – resultsfrom a large epidemiological study. Journal of Urology,
185:2303-2307.

Vijverberg MAW, Elzinga-Plomp A, Messer AP et al (1997).
Bladder rehabilitation, the effect of a cognitive training
programme on urge incontinence. European Urology,
31:68-72.

von Gontard A, Baeyens D, Van Hoecke E et al (2011b).
Psychological and psychiatric issues in urinary andfecal incontinence. Journal of Urolog, 185:1432-1437.

von Gontard A, Nevéus T (2006). Management of Disorders of
Bladder and Bowel Control in Childhood. London:
MacKeith Press.

von Gontard A, Moritz AM, Thome-Granz S et al (2011c).
Association of attention deficit and elimination
disorders at school entry – a population-based study.
Journal of Urology, 186:2027-2032.

von Gontard A, Plück J, Berner W et al (1999). Clinicalbehavioral problems in day and night wetting
children. Pediatric Nephrology, 13:662-667.

Wolfish NM, Pivik RT, Busby KA (1997). Elevated sleep arousal
thresholds in enuretic boys: clinical implications. Acta
Paediatrica, 86:381-384.

von Gontard A, Schaumburg H, Hollmann E et al (2001). The
genetics of enuresis – a review. Journal of Urology,
166:2438-2443.

World Health Organisation (2008). Multiaxial Classification ofChild and Adolescent Psychiatric Disorders: The ICD-10
Classification of Mental and Behavioural Disorders inChildren and Adolescents. Cambridge, UK: Cambridge
University Press.

von Gontard A, Freitag CM, Seifen S et al (2006). Neuromotor
development in nocturnal enuresis. Developmental
Medicine and Child Neurology, 48:744-750.

It is not known when enuresis became a medical problem, but it has been recognized as a disturbance of childhoodnecessitating medical treatment since the time of the Papyrus Ebers’ which is dated 1550 BC. Juniper berries were therecommended treatment (Glicklich, 1951).

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IACAPAP Textbook of Child and Adolescent Mental HealthAppendix C.4.1
CLINICAL HISTORYOF WETTING PROBLEMS AND POSSIBLE COMORBID DISORDERS(von Gontard, 2001; von Gontard & Neveus, 2006, with permission)
PRESENTING SYMPTOMSGeneral introduction:

Do you know why you and your parents are here today?

Time of wetting:

Is it because you wet the bed or because your pants are wet during the day?

Start with the most important symptom, i.e., night or daytime problems
NOCTURNAL WETTING
Frequency of wetting:Do you wet the bed every night or are there dry nights? How many nights
per week is your bed wet (or dry)?

Amount of wetting:		

Is the bed damp or completely wet?

Depth of sleep:

How deep does your child sleep? Is it easy or difficult to wake him/her?
What do you have to do to get you child awake? Does your child sometimes
wake up at night to go to the toilet (nocturia)?

Dry intervals:

What is the longest period of time that your child has been completely dry(days, weeks, months)? How old was your child then? Did anything happen
around the time of the relapse that might have had an impact for your childto start wetting again?

Impact and distress:

How is it for you when your bed is wet? Are you sad? Annoyed? Angry?
Ashamed? Or do you feel it does not matter? Do you want to get dry? Are
you willing to do something about it and put some effort into the therapy?

Social consequences:

Have you been teased by somebody else about the wetting? Have you
avoided sleeping over with friends or join in on outings with your schoolclass because of that?

DAYTIME WETTING AND MICTURITION PROBLEMS DURING THE DAY
Frequency of wetting:

Are your pants wet every day or do you also have dry days? How many days
per week are your trousers wet? Does it happen that you wet during the day
not once, but several times? How many times does it usually occur?

Amount of wetting:

Are the pants damp or really wet? Can the wet spot be seen through theclothing?

Timing during the day:

Do you usually wet during the morning, in the afternoon or on theevening?

Frequency of micturition:

How often does your child go to the toilet during the day (3, 5, 10 or 20
times? (Normal range is 5 to 7 times per day).

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IACAPAP Textbook of Child and Adolescent Mental Health

Voiding postponement:

Have you ever noticed that your child does not go to the toilet right away,
but puts off the voiding for as long as possible? In which situations does
this happen most often (for example: in school, coming home from school,
while playing, while watching TV or during other activities)?

Holding manoeuvres:

How do you notice that your child needs to go to the toilet? Does it seem tobe absent-minded? What exactly does your child do to delay voiding? Haveyou ever noticed that he/she crosses their legs, jumps from one leg to theother, holds its tummy or genitals, squats or sits on its heels?

Urge symptoms

Does it happen that your child feels a sudden and strong urge to go to thetoilet (even though it goes to the toilet often)? For example, how long can
you drive the car or go shopping, before your child has to go to the toilet?
Do you have enough time to wait for the next rest room or do you have tostop right away to let your child void?

Dry intervals during the day:

When did your child get dry during the day? Is your child still wetting
during the day? What was the longest time period your child has ever beendry (days, weeks, months)? How old was your child then? Were important
things happening at the time of the relapse that might have had an effect on
your child to start wetting again?

Problems with micturition:

Does your child have to strain at the beginning of micturition or does theurine come spontaneously? Is there one continuous stream when voiding oris the voiding interrupted? If it is interrupted, how many times? Does yourchild need to strain to get it going again?

Urinary tract infections:

Does your child complain about pain during voiding? Does your child haveto go the toilet more often than usual? How many urinary tract infections
has your child had so far? When did the first infection occur? Has yourchild had infections with fever and pain in the kidney areas? Have theinfections been treated with antibiotics? Has your child had long-term
prophylaxis with antibiotics? Is taking medication at the moment? Has yourchild had skin infections in the genital area (dermatitis)?

Medical complications:Have there been other medical complications such as refluxes, operations,etc?

Eating and drinking habits:

Please describe the eating habits of your child. Prefers biscuits, white breadother low fibre food? How much and what does your child drink each theday?

Attributions:

What do you think is the cause of your child’s wetting problem? Do you
have any idea about how it happened? Have you ever felt guilty about it?
Have you ever blamed yourself for it? Have you ever been blamed by others?
Do you think your child is doing it on purpose? Who is distressed the mostabout the wetting: you or your child? What do you think should change?
What are your expectations? Are you and your child willing to cooperate
actively with treatment?

TREATMENT TRIALSPrevious therapy:

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What have you tried so far to get your child dry? (Ineffective forms oftreatment) Fluid restriction, waking, holding, punishment, other measures?
(Effective forms of treatment) Charts and calendars, rewards, alarm
treatment, medication? Which medications(Minirin, Imipramine, others)?
How were the treatment trials conducted, please describe for how long withwhat effects? Whom have you consulted for your child’s wetting problem:

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IACAPAP Textbook of Child and Adolescent Mental Healthpaediatrician, urologist, psychologist, psychiatrist, child guidance centres,
etc.? Which investigations have been performed so far?
ENCOPRESIS
Soiling:

Does your child sometimes soil his underwear? How many times per week
does it happen? Are they large amounts or stool smearing? Does it happen
only during the day or also at night? How does your child react when it
soils? How old was your child when he became clean (stools in the toilet
and not in the diapers)? Have there been any relapses in the past?

Toilet habits:

How often does your child have bowel movements per week? Does it ever
happen that it does not have bowel movements for several days in a row?
Is your child constipated regularly? Is defecating painful? Has there been
blood on the stools? What have you done about it so far?

THE CHILD PSYCHIATRIC HISTORY
The child psychiatric history is divided into the presenting symptom(s), personal and developmental history
and the family history (see Chapter A.5). In most cases, parents and child are interviewed together – in thisway differing views can be assessed easily. In some cases, it is best to interview parents alone (i.e., maritalconflicts, abuse, etc.). In others, it can be useful to see and talk to the child alone, particularly older children.
Some children are more open to talk about their problems when parents are not present.
PRESENTING SYMPTOMSAt the end of the wetting history, it is useful to ask an open question regarding other problem areas.

Other behavioural problems:

Are there other areas in your child’s behaviour that you are worried about?
Please describe them in detail.

As in the history of the wetting problem, each presenting symptom should be dealt with in turn. The
following points are worth considering.
Presenting symptoms:

Please describe the problem in your own words in as much detailed as
possible. How often does it occur? In which situations (at home, at school,with friends)? How does your child react? How do you react? When did it
begin? How has it developed so far? Has it remained the same, got worse
or diminished in intensity or frequency? What have you done about it so
far? Has the child been seen or treated for the problem? Where, by whom
and with which effect? What are your main worries? What would you liketo change? How do you think this could change? What do you expect fromthis consultation?

It is also useful to ask a few general questions about possible problem domains that often occur inchildren and that might be missed by open questions. If parents answer positively, each of the problems
need to be explored in detail.

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IACAPAP Textbook of Child and Adolescent Mental Health

OTHER PROBLEM AREAS
Externalising problems:

Is your child restless, constantly fidgeting or too active? Is easily distracted?
For how long can concentrate? Are there certain situations in which he finds
it especially difficult to concentrate, for example at school? Does your childseem to act impulsively, without thinking? Is sometimes aggressive verbally,
towards objects or people? How does your child respond to rules? Does heobey your rules? Is he oppositional? How does it react to your setting limits
and saying no? Are there particular problem areas: homework, coming
home too late, lying, stealing…?

Internalising problems:

Is your child sad, unhappy or withdrawn? Has your child lost interestin play, seeing other children? Does she find it difficult to get an activity
going? Does your child worry a lot? Are there problems with sleeping or
eating? Is she afraid of certain objects, situations or animals (phobias)?
Afraid of strangers, groups of children (social anxiety)? When you go away
(separation anxiety)? Without apparent reason (generalised anxiety)? Has
your child developed any peculiar habits, rituals or interests? Does she tend
to repeat things in the same way?

PERSONAL AND DEVELOPMENTAL HISTORY
Pregnancy:

Was the pregnancy planned (desired) or unexpected? What were yourfeelings during pregnancy? Were there medical complications? Did anything
happen that you found stressful?

Birth:

Was delivery at the expected date, too early, too late? Was it a spontaneous
birth? Were there complications during or after birth? What was the birthweight of your child?

Infancy:

Was your child breast-fed? For how long? If not, what were the reasons?
Was your child a quiet, content or active baby (temperament)? Were there
problems with feeding, weight gain, sleeping, excessive crying?

Motor development:

When did your child start sitting, standing, walking freely?

Speech and language:

When did your child say its first words (and which were they)? When did
your child say its first two-word sentences? Were there any problems witharticulation, the way sentences were formed (expressive language) or with
understanding (receptive language)?

Kindergarten:

When did your child enter kindergarten? Did he show problems staying
there, i.e. about being away from you? Were there problems with otherchildren or with teachers? If yes, please describe.

School:When did your child enter school? Which grade is he doing now? What
type of school? Did he have to repeat a grade? Does he like to go to school?
Please describe. What are his favourite subjects? What are the grades in the
different subjects? Does your child have special problems with teachers?
With other children? Please describe.

Leisure time:

What does your child do during free time? What are his favourite games
and type of play (role playing, construction games, activity games, computer
games, etc.)? Are there planned activities? What are his interests andhobbies? Does he practice sports? Does your child have friends (how manyand how close)? Does he spend his free time alone or with friends? Whatrole does your child play in groups with other children of the same age?

Illnesses:

What illnesses, operations, hospital treatment, accidents, and allergies has
your child had so far?

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IACAPAP Textbook of Child and Adolescent Mental Health

FAMILY HISTORY
Parents:

Age, occupation (educational achievemnt), illnesses. Marital relationship?
Did you wet the bed as a child? How would you describe your relationshipto your child?

Siblings:

Age. Biological siblings? School-grade, illnesses and wetting problems. How
do your children relate to each other? Are there especially close bonds orrivalries?

Other relatives:

Did other relatives wet the bed as children? Other illnesses, especiallypsychiatric or kidney?

Regarding the problems of enuresis and urinary incontinence (as well as nocturia and micturition problems
such as urge) we have made it a routine to draw a complete pedigree over three generations. Often, otherrelatives will be missed unless one asks directly and explicitly if they have wetted in the past (or currently).
It is usually best to end the history by asking one open question, such as “is there anything else we may
have missed or that you think it may be important?”

Appendix C.4.2
FREQUENCY/ VOLUME CHART(von Gontard & Neveus, 2006, with permission)
Instructions:
Dear parents,
To assess and treat the wetting problem of your child in the best possible way, we would bevery thankful for your help and your observations.
Please fill out this chart on a day without school or kindergarten (weekend or holiday). You mustnote every time that your child goes to the toilet or wets him or herself. This should start on one
morning and continue through to the next morning (24 hours). If possible, please fill out two
charts on two consecutive days, this is even more useful.
Please talk to your child about it beforehand. You should not send your child to the toilet.
Instead, he/she should tell you when he/she wants to go to the toilet and should urinate into ameasuring cup. Please measure the amount of urine, record it and the time of day in the chart.
You can discard the urine afterwards.
If your child needs to strain to start urinating of if the stream of urine is interrupted (e.g., stops
and starts) please note this in the appropriate column in the chart (3rd from the left).
If your child wets his/her clothes, again please note the time and if they were wet (large amountof urine) or just damp (small amount).
If your child feels a sudden urge to go to the toilet, please note this with the time in the next
column.
If you observe that your child crosses his/her legs, squats or tries to hold back the urine in any
other way, please note this (with the time) in the column headed “Urge”.
Finally, please measure and note the amount of ALL fluids your child drinks during the day (withtimes).
Thank you very much for your help!

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IACAPAP Textbook of Child and Adolescent Mental Health

48-HOUR-FREQUENCY/VOLUME CHART
Name__________________________________  Date of birth__________________
Date___________________________________
  Time ofday

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Urinevolume(ml)

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Straining/interrupted
stream

Wetting: Urge
damp/wet?

Comments/
observations

Drinking
fluids(ml)28

IACAPAP Textbook of Child and Adolescent Mental HealthAppendix C.4.3
PARENT QUESTIONNAIRE
ENURESIS/URINARY INCONTINENCE(Beetz, von Gontard, Lettgen, 1994; translated and adapted by von Gontard, 2003)
Name:_____________________________  Date of birth:___________________
Date:_____________________________DAYTIME WETTING 							

YES

NO

Does your child wet his/her clothes during the day?

[][]Has your child ever been dry during the day?

[][]If yes, for how long? _____________ (weeks/months/ years)
And at which age? _______________ (years)
On how many days a week does your child wet during daytime? __________(days per week)
How many times a day does your child wet? _______________(times per day)Is the clothing usually damp?

[][]

Is the clothing usually wet?

[][]

Does urine dribble constantly?

][]

having gone to the toilet?

[][]

Does your child notice when he/she wets?

[][]

NIGHTTIME WETTING						

YES

NO

Does your child wet the bed (or diapers) during the night?

[][]

Has your child ever been dry during the night?

[][]

Does your child wet his/her clothes immediately afterIf yes, for how long? _____________ (weeks/months/ years)
And at which age? _______________ (years)
On how many nights a week does your child wet? ______________(nights per week)
Is the bed usually damp?

[][]

Is the bed usually wet?

[][]

Does your child wake up to go to the toilet?

[][]

Does your child wake up after wetting the bed?

[][]

Is your child a deep sleeper, i.e. difficult to wake up?

[][]

Has any other member of your family wetted (day or night)?

[][]

If yes, who? _______________________________

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IACAPAP Textbook of Child and Adolescent Mental Health

TOILET HABITS							

YES

NO

How many times a day does your child void(on average)?______________(times/day)
How long can your child manage without goingto the toilet (during shopping, car trips, etc.)? ________(hours)
Does your child go to the toilet him/herself if he/she needs to?

[][]

Do you have to send your child to the toilet?

[][]

If your child wants to pee, does he/she have to strain
at the beginning or during voiding?

[][]

When your child voids, is the stream interrupted?

[][]

Does your child hurry and not take enough time for voiding?

[][]

OBSERVABLE REACTIONS						

YES

NO

Does your child feel a sudden urge to go to the toilet?

[][]

When your child needs to void, does he/she have to rush to[][]

the toilet immediately?

[][]

Does your child cross his/her legs, squat, sit on a heel, etc.
to prevent wetting?

[][]

Does your child postpone going to the toilet as longas possible?

[][]If, yes, in which situations (school, play, TV, etc.), please specify ________________________
URINARY TRACT INFECTIONS					

YES

NO

Has your child ever had a urinary tract infection?

[][]

Has your child had urinary tract infections with fever?

[][]Has your child been treated for an illness of theurinary tract?

[][]

If yes, how many ________________(times)

If yes, please specify ________________________________________________________STOOL HABITS							

YES

NO

Does your child have daily bowel movements?

[][]

Is your child regularly constipated?

[][]

Does your child soil his/her underwear (during the day)?

[][]

Does your child soil during sleep?

[][]

If yes, small amounts (smear)[][]

Or large amounts (stool)[][]

If not, how many times/ week?__________(times/week)

How often does your child soil?________(times/week)_______(times/month)Has your child previously had complete bowel control?

[][]

If yes, at what age ____________(years)

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IACAPAP Textbook of Child and Adolescent Mental HealthAnd for how long _____________(months/years)
Does soiling occur in special situations?

[][]

If yes, please specify________________________________________________________
BEHAVIOUR: WETTING						

YES

NO

Is your child distressed by the wetting?

[][]

Are you distressed because of your child’s wetting?

[][]Has your child been teased because of the wetting?

[][]

Are there things your child did not do (school outings,
sleeping over with friends) because of the wetting?

[][]

Does your child wet more often in stressful times?

[][]

Is your child cooperative and motivated for treatment?

[][]

If your child had been dry before, do you see any eventthat might be associated with the relapse?

[][]

If yes, please specify _______________________________________________________
What in your opinion is the reason for the wetting?
Please specify____________________________________________________________
BEHAVIOUR: GENERNAL						

YES

NO

Does your child have difficulties obeying rules?

[][]

Is your child restless, on the go, easily distracted?

[][]

Does your child have difficulty concentrating?

[][]Is your child sometimes anxious?

[][]

Is your child sometimes sad, unhappy, withdrawn?

[][]

Does your child have problems in school?

[][]

If yes, please specify ______________________________________________________
Does your child have problems in other areas?

[][]

If yes, please specify_______________________________________________________

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IACAPAP Textbook of Child and Adolescent Mental HealthAppendix C.4.4
EXAMPLE OF NOCTURNAL ENURESIS BASELINE CHART(Dry night recorded as ‘sun’, wet one as ‘cloud’– or any other symbol chosen by
the child)This chart belongs to:________________WEEK

MondayTuesday

WednesdayThursdayFridaySaturday

Sunday

1.
2.
3.
4.

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IACAPAP Textbook of Child and Adolescent Mental HealthAppendix C.4.5
EXAMPLE OF A CHART TO MONITOR ALARM TREATMENT(modified from Butler 1988)

IF DRY
Date

Monday
10th

Dry



Tuesday
11th

IF WET
Got upand went
to toilet
without
alarmTime ofalarmChild awoke by
him/herself
YesNo

Amount of urine inbed (diaper)
L=large
M=medium
S=small

Passed urine
in toilet
Yes

No


11.30

yes

M



Wed 12th

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IACAPAP Textbook of Child and Adolescent Mental HealthAppendix C.4.6
TITRATION CHART FOR ORAL DESMOPRESSIN(von Gontard & Neveus, 2006)
1st and 2nd weeks: Desmopressin tablets: 0.2 mg (200μg) in the evening (one tablet)
Date

Dry

Monday 16No

Tuesday 17

Yes

Amount of urine
ReducedSame as before
Yes

Remarks
Did not want to go to school
Very happy

3rd and 4th weeks: Desmopressin tablets: 0.4mg (400μg) in the evening (two tablets)**If dry or marked reduction of wet nights → continue with this dose (0.2mg: one tablet)*If not effective (no reduction of wet nights) → increase to 0.4mg (two tablets).
Date

Dry

Amount of urine
ReducedRemarks

Same as before*If dry or marked reduction of wet nights → continue with this dosis (0.4mg: two tablets)*If not effective → discontinue (desmopressin non-responder)

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