Secondary enuresis in boys and girls: symptoms, causes and treatment

Enuresis, also known as urinary incontinence, could be defined as the repeated emission of urine involuntarily during the day or at night while sleeping. In order for this incontinence to be taken into consideration to carry out a diagnosis and the pertinent treatment, it should meet a series of criteria.

On the other hand, we can find different types of enuresis: diurnal or nocturnal, primary or secondary. Secondary enuresis in boys and girls is the one we are going to talk about in this article and is fundamentally characterized by the onset of urinary incontinence once at least 6 months have passed after having learned to control the bladder.

In this article we will talk in more detail about secondary enuresis in boys and girls , but first it is important to see what the diagnosis of enuresis consists of according to the diagnostic and statistical criteria of the international reference manuals.

Diagnosis of bedwetting

In the main diagnostic manuals, the DSM-5 of the American Psychiatric Association and the ICD-11 of the World Health Organization, we can find quite similar criteria for diagnosing enuresis, as we can see below.

The main diagnostic criteria for enuresis according to the DSM-5 manual with the following:

• That an emission of urine occurs repeatedly (involuntarily or voluntarily) in inappropriate places.
• Enuresis is clinically significant (at least 2 episodes per week for at least 3 months).
• The child must be at least 5 years old to make the diagnosis of enuresis.
• Enuresis is not due exclusively to the physiological effect of any substance or to a general medical condition.
• It should be specified if the enuresis is only daytime, nocturnal or both.

On the other hand, in the ICD-11, enuresis is within the category of "elimination disorders" , with the following diagnostic criteria:

• Repeated urination of urine in bed and/or on clothes, either during the day or at night.
• The child must be at least 5 years old.
• Normally urination occurs involuntarily.
• Enuresis is not explained by health conditions that interfere with continence or by any abnormality in the urinary tract.
• Specify: night, day, or both; without specification.

These criteria serve to make the diagnosis at a general level ; however, in order to make the diagnosis of secondary enuresis in boys and girls, some additional criteria are needed, as we will see in the next section.

What is secondary enuresis in boys and girls?

Now that we have seen what the diagnostic criteria for enuresis are according to the DSM-5 and the ICD-11, it is time to specify what secondary enuresis in children consists of. Later we will see what the possible causes of this condition that causes this type of urinary incontinence would be, noting that secondary enuresis is much less common than primary enuresis.

Secondary enuresis is mainly characterized by the onset of urinary incontinence, usually involuntary, once at least 6 months have passed after the child has learned to control the bladder (it may even be years since the child will begin to control his bladder).

Given this, it is important to seek help from a professional so that you can evaluate the case, look for possible causes and carry out the most appropriate treatment depending on each particular case.

Possible causes of this alteration

Secondary enuresis is quite often due to certain emotional and/or psychological causes, and in this type of case it is important to seek professional help in order to address these problems and promote the well-being of the child and their parents. Next we will see what the possible emotional and psychological causes of secondary enuresis would be.

1. Post Traumatic Stress Disorder (PTSD)

One of the main causes that could cause the development of secondary enuresis in boys and girls is the experience of a highly stressful or traumatic event that triggers the development of PTSD and, consequently, secondary enuresis. Among the main causes of the possible development of PTSD, we can highlight the following: suffering a traffic accident, having had to be hospitalized for a time, suffering a robbery with violence, natural disasters, wars, the death of a family member, etc.

2. Family and/or interpersonal-social problems

Another cause of the development of this type of enuresis could be the fact that you are suffering from some family problems (eg, alcoholism, neglect, abuse, fights between parents or their divorce) or have other interpersonal problems (eg, being bullied at school). Unfortunately, these types of problems are often covered up or tried to hide , so that it is more difficult to detect the root of the development of secondary enuresis in boys and girls.

3. Major changes in your life

Throughout life and even from an early age, people can suffer various changes of great importance, which can lead to a series of difficulties and problems. Among them, it could be the case that an important change could cause a secondary enuresis. Some of those changes could be the following: change of address, living with only one parent after divorce, having to change schools, the birth of a sibling, etc.

For these reasons and some more, it is important that if parents detect that their child is suffering from urinary incontinence, they go to a specialist so that they can find a solution and, most importantly, find the causes of this secondary enuresis, since the problem that could have caused this situation may be more serious and require psychological and/or medical support to be provided as soon as possible .

Other factors that can influence the development of secondary enuresis in boys and girls

In addition to the psychological factors that could cause the development of secondary enuresis in boys and girls, it should be noted that there are also other factors that could cause this condition. Among them, we will highlight below the most common in this type of case.

1. Bladder problems

One of the possible causes of bedwetting is having a small bladder that cannot hold a larger amount of urine . In addition, there are children who may need to pass a large amount of urine at night. On the other hand, other children may experience certain muscle spasms causing their bladder to be unable to hold a normal amount of urine.

Another of the possible bladder problems that cause bedwetting is the “overactive bladder”. This problem is characterized by the fact that some children need to urinate more often than usual for their age. In this type of case it is quite common that they have to run to get to the bathroom on time and, quite often, they can wet their pants.

2. A sleep disorder

Other factors that could trigger this type of enuresis are some sleep disorders or certain problems related to rest and sleep. Among them, it should be noted that some children sleep very deeply, often they are not able to wake up on time and urinate in bed while they are asleep. On the other hand, obstructive sleep apnea , although rare, could also cause secondary enuresis.

3. Medical problems and/or hereditary factors

Lastly, it is worth noting among the possible factors associated with the development of secondary enuresis in boys and girls the existence of various medical problems (eg, some neurological disease, certain hormonal problems, etc.) or hereditary factors (eg. (eg, the fact that one of the parents had suffered from enuresis during childhood).

Treatments against secondary enuresis in boys and girls

Among the main treatments for secondary enuresis in boys and girls, which can also be used for primary enuresis, a series of pharmacological and psychological treatments should be highlighted, which will be briefly explained below.

1. Alarm method

The alarm method, also known as "pee-stop" or "urination alarm" (AO), is the psychological treatment of first choice as it is more effective and efficient than other treatments.

The fundamental objective of this Betic is to establish 2 responses for nocturnal continence :

• The impediment of the involuntary emission of urine and for this the sphincter must be adequately contracted.
• That the child is able to wake up to the stimulus that the bladder is full and must go to the bathroom.

This method also seeks to wake up the child so that the procedure of this method can take effect . For this, a device must be used on which the child must be placed when sleeping and, when detecting any urine leak, it will sound an alarm so that the child wakes up and thus promotes the connection between the need to go to the bathroom to urinate and wake up. In case the child is able to wake up to the alarm, her parents should wake him up to make sure that he is really aware of what is happening and what she should do.

2. Dry bed training

This treatment would be the alternative to the alarm method that we have just seen, being less used because it requires more effort for the family of the affected child than the previous treatment. Dry bed training is based on the use of operant learning principles .

The main component of this treatment for enuresis is the use of a weapon that must be programmed to wake the child every hour of the night during the first night of training in order to go to the bathroom to urinate . Parents should positively reinforce urine retention and dry bedding; whereas if urine leakage occurs, there should be a verbal reprimand and then the child should undergo cleanliness training and positive practice.

3. Pharmacological treatment

This would be another of the treatments used to treat enuresis, with desmopressin being one of the most widely used drugs in this type of case. With an antidiuretic function, it acts against the possible overproduction of urine in those cases in which there is a natural insufficiency of the antidiuretic hormone.

On the other hand, we can find imipramine . This medicine can facilitate awakening and also produces a series of anticholinergic and antispasmodic effects that help reduce bladder count. On the other hand, this type of medication helps with urinary continence thanks to its adrenergic properties.

Another widely used medication is "oxybutynin" that acts directly on the bladder muscle, being the most suitable for daytime enuresis or those types of enuresis in which there is bladder instability.