Enuresis DSM-5 307.6 (F98.0)

Enuresis DSM-5 307.6 (F98.0)

DSM-5 Category: Elimination Disorders 

Introduction

Enuresis is the persistent inability to control urination that is not consistent with one’s development age. Also known as urinary incontinence, the condition is common in children, with anywhere from 2-10% of children affected. Nocturnal enuresis is more commonly known as bedwetting. The DSM-5 has widened the scope of the criteria for enuresis. In the past, four criteria for enuresis were universally applied, but currently, the DSM-5 recognizes different subtypes of enuresis and their different clinical symptoms. The three main types of enuresis are nocturnal (night-time) only, diurnal (daytime) only, and nocturnal and diurnal. Nocturnal enuresis is more common in boys. Elimination often takes place in the first one third of the night, which could be caused by behavior (inadequate elimination before bedtime), high levels of stress or anxiety, or an underlying physical issue (the bladder does not completely fill). Diurnal enuresis is more likely to happen in the afternoon when a child is at school or with playmates, and thus can be a source of embarrassment and teasing from peers.   With nocturnal and diurnal enuresis, occurrences happen any time, whether day or night.

Enuresis Symptoms

Under DSM-5, the main symptom of enuresis remains the inappropriate elimination of urine, involuntarily or intentionally. Enuresis may be comorbid with mood and emotional disorders. It has a high level of comorbidity with attention deficit hyperactivity disorder (ADHD). Anxiety, expression and insomnia are experienced by persons who have elimination disorders related to distress and social stigma.

The DSM-5 criteria for enuresis is as follows (APA, 2013):

  • Repeated voiding of urine into bed or clothes (whether involuntary or intentional)
  • Behavior must be clinically significant as manifested by either a frequency of twice a week for at least 3 consecutive months or the presence of clinically significant distress or impairment in social, academic (occupational), or other important areas of functioning.
  • Chronological age is at least 5 years of age (or equivalent developmental level).
  • The behavior is not due exclusively to the direct physiological effect of a substance (such as a diuretic, antipsychotic or SSRI) or to incontinence uncured as a result of polyuria or during loss of consciousness.
  • All of the DSM-5 criteria must be met in order to diagnose an individual.
  • These symptoms must not be due to a general medical condition.

Specific types: nocturnal (night-time) only, diurnal (daytime) only, nocturnal and diurnal

Enuresis Risk Factors

Under the age of five, inappropriate elimination of urine or feces is common as children are potty trained and learn to control voiding behavior. Urinary incontinence is considered enuresis by the DSM-5 when a child is five years of age or older. The incident rate of nocturnal enuresis declines by age as the child moves into adolescence, decreasing from 20% in five-year-olds to 2% in adulthood (Ju, 2013). More girls experience daytime enuresis while more boys experience night-time enuresis, or bedwetting. In adolescence twice as many boys than girls experience enuresis. Daytime enuresis often takes place towards the end of the school day in children, most likely because they are too preoccupied by school or play to take a urine break.

Low self-esteem is common in children suffering from enuresis. Since uncontrolled elimination is associated with babies, children feel ashamed when they experience an incontinence event because they cannot control their bladder. The condition affects interpersonal relationships. Parents’ quality of life is also affected. Mothers experience higher levels of anxiety and depression and worry that their children may suffer from slower development (Ju, 2013). In children, measures of depression, sleep quality, academic performance and health have been shown to decline with age, resulting in a decreasing quality of life (Üçer, & Gümüs, 2013).

The causes of enuresis are multifaceted. Enuresis has been linked to anxiety, slow development, and medical conditions. Underlying physical problems include the increase of urine volume through vasopressin release during sleep, bladder abnormalities such as small functional size or hyperactivity, and inability to fill the bladder during sleep due to inadequate arousal (Patel et al., 2012). Patel et al. also find that a number of factors implicate an emotional component in enuresis. Enuresis can be triggered by separation from a parent, the birth of a sibling or family conflict. The higher incidence of enuresis in orphanages could be explained by emotional factors or less toilet training. The high comorbidity of enuresis with ADHD is consistent with a higher incidence of development delays in children with enuresis.

Finding a cure for enuresis is a priority for both mother and child. Some daycares will reject a child or insist on parental or caregiver support for a child with enuresis or encopresis (the passage of feces in inappropriate places). A person with voiding postponement can be treated through behavioral therapy. A person with urge incontinence experiences sudden urges to urinate, which requires a more in-depth exploration of the underlying physical and psychological causes.

Enuresis Therapy

The most common therapeutic approaches to enuresis are conditioning therapy with a moisture alarm and pharmacotherapy, which involves taking desmopressin. A bed-wetting alarm has a moisture sensor to alert the child of the start of urination. Desmopressin is a synthetic form of vasopressin, a hormone that reduces urine production. Often, a combined therapy is used. Family commitment to supporting these therapies is critical to their success. A survey of studies on the two therapies showed a larger relapse rate for desmopressin. However, in some studies alarm therapy had a higher dropout rate, which likely reflects the greater support required by parents and health care professionals (Perrin, Sayers, & While, 2013).

Increasingly, behavioral therapy (BT) is being applied. In a Korean study about a third more parents preferred pharmacotherapy over behavioral therapy. The attitudes of the parents can affect the treatment outcomes. A Swedish study determined that successful BT required supportive parents and a motivated child, and about 6 months of therapy ((Üçer, & Gümüs, 2013).

It is worthwhile to review several alternative therapies that have produced impressive results in the treatment of enuresis. An Egyptian study researching the effectiveness of Chinese acupuncture on nocturnal enuresis reported a 92% cure and 8% failure rate following treatment and 12-month follow-up (El-Koumy, El-Sayed, & Salama, 2011). There is some evidence that psychotherapy is more effective than alarm, and medicinal herbs are more effective than desmopressin (Huang, Shu, Huang, & Cheuk, 2011).

DSM-5 reports an overall positive prognosis for enuresis. Enuresis is typically resolved in adolescence and has a small 1% incident rate in adulthood (APA, 2013). Nonetheless, it can create severe psychological stress for a child and may have a physical cause and should be treated. The longer enuresis persists, the higher the risk of the frequency of urination increasing.

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.

El-Koumy, M. A., El-Sayed, S. A., & Salama, A. M. (2011). Treatment of primary persistent nocturnal enuresis by acupuncture: a follow-up study. Medical Research Journal, 10(1), 14-17.

Huang, T., Shu, X., Huang, Y. S., & Cheuk, D. K. (2011). Complementary and miscellaneous interventions for nocturnal enuresis in children. Cochrane Database Syst Rev, 12.

Ju, H. T., Kang, J. H., Lee, S. D., Oh, M. M., Moon, D. G., Kim, S. O., ... & Woo, S. H. (2013). Parent and Physician Perspectives on the Treatment of Primary Nocturnal Enuresis in Korea. Korean journal of urology, 54(2), 127-134.

Patel, V., Golwalkar, R., Beniwal, S., Chaudhari, B., Javdekar, A., Saldanha, D., & Bhattacharya, L. (2012). Elimination disorders: Enuresis. Medical Journal of Dr. DY Patil University, 5(1), 14.

Perrin, N., Sayer, L., & While, A. (2013). The efficacy of alarm therapy versus desmopressin therapy in the treatment of primary mono-symptomatic nocturnal enuresis: a systematic review. Primary health care research & development, 1-11.

Üçer, O., & Gümüs, B. (2013). Quantifying subjective assessment of sleep quality, quality of life and depressed mood in children with enuresis. World journal of urology, 1-5.


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