Abstract
It is estimated that enuresis affects 5 to 7 million children in the United States. Although the problem is common and well known, appropriate and effective treatment is not always provided. This may be due to the many etiological theories associated with this condition as well as a correspondingly high number of interventions. The present paper summarizes the empirical literature regarding primary nocturnal enuresis (PNE), with an emphasis on pharmacological and behavioral interventions. The data support the view that children with enuresis have a wide range of negative experiences that can affect self-esteem and development, but that enuresis is not associated with significant psychiatric or behavioral difficulties. Given the strong empirical support for several interventions for PNE, children who have this condition should not go untreated.
Similar content being viewed by others
References
Allen, K.D., Warzak, W.J., Greger, N.G., Bernotas, T.D. & Huseman, C.A. (1993). Psychosocial adjustment of children with isolated growth hormone deficiency.Children's Health Care. 22: 61–72.
Ambrose, G. (1983). Hypnotherapy for enuresis (letter).Journal of the Royal Society of Medicine. 76: 1080.
Ambrosini, P.J. (1984). A pharmacological paradigm for urinary incontinence and enuresis.Journal of Clinical Psychopharmacology. 4: 247–253.
American Psychiatric Association (1987).Diagnostic and Statistical Manual of Mental Disorders (DSM-III-R). American Psychiatric Association, Washington, D.C.
Ayllon, T. & Azrin, N. (1968).The Token Economy. A Motivational System for Therapy and Rehabilitation (79–83). Englewood Cliffs, N.J.: Prentice-Hall.
Azrin, N.H. & Thienes, P.M. (1978). Rapid elimination of enuresis by intensive learning without a conditioning apparatus.Behavior Therapy. 9: 342–354.
Baker, B.L. (1969). Symptom treatment and symptom substitution in enuresis.Journal of Abnormal Psychology. 74: 42–49.
Bakwin, H. (1973). The genetics of enuresis: In I. Kolvin, R.C. Mac Keith & S.R. Meadow (Eds.),Bladder Control and Enuresis (73–77). Philadelphia: J.B. Lippincott.
Blackwell, B. & Currah, J. (1973). The psychopharmacology of nocturnal enuresis. In I. Kolvin, R.C. Mac Keith, S.R. Meadow (Eds.),Bladder Control and Enuresis (231–257). Philadelphia: J.B. Lippincott.
Bloom, D.A. (1993). The American experience with desmopressin.Clinical Pediatrics. 31: 28–31.
Bollard, J. & Nettlebeck, T. (1982). A component analysis of dry-bed training for treatment of bedwetting.Behaviour Research and Therapy. 20: 383–390.
Cohen, M.W. (1975). Enuresis.Pediatric Clinics of North America. 22: 545–560.
Creer, T.L. & Davis, M.H. (1975). Using a staggered wakening procedure with enuretic children in an institutional setting.Journal of Behavior Therapy and Experimental Psychiatry. 6: 23–25.
De Leon, G. & Mandell, W. (1966). A comparison of conditioning and psychotherapy in the treatment of functional enuresis.Journal of Clinical Psychology. 22: 326–330.
Doleys, D.M. (1977). Behavioral treatments for nocturnal enuresis in children. A review of the recent literature.Psychological Bulletin. 84: 30–54.
Doleys, D.M., Ciminero, A.R., Tollison, J.W., Williams, C.L. & Wells, K.C. (1977). Drybed training and retention control training: A comparison.Behavior Therapy. 8: 541–548.
Esperanca, M. & Gerrard, J.W. (1968). Nocturnal enuresis: Comparisons of the effect of imipramine and dietary restriction on bladder capacity.Canadian Medical Association Journal. 101: 721–724.
Ferber, R. (1985).Solve Your Child's Sleep Problems (174–188). New York: Simon & Schuster.
Fergusson, D.M., Horwood, L.J. & Shannon, F.T. (1986). Factors related to the age of attainment of nocturnal bladder control: An 8-year longitudinal study.Pediatrics. 78: 884–890.
Fernandez de Gatta, M.M., Galindo, P., Rey, F., Gutierrez, J., Tamayo, M., et al. (1990). The influence of clinical and pharmacological factors on enuresis treatment with imipramine.British Journal of Clinical Pharmacology. 30: 693–698.
Forsythe, W.I. & Redmond, A. (1974). Enuresis and spontaneous cure rate: Study of 1129 enuretics.Archives of Disease in Childhood. 49: 259–269.
Foxman, B., Valdez Burciaga, R. & Brook, R.H. (1986). Childhood enuresis: Prevalence, perceived impact, and prescribed treatments.Pediatrics. 77: 482–487.
Friman, P.C. (1986). A preventive context for enuresis.Pediatric Clinics of North America. 33: 871–886.
Friman, P.C., McPherson, K.M., Warzak, W.J. & Evans, J. (1993). Influence of thumb sucking on peer social acceptance in first-grade children.Pediatrics. 91: 784–786.
Friman, P.C. & Warzak, W.J. (1990). Nocturnal enuresis: A prevalent, persistent, yet curable parasomnia.Pediatrician. 17: 38–45.
Gross, R.T. & Dornbusch, S.M. (1983). Enuresis. In M.D. Levine, W.B. Carey, A.C. Crocker & R.T. Gross (Eds.),Developmental-Behavioral Pediatrics (575–586). Philadelphia: W.B. Saunders.
Hägglund, T.-B. & Parkkulainen, K.V. (1964). Enuretic children treated with imipramine (Tofranil™): a cystometric study.Annals of Paediatric Fenn. 11: 53–59.
Hallgren, B. (1956). Enuresis. I. A study with reference to the morbidity risk and symptomatology.Acta Psychiatrica et Neurologica Scandinavica. 31: 379–401.
Harris, L.S. & Purohit, A.P. (1977). Bladder training and enuresis: A controlled trial.Behaviour Research and Therapy. 15: 485–490.
Hjälmås, K. & Bengtsson, B. (1993). Efficacy, safety, and dosing of desmopressin for nocturnal enuresis in Europe.Clinical Pediatrics. 31: 19–24.
Houts, A.C. (1991). Nocturnal enuresis as a biobehavioral problem.Behavior Therapy. 22: 133–151.
Houts, A.C., Berman, J.S. & Abramson, H. The effectiveness of psychological and pharmacological treatments for nocturnal enuresis.Journal of Consulting and Clinical Psychology. 62(4): 737–745.
Järvelin, M.R., Vikeväinen-Tervonen, L., Moilanen, I. & Huttunen, N.-P. (1988). Enuresis in seven-year-old children.Acta Paediatrica Scandinavica. 77: 148–153.
Kaffman, M. & Elizur, E. (1977). Infants who become enuretics: A longitudinal study of 161 kibbutz children.Monograph of the Society For Research in Child Development. 42.
Khazan, N. & Sulman, F.G. (1966). Effects of imipramine on paradoxical sleep in animals with reference to dreaming and enuresis.Psychopharmacologia. 10: 89–95.
Kolko, D.J. (1987). Simplified inpatient treatment of nocturnal enuresis in psychiatrically disturbed children.Behavior Therapy. 2: 99–112.
Labay, P. & Boyarsky, S. (1973). The action of imipramine on bladder musculature.Journal of Urology. 109: 385–387.
Lovering, J.S., Tallet, S.E. & McKendry, J.B.J. (1988). Oxybutynin efficacy in the treatment of primary enuresis.Pediatrics. 82: 104–106.
Lovibond, S.H. (1964).Conditioning and Enuresis. New York: MacMillan Co.
McGuire, E.J. & Savastano, J.A. (1984). Urodynamic studies in enuresis and the nonneurogenic neurogenic bladder.Journal of Urology. 132: 299–302.
Meadow, R. (1977). How to use buzzer alarms to cure bed-wetting.British Medical Journal 2: 1073–1075.
Michaels, J.J. (1955).Disorders of Character. Springfield, IL: Charles C. Thomas.
Mikkelsen, E.J. & Rapoport, J.L. (1980). Enuresis: Psychopathology, sleep stage, and drug response.Urology Clinics of North America. 7: 361–377.
Miller, K., Atkin, B., & Moody, M.L. (1992). Drug therapy for nocturnal enuresis. Current treatment recommendations.Drugs. 44: 47–56.
Mills, J.N. (1951). Diurnal rhythm in urine flow.Journal of Physiology. 113: 528–536.
Mishne, J.M. (1993). Primary nocturnal enuresis: A psychodynamic clinical perspective.Child and Adolescent Social Work Journal. 10: 469–495.
Moffatt, M.E.K. (1989). Nocturnal enuresis: Psychologic implications of treatment and nontreatment.Journal of Pediatrics. 114: 697–704.
Moffatt, M.E.K., Harlos, S., Kirshen, A.J. & Burd, L. (1993). Desmopressin acetate and nocturnal enuresis: How much do we know?Pediatrics. 92: 420–425.
Moffatt, M.E.K., Kato, C. & Pless, I.B. (1987). Improvements in self-concept after treatment of nocturnal enuresis: Randomized control trial.Journal of Pediatrics. 110: 647–652.
Mowrer, O.H. & Mowrer, W.M. (1938). Enuresis—A method for its study and treatment.American Journal of Orthopsychiatry. 8: 436–459.
Nelson, R. (1978). Methodological issues in assessment via self-monitoring. In J.D. Cone & R.R. Hawkins (Eds.),Behavioral Assessment: New Dimensions in Clinical Psychology (217–240). New York: Bruner/Mazel.
Nørgaard, J.P. (1991). Pathophysiology of nocturnal enuresis.Scandinavian Journal of Urology and Nephrology. 140 (supp): 7–35.
Nørgaard, J.P. & Djurhuus, J.C. (1993). The pathophysiology of enuresis in children and young adults.Clinical Pediatrics. 31: 5–9.
Nørgaard, J.P., Pedersen, E.B. & Djurhuus, J.C. (1985). Diurnal anti-diuretic-hormone levels in enuretics.Journal of Urology. 134: 1029–1031.
Nørgaard, J.P., Rittig, S. & Djurhuus, J.C. (1989). Nocturnal enuresis. An approach to treatment based on pathogenesis.Journal of Pediatrics. 114: 705–710.
Oppel, W.C., Harper, P.A. & Rider, R.V. (1968). The age of attaining bladder control.Pediatrics. 42: 614–626.
Pierce, C.M., Whitman, R.M., Mass, J.W. & Gay M.L. (1961). Enuresis and dreaming: Experimental studies.Archives of General Psychiatry. 4: 166–170.
Popler, K. (1976). Token reinforcement in the treatment of nocturnal enuresis: A case study and six month follow-up.Journal of Behavior Therapy and Experimental Psychiatry. 7: 83–84.
Puri, V.N. (1986). Increased urinary antidiuretic hormone excretion by imipramine.Experimental and Clinical Endocrinology. 88: 112–114.
Radó, J.P., Marosi, J., Fisher, J., Takó, J. & Kiss, N. (1975). Relationship between the dose of 1-deamino-8-d-arginine vasopressin (DDAVP) and the antidiuretic response in man.Endokrinologie. 66: 184–195.
Rapoport, J.L., Mikkelsen, E.J., Zavadil, A., Nee, L., Gruenau, C., et al.. (1980) Childhood enuresis. II. Psychopathology, tricyclic concentration in plasma and antienuretic effect.Archives of General Psychiatry. 37: 1146–1152.
Richman, N., Stevenson, J.E. & Graham, P.J. (1975). Prevalence of behaviour problems in 3-year-old children: An epidemiological study in a London borough.Journal of Child Psychology and Psychiatry. 16: 277–287.
Rittig, S., Knudsen, U.B., Nørgaard, J.P., Pedersen, E.B. & Djurhuus, J.C. (1989). Abnormal diurnal rhythm of plasma vasopressin and urinary output in patients with enuresis.American Journal of Physiology. 256: F664–F671.
Robinson, A.G. (1976). DDAVP in the treatment of central diabetes insipidus.The New England Journal of Medicine. 294: 507–511.
Ruley, E.J. (1987). Urinary tract infections. In R.A. Hoekelman (Ed.),Primary Pediatric Care (1520–1525). St. Louis: Mosby.
Rushton, H.G. (1993). Evaluation of the enuretic child.Clinical Pediatrics. 31: 14–18.
Rushton, H.G. (1993). Older pharmacologic therapy for nocturnal enuresis.Clinical Pediatrics. 31: 10–13.
Rutter, M., Yule, W. & Graham, P. (1973). Enuresis and behavioural deviance: Some epidemiological considerations. In I. Kolvin, R.C. Mac Keith, S.R. Meadow (Eds.),Bladder Control and Enuresis (137–147). Philadelphia: JB Lippincott.
Sacks, S., De Leon, G. & Blackman, S. (1974). Psychological changes associated with conditioning functional enuresis.Journal of Clinical Psychology. 30: 271–276.
Scharf, M.B. & Jennings, S.W. (1988). Childhood enuresis. Relationship to sleep, etiology, evaluation, and treatment.Annals of Behavioral Medicine. 10: 113–120.
Scharf, M.B., Pravda, M.F., Jennings, S.W., Kauffman, R. & Ringel, J. (1987). Childhood enuresis: A comprehensive treatment program.Psychiatric Clinics of North America. 10: 655–666.
Schmitt, B.D. (1984). Nocturnal enuresis.Primary Care. 11: 485–495.
Shaffer, D. (1973). The association between enuresis and emotional disorder: A review of the literature. In I. Kolvin, R.C. Mac Keith, S.R. Meadow (Eds.),Bladder Control and Enuresis (118–136). Philadelphia: JB Lippincott.
Shelov, S.P., Gundy, J., Weiss, J.C., McIntire, M.S., Olness, K., et al. (1981). Enuresis: A contrast of attitudes of parents and physicians.Pediatrics. 67: 707–710.
Sperling, M. (1965). Dynamic considerations and treatment of enuresis.Journal of the American Academy of Child Psychiatry. 4: 19–31.
Starfield, B. (1972). Enuresis: Its pathogenesis and management.Clinical Pediatrics. 11: 343–350.
Starfield, B. & Mellits, E.D. (1968). Increase in functional bladder capacity and improvements in enuresis.Journal of Pediatrics. 72: 483–487.
Stein, A.W. (1885). Enuresis, or incontinence of urine.The Medical Record. 27: 701–705.
Stephenson, J.D. (1979). Physiological and pharmacological basis for the chemotherapy of enuresis.Psychological Medicine. 9: 249–263.
Sulzer-Azaroff, B. & Mayer, G.R. (1977). Maintaining behavior: intermittent reinforcement. In B. Sulzer-Azaroff & G.R. Mayer (Eds.),Applying Behavior Analysis Procedures with Children and Youth. New York: Holt, Rinehart & Winston.
Terho, P. & Kekomäki, M. (1984). Management of nocturnal enuresis with a vasopressin analogue.The Journal of Urology. 131: 925–927.
Tuvemo, T. (1978). DDAVP in childhood nocturnal enuresis.Acta Paediatrica Scandinavica. 67: 753–755.
Warady, B.A., Alon, U., & Hellerstein, S. (1991). Primary nocturnal enuresis: Current concepts about an old problem.Pediatric Annals. 20: 246–255.
Warzak, W.J. (1993). Psychosocial implications of nocturnal enuresis.Clinical Pediatrics, 31: 38–40.
Werry, J.S. (1967). Enuresis—a psychosomatic entity.Canadian Medical Association Journal. 97: 319–327.
Werry, J.S. & Cohrssen, J. (1965). Enuresis—an etiologic and therapeutic study.The Journal of Pediatrics. 67: 423–431.
Whelan, J.P. & Houts, A.C. (1990). Effects of a waking schedule on primary enuretic children treated with full-spectrum home training.Health Psychology. 9: 164–176.
Zaoral, M., Kolc, J., Šorm, F. (1967). Synthesis of 1-deamino-8-d-γ-aminobutyrine-vasopressin, 1-deamino-8-d-lysine-vasopressin, and 1-deamino-8-d-arginine-vasopressin.Collection of Czechoslovak Chemical Communications. 32: 1250–1257.
Author information
Authors and Affiliations
Additional information
This paper was supported, in part, by a grant from Rhône-Poulenc Rorer. The comments of Christine T. Majors, M.S., University of Nebraska Medical Center, Omaha, NE, are gratefully acknowledged.
Dr. Friman is with Father Flanagan's Boy's Town.
Rights and permissions
About this article
Cite this article
Warzak, W.J., Friman, P.C. Current concepts in pediatric primary nocturnal enuresis. Child Adolesc Soc Work J 11, 507–523 (1994). https://doi.org/10.1007/BF01876573
Issue Date:
DOI: https://doi.org/10.1007/BF01876573