Enuresis 157Diurnal enuresis
As already noted, diurnal enuresis is rarer than nocturnal enuresis. In the
Isle of Wight study, 2% of 5-year-olds experienced diurnal enuresis at least
once a week. There is a female excess at all ages. The most common form
involves the sort of bladder over-activity or instability that is also seen in
a minority of those with nocturnal enuresis (see above). There is often
urge incontinence, with wetting of small volumes, and frequent daytime
urination (over seven times per day). Bladder training and anticholinergic
medication may be helpful. It is good practice to test routinely for urinary
infections.
A less common form of diurnal enuresis that affects more boys than girls
involves children postponing urination because they are too busy doing
other interesting things to notice (or choose to pay attention to) the fact
that they have a full bladder. They wet large volumes. Regular reminders
to use the toilet may help, and this is less likely to be resented as nagging if
the reminders can be delivered automatically via a watch or mobile phone
rather than by a parent or teacher.
The link with psychiatric problems
Since an association between enuresis and psychiatric problems has been
well demonstrated in epidemiological samples, the link cannot simply be
an artefact of referral bias. Although the rate of psychiatric disorder is
roughly two to six times higher in those with enuresis than in controls,
it is important to remember that over half of all those with enuresis
have no psychiatric disorder. The presence of a psychiatric disorder is
more likely to occur in girls, when the enuresis is diurnal rather than
nocturnal, and when there are associated developmental problems. It is
probably more likely when the enuresis is secondary rather than primary.
It is unrelated to the frequency of wetting, or to the presence or absence
of a family history. Among those with both enuresis and a psychiatric
disorder, the type of disorder is not specific: behavioural and emotional
disorders predominate just as they do in the general population. The link
between enuresis and psychiatric disorder could reflect three sorts of causal
mechanism:
1 Both enuresis and psychiatric problems result from theoperation of a
third factor, for example, social disadvantage or biological-developmental
problems. Overall, this is the best supported causal mechanism, though
the other two probably are important for some children.
2 Psychiatric problems cause enuresis. There are some children who are more
likely to wet the bed when they are anxious, for example, after first
starting school. One prospective study has shown that children who
developed secondary enuresis were more likely than controls to have
had emotional or behavioural problems before the enuresis began.