DSM-IV-TR › Disorders usually first diagnosed in infancy, childhood, or adolescence › Elimination disorders › Enuresis (not due to a general medical condition) 

307.6 Enuresis (Not Due to a General Medical Condition)

Diagnostic Features

The essential feature of Enuresis is repeated voiding of urine during the day or at night into bed or clothes (Criterion A). Most often this is involuntary but occasionally may be intentional. To qualify for a diagnosis of Enuresis, the voiding of urine must occur at least twice per week for at least 3 months or else must cause clinically significant distress or impairment in social, academic (occupational), or other important areas of functioning (Criterion B). The individual must have reached an age at which continence is expected (i.e., the chronological age of the child must be at least 5 years, or, for children with developmental delays, a mental age of at least 5 years) (Criterion C). The urinary incontinence is not due exclusively to the direct physiological effects of a substance (e.g., diuretics) or a general medical condition (e.g., diabetes, spina bifida, a seizure disorder) (Criterion D).

Subtypes

The situation in which the Enuresis occurs may be noted by one of the following subtypes:

• Nocturnal Only. This is the most common subtype and is defined as passage of urine only during nighttime sleep. The enuretic event typically occurs during the first one-third of the night. Occasionally the voiding takes place during the rapid eye movement (REM) stage of sleep, and the child may recall a dream that involved the act of urinating.
• Diurnal Only. This subtype is defined as the passage of urine only during waking hours. Diurnal Enuresis is more common in females than in males and is uncommon after age 9 years. Individuals with diurnal Enuresis can be divided into two groups. One group with "urge incontinence" has Enuresis characterized by sudden urge symptoms and detrusor instability on cystometry. Another group with "voiding postponement" consciously defer micturition urges until incontinence results, with the deferral sometimes due to a reluctance to use the toilet because of social anxiety or a preoccupation with school or play activity. This latter group has a high rate of symptoms of disruptive behavior. The enuretic event most commonly occurs in the early afternoon on school days.
• Nocturnal and Diurnal. This subtype is defined as a combination of the two subtypes above.

Associated Features and Disorders

The amount of impairment associated with Enuresis is a function of the limitation on the child's social activities (e.g., ineligibility for sleep-away camp) or its effect on the child's self-esteem, the degree of social ostracism by peers, and the anger, punishment, and rejection on the part of caregivers. Although most children with Enuresis do not have a coexisting mental disorder, the prevalence of coexisting behavioral symptoms is higher in children with Enuresis than in children without Enuresis. Developmental delays, including speech, language, learning, and motor skills delays, are also present in a portion of children with Enuresis. Encopresis, Sleepwalking Disorder, and Sleep Terror Disorder may be present. Urinary tract infections are more common in children with Enuresis, especially the Diurnal Type, than in those who are continent. The Enuresis commonly persists after appropriate treatment of an associated infection. A number of predisposing factors have been suggested, including delayed or lax toilet training, psychosocial stress, delays in the development of normal circadian rhythms of urine production with resulting nocturnal polyuria or abnormalities of central vasopressin receptor sensitivity, and reduced functional bladder capacities with bladder hyperreactivity (unstable bladder syndrome).

Prevalence

The prevalence of Enuresis is around 5%-10% among 5-year-olds, 3%-5% among 10-year-olds, and around 1% among individuals age 15 years or older.

Course

Two types of course of Enuresis have been described: a "primary" type in which the individual has never established urinary continence, and a "secondary" type in which the disturbance develops after a period of established urinary continence. By definition, primary Enuresis begins at age 5 years. The most common time for the onset of secondary Enuresis is between the ages of 5 and 8 years, but it may occur at any time. After age 5 years, the rate of spontaneous remission is between 5% and 10% per year. Most children with the disorder become continent by adolescence, but in approximately 1% of cases the disorder continues into adulthood.

Familial Pattern

Approximately 75% of all children with Enuresis have a first-degree biological relative who has had the disorder. The risk of Enuresis is five- to sevenfold greater in the offspring of a parent who had a history of Enuresis. The concordance for the disorder is greater in monozygotic twins than in dizygotic twins. Although molecular genetic analyses have detected links to several chromosomes, no significant associations between linkage to a chromosome interval and type of enuresis have been identified.

Differential Diagnosis

The diagnosis of Enuresis is not made in the presence of a neurogenic bladder or the presence of a general medical condition that causes polyuria or urgency (e.g., untreated diabetes mellitus or diabetes insipidus) or during an acute urinary tract infection. However, a diagnosis of Enuresis is compatible with such conditions if urinary incontinence was regularly present prior to the development of the general medical condition or if it persists after the institution of appropriate treatment.

Diagnostic criteria for 307.6 Enuresis

1. Repeated voiding of urine into bed or clothes (whether involuntary or intentional).
2. The behavior is 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.
3. Chronological age is at least 5 years (or equivalent developmental level).
4. The behavior is not due exclusively to the direct physiological effect of a substance (e.g., a diuretic) or a general medical condition (e.g., diabetes, spina bifida, a seizure disorder).

Specify type:

• Nocturnal Only
• Diurnal Only
• Nocturnal and Diurnal

Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision^TM. Copyright 2000 American Psychiatric Association. All Rights Reserved.