PSYC 350 Lecture Notes - Enuresis, Urology, Nocturnal Enuresis
2 May 2018
School
Department
Course
Professor
I. Childhood disorders
A. Enuresis nocturna: the involuntary discharge of urine during sleep after the age of six, which
occurs in the absence of demonstrable organic pathology (e.g. a UTI). To qualify as enuresis, the wetting
has to occur at least 2-3 nights per week.
1. Prevalence, demographic and other features, organic factors and etiology
• There is a distinction between primary and secondary enuresis, but treatment is
the same
o Primary enuresis: enuresis that has occurred since birth
o Secondary enuresis: enuresis that arises after a dry period
• We are focusing on nocturnal rather than diurnal enuresis
• Occurs more frequently in boys than in girls
o Psychoanalysts blamed it on the Oedipus Complex
▪ According to them, the unresolved cause of bedwetting only
leads to symptom substitution, like oppositional behavior
▪ This is not falsifiable
▪ Symptom substitution: you may be treating the symptom but
not the cause; unresolved cause will manifest in some other
symptom
• More likely to occur when there is a family history of enuresis
• Enuretic kids expel urine more frequently yet urinate the same total volume per
day as normal kids
o Normal kids urinate 3.5 times per day, while enuretic kids urinate an
average of 5.8 times per day
o Some have suggested that they have a smaller “functional bladder
capacity”
▪ This means that their bladder is normal in size, but they feel as
though they have to urinate at smaller capacities
• About 20% of 3-year-olds still wet the bed, but this has decreased to 10% by age
6 and continues to decrease exponentially
• Enuretic kids show no sleep or EEG abnormalities
• In about 4% of cases, the enuresis may be related to organic factors
o E.g. urologic lesions, UTIs, abnormal urine stream, chronic renal
disease, and stenosis of the urethral meatus
o Parents usually check these possibilities with a pediatrician or urologist
before going to a psychologist
• Hypotheses for the etiology of enuresis
o Failure to learn control of the urinary sphincter
▪ This raises the question of why patients have control during
the day but not at night
o Small bladder functional capacity
o Bedwetting as an expression of anger or unhappiness
o Food allergy (this was disproved)
• Etiology does not need to be known in order to effectively treat the problem
2. Standard treatment procedures
a. Mowrer pad
Treatment
Success rate
How many
studies
Criterion for Success
Relapse Rate
Mower Pad (a classical
conditioning device)
80% (this is
very high)-
success rate
is after two
applications
A large
number
12-20 year-long dry
period (after applying
treatment, they must be
dry for 12-20 years)
Minimal (when the
procedure is applied
correctly)
find more resources at oneclass.com
find more resources at oneclass.com
• Mowrer Pad is the treatment of choice. It is the most effective
treatment and has a strong criterion and minimal relapse rate
• The pad, which is put on the bed, is basically two cardboard pieces
covered with an electrical conducting surface. The two sheets of
the pad are connected to an alarm that is plugged into a D-cell
battery. The top sheet has holes, and when urine seeps through the
holes, the circuit is completed, and the alarm turns on.
• This is Pavlovian conditioning, where bladder distension is paired
with the alarm
o The UR is urinary sphincter contraction/physiological
arousal
o The US is the alarm
o The CS is the sensation of a full bladder
o CR is some form of the UR
▪ Contracting urinary sphincter
▪ The UR may be waking up, but the CR may be
just contraction without waking up
• The CR may be similar but not identical
to the UR
• Avoidance behavior may also be involved, where you
unconsciously contract the urinary sphincter while you sleep in
order to avoid the alarm
• The conditioning period occurs for 14 days
• There is often a relapse when you remove the pad from the bed
o If so, you can try a number of things to make conditioning
more effective:
▪ Giving the kid fluid before bed will lead to more
opportunities to urinate, which will result in
more CS-US pairings
▪ Intermittent pairings will make it more resistant
to extinction
• This would mean attaching the clips
(connected to alarm) to the pad only on
certain nights
b. Kimmel & Kimmel direct bladder training
Treatment
Success rate
How many
studies
Criterion for
Success
Relapse Rate
Kimmel and Kimmel
Direct Bladder
Training (DBT)
43%
Few
1 week dry (this
is pretty weak)
Unknown
(because few
have followed
up)
• This treatment approach is based on the hypothesis of smaller
functional bladder capacity
o It was observed that kids who wet the bed have a smaller
functional bladder capacity than their non-enuretic
siblings
• The objective is to teach kids to better retain urine during the day.
o The kid first records the volume of urine retained between
bathroom visits in order to produce baseline
measurements for about a week. He then practices
retaining urine.
▪ Progress is paired with praise
find more resources at oneclass.com
find more resources at oneclass.com
• The goal is to eventually retain a normal
volume of urine (e.g. 8.5-10.5 oz. is the
standard for 5-7-year olds)
▪ The kid also keeps a record of number of nights
dry
▪ Also, the kid practices starting and stopping
urine flow (constricting the urinary sphincter) at
least once a day
• Treatment continues until there have been 14 consecutive nights
dry
c. Azrin dry bed
Treatment
Success rate
How many studies
Criterion for
Success
Relapse Rate
Azrin Dry Bed
90% according to
Azrin, but a
replicate study
reported 62%
Few reporting
90%, 1 reporting
62%
2 weeks dry after
end of treatment
for 90%, 2 years
dry for 62%
unknown
• Training is completed in one night
• The Mowrer pad is used
• There is an alarm in the child and parent’s room. One hour before
bedtime, kid gets positive practice. He lies down in bed, gets up,
goes to bathroom, stands in front of toilet and unzips, acts like
going to bathroom, then goes back to bed and counts to 50. He
does this 20 times.
o Then at bedtime, the kid drinks fluids and the
psychologist stays all night long, waking the kid up every
hour. Each time he is woken up, he is asked if he has to
go to the bathroom. Gets praised if bed is dry.
o If bell ever goes off, he gets reprimanded, finishes
urinating in bathroom, then has to change his pajamas,
change his sheets, then 20 more trials of positive practice.
Has to repeat entire procedure the next night.
o If you don’t wet the bed, you don’t have to repeat the next
night.
• Aversive to child and parent, costly
3. Imipramine
Treatment
Success rate
How many
studies
Criterion for
Success
Relapse Rate
Imipramine (Tofranil-
a former antidepressant
with side effect of
urinary retention)
30%
Few
2 months dry
100% relapse
• Problem of state-dependent learning
o If you do conditioning in the drug state, then take the stimulant medication
away, you’ll see enuresis again
4. Clinical research methodology: case studies, clinical series and outcome studies
• Case studyclinical studyIf you get 8/10 in a clinical series successfully treated,
move onto an outcome study where subjects are assigned to treatment and control
groups
o One control group would be attention placebo control
o Also need a wait list control group
B. Encopresis- disorders of defecation (three kinds). Far less common than enuresis and not
restricted to boys.
1. Inappropriate defecation (“soiling”)
find more resources at oneclass.com
find more resources at oneclass.com
Document Summary
Childhood disorders occurs in the absence of demonstrable organic pathology (e. g. a uti). 6 and continues to decrease exponentially: enuretic kids show no sleep or eeg abnormalities. 80% (this is very high)- success rate is after two applications. 12-20 year-long dry period (after applying treatment, they must be dry for 12-20 years) Treatment: mowrer pad is the treatment of choice. It is the most effective treatment and has a strong criterion and minimal relapse rate: the pad, which is put on the bed, is basically two cardboard pieces covered with an electrical conducting surface. The two sheets of the pad are connected to an alarm that is plugged into a d-cell battery. If so, you can try a number of things to make conditioning more effective: giving the kid fluid before bed will lead to more opportunities to urinate, which will result in more cs-us pairings.
