BED WETTING (ENURESIS)

BED WETTING (ENURESIS):

Dear Sumner:

I need your advice on how to handle Beverly, a four year old girl, who wets her bed nightly. I realize that this situation of itself is not unusual, but her parents are very distraught, and are not willing to accept the fact that she will likely “outgrow it.” Her mother has told me--numerous times--how bright and well-adjusted she is and how she gets along so well with her pre-school classmates. However, as soon as Beverly walks through the door of my office, she becomes very emotional and immediately starts crying and clinging to her mother. Her urine is free of infection and no gross abnormalities are noted on physical exam. When I suggested a trial of medication, her parents refused this approach. When I suggested some “counseling” they became very angry. However, they did agree, and in fact, were most pleased, when I suggested that they have you see her. Are you willing? I hope so since they’ve already made an appointment.

Dear Phil:

I appreciated very much your introductory note on Beverly, particularly with the warning of her seeming emotional lability. As my office manager always tells me: “Forewarned is forearmed!” For that reason, when Beverly first walked into my office (clinging to her mother), I informed her that I’m a cookie doctor, not a “shot” doctor. (I always have a supply of chocolate chip cookies in my office). I chose to examine her in my office (consultation room), rather than in a separate examining room. Sitting on her mother’s lap during the exam seemed to add to her feeling of security. Before embarking on my examination of Beverly, she and I examined her doll. No abnormalities were found on either Beverly or her doll.

My approach with Beverly was an attempt to involve her in solving the problem. Assuming that Beverly really wanted to stop wetting the bed, I asked her to make a calendar and, if she woke up dry, to affix a star of her favorite color to that day (for daytime wetting one can modify the calendar accordingly). If she wet, she will record possible causes—with the help of her parents. (Phil, I want you to know that some of the things the kids write down are quite original: e.g. “the dog peed on my leg “or “my pajamas fell into the toilet.”) In addition, I asked her to postpone voiding as long as possible, noting the maximum volume of urine she could produce at any one time. Obviously one of her parents will have to help her collect and measure the urine. (Whether this actually increases her bladder capacity is not as important as making her aware of the sensation of bladder fullness, and then recognize that the time has come to deposit the urine in a proper receptacle.) I further suggested that she stop and start the stream during voiding to try to reinforce her awareness that she can control her voiding pattern. I am well aware that these steps may not result in totally dry beds, but if we can get any dry nights, this will be a positive start.

I then asked the family to make an appointment for 3-4 weeks hence in order for me to go over the record with the child. (Her parents’ eyebrows rose at the thought of paying for another office visit, but quickly relaxed when they are told there will be no charge for that subsequent visit.) Phil, it is very gratifying when a child appears with a big smile, so pleased that there are some stars on the calendar to show me (besides which, she also gets a chocolate chip cookie along with my encouraging words). The main point is that she must answer to a person other than a parent.

As a reward for sending me this “challenge,” I’d like to share with you a couple of experiences I had with some other families involving bed wetters. As you know it is critical to observe the interchange between the child and family members. For example, I had one 5 year old boy who sat quietly in the room sucking his thumb as his mother pointed an accusing finger at him, telling me how “this little brat can never stay dry and always embarrasses us with his constant wetting.” This is certainly not a very healthy family constellation! Another example involved a 6 year old youngster who came to office with his mother. Unlike with the other case, this mother looked lovingly at her son, smiling at his every word and action. “Dear Johnny,” said she, “tries so hard to stay dry and whenever he does, we give him a reward. Why last week alone he got a new tricycle, a special puzzle and a Mickey Mouse watch.” When I talked to Johnny separately, I asked him how he felt about being dry. He acknowledged that, while it did make him happy to wake up dry. he didn’t want to wake up dry every day, at least not right away. His reason: “Doc, I got it made! Do you see the way I got my Mom twisted around my little finger?”

However, not all parents will accept my approach. I had one mother who wore a very satisfied look on her face when she brought her son back for a follow-up visit. “Doctor” she said, “you may have all your fancy calendars and chocolate chip cookies, but I discovered a quicker way to stop my son from wetting. I got him an electric blanket and told him that if he wet the bed, he’d electrocute himself. (I personally do not recommend this approach for the treatment of enuresis!)

Medications or alarm systems remain other options.