How to manage enuresis (urinary incontinence) of less than 3 months duration or of sudden onset within the last 2 months, possibly caused by psychiatric stress?

Secondary Enuresis Due to Psychiatric Stress

Secondary enuresis lasting less than 3 months or with sudden onset within the last 2 months due to psychiatric stress is a regressive symptom in response to psychological trauma that requires addressing the underlying psychological stressor through individual psychotherapy or family therapy. 1

Definition and Classification

Secondary enuresis refers to the resumption of wetting after at least 6 months of dryness. When this occurs:

• For less than 3 months duration
• With sudden onset within the last 2 months
• In association with psychological stressors

This presentation strongly suggests a psychological etiology rather than a primary physiological cause.

Etiology

Psychological factors are clearly contributory in a minority of children with enuresis, particularly in secondary enuretics. Common psychological stressors include:

• Parental divorce
• School trauma
• Sexual abuse
• Hospitalization
• Out-of-home placement 1

In these cases, the enuresis represents a regressive symptom in response to the stress or trauma, rather than a primary physiological dysfunction.

Assessment Approach

1. Detailed history focused on:

   • Timing of onset in relation to stressful events
   • Previous periods of dryness (confirming secondary nature)
   • Pattern of wetting (frequency, time of day)
   • Child's emotional reaction to the symptom
   • Family's response to the symptom 1

2. Physical examination:

   • Rule out physical causes (though less likely in this presentation)
   • Check for signs of physical or sexual abuse if suspected 1

3. Basic laboratory tests:

   • Urinalysis to exclude infection or other medical causes 1

Treatment Approach

Since the enuresis is of recent onset and has a clear psychological trigger, the treatment should focus on addressing the underlying psychological stressor:

1. Primary intervention:

   • Individual psychotherapy
   • Crisis intervention
   • Family therapy applied on an individual basis 1

2. Supportive approaches:

   • Education and demystification for both child and parents
   • Ensure parents do not punish the child for enuretic episodes
   • Maintain a matter-of-fact attitude about the symptom 1, 2

3. Monitoring progress:

   • Keep a journal/chart of wet and dry nights
   • Involve the child in age-appropriate management 2

Important Considerations

• The American Academy of Child and Adolescent Psychiatry emphasizes that effective treatment of the underlying psychological problem typically eliminates the enuresis in such cases 1
• Avoid medication as first-line treatment for psychologically-triggered secondary enuresis
• Punishing the child for wetting episodes is counterproductive and harmful 2
• The psychological impact of enuresis should not be overlooked, as it can significantly affect quality of life 2

When to Consider Additional Interventions

If the enuresis persists despite addressing the psychological stressor:

• Re-evaluate for missed comorbidities
• Consider adding behavioral interventions such as enuresis alarms
• Consider medication (desmopressin or imipramine) only after psychological interventions have been tried 1

Prognosis

With appropriate psychological intervention addressing the underlying stressor, the prognosis for recent-onset secondary enuresis due to psychiatric stress is generally good, with resolution of the symptom expected once the psychological issues are effectively managed.