Enuresis

Essential (Required) Features:

• Repeated and persistent voiding of urine into bed or clothes (e.g., several times per week over several months), which may occur during the day or at night.
• The individual has reached a developmental age when urinary continence is ordinarily expected (approximately equivalent to a chronological age of 5 years).
• The symptoms are not better accounted for by the physiological effects of a substance or medication or by another medical condition (e.g., a Disease of the Nervous System, a Disease of the Musculoskeletal System or Connective Tissue, or congenital or acquired abnormalities of the urinary tract).

Specifiers for nocturnal or diurnal occurrence:

6C00.0 Nocturnal Enuresis:

• Inappropriate voiding of urine occurs only during the night. This is the most common form of enuresis and typically occurs during the first part of the night soon after the individual has gone to sleep.

6C00.1 Diurnal Enuresis:

• Inappropriate voiding of urine occurs only during waking hours. This form of enuresis is also referred to as urinary incontinence.

6C00.2 Nocturnal and Diurnal Enuresis:

• Inappropriate voiding of urine occurs both during the night and during waking hours.

Additional Clinical Features:

• Voiding of urine is typically involuntary but, in some cases, may appear to be voluntary. The diagnosis can be assigned in either case.
• Voiding of urine during sleep may take place during rapid eye movement (REM) sleep, leading some individuals to report having dreamt of urinating.
• Diurnal enuresis may occur in children who avoid urination due to social anxiety about using a public bathroom or due to refusal to cease an activity that is enjoyable (e.g., playing a game).
• Enuresis may lead to the development of psychological problems due to associated distress or stigma. Enuresis may be an aspect of another Mental, Behavioural, or Neurodevelopmental Disorder. Or, both Enuresis and another emotional/behavioural disturbance may arise in parallel due to related etiological factors. A diagnosis of Enuresis may be assigned together with other Mental, Behavioural, or Neurodevelopmental Disorder diagnoses if the Enuresis is a distinct focus of clinical attention.
• Enuresis is common among individuals with Disorders of Intellectual Development. The diagnosis should only be assigned if all diagnostic requirements of Enuresis are met and the individual’s developmental age is equivalent to that of the age at which urinary continence in normally expected (approximately equivalent to a chronological age of 5 years).
• Enuresis can occur among individuals with Neurocognitive Disorders (e.g., Dementia). The additional diagnosis of Enuresis can be assigned if all diagnostic requirements are met and the condition requires separate clinical attention.
• Enuresis is more common among children with a parent who has a history of Enuresis.

Boundary with Normality (Threshold):

• It is not uncommon for children to experience occasional urinary incontinence up until middle childhood.

Course Features:

• Most children establish urinary control by adolescence with a small number of individuals continuing to experience Enuresis into adulthood.
• Enuresis that persists into adolescence is often associated with an increase in frequency of urinary voiding episodes.

Developmental Presentations:

• Enuresis may have been present from birth (i.e., an atypical extension of normal infantile incontinence) or it may have its onset following a period of acquired bladder control.
• The common age of onset for children who have previously acquired urinary continence, yet develop Enuresis, is between the ages of 5 to 8 years.
• Diurnal Enuresis is less common in children over the age of 9 years.

Culture-Related Features:

• Cultural variation exists with regard to toilet training. Expectations regarding the age when continence occurs and whether Enuresis is viewed as pathological varies by cultural group. Cultural norms may affect tolerance for the behaviours, expectations regarding their course, and the associated level of shame and stigma.

Sex- and/or Gender-Related Features:

• Nocturnal Enuresis is more common in males, whereas Diurnal Enuresis is more common in females.

Boundaries with Other Disorders and Conditions (Differential Diagnosis):

• Boundary with the effects of substances including medications: Enuresis may occur due to certain antipsychotic medications, diuretics, or other substances or medications that stimulate incontinence. In these cases, incontinence should be considered a side effect and a diagnosis of Enuresis is typically not warranted. If the enuresis was present before administration of medication, it may be appropriate to assign a diagnosis.
• Boundary with other medical conditions: Enuresis should not be diagnosed if the child has a urinary tract infection, a neurogenic bladder, or another medical condition that causes polyuria or urgency (e.g., untreated diabetes mellitus). A diagnosis may be warranted if the urinary incontinence was present before the other medical condition developed or persists after the child has received treatment.