Is bed-wetting as an adult bad

Also think of enuresis!

Urinary incontinence, more than many other chronic complaints, represents a considerable reduction in quality of life. Many patients feel that they are not being adequately cared for, and they also suffer from side effects from medication or complications after surgery. In addition, enuresis in adults and stress urinary incontinence are often confused.

In particular, the psychosomatic incontinence form of enuresis in adults is problematic in diagnosis and treatment. Because it is often wrongly assumed that it only occurs in children and only at night.

Enuresis is a psychosomatic urinary incontinence from the age of five. It occurs in both children and adults and is an expression of dysfunctional coping with stress in the case of psychosocial stress with continued increased internal tension. So there is no neurogenic or somatic incontinence caused by pelvic floor insufficiency. Here, too, there is no functional obstructive micturition disorder, which means that enuresis can also be clearly separated from the somatoform overactive bladder.

Primary and Secondary Enuresis

One speaks of primary enuresis when the child or adult has never had intermittent phases of continence longer than six months. Secondary enuresis is the recurrence of wetting in children or adults after continence has already existed.

The urine leakage often occurs initially during night or midday sleep. Then in the primary form the continence has usually been regularly reached in the waking state, with manifestation of the secondary form the continence in the waking state often remains unchanged for the time being. That does not have to be that way. It is entirely possible that there are only daytime symptoms - as in the so-called Giggle urinary incontinence or in a form similar to stress urinary incontinence. Typically, incontinence episodes while awake are the main triggers for a doctor's consultation in the primary and secondary forms. Obviously the suffering is so great that the shame can be overcome and a visit to the doctor is possible.

Paroxysmal sphincter relaxation in enuresis

While all other diseases with psychosomatic micturition disorders (overactive bladder, recurrent urinary tract infections and chronic pelvic pain syndrome) are based on situational or permanent hyperactivity of the external urethral sphincter, enuresis has normal sphincter tone with only occasional short-term hypoactivity. That means: Depending on the situation, the sphincter muscle relaxes and physiological micturition is initiated. Accordingly, the enuresis of the child is typically characterized by the complete leakage of the bladder, while with the somatoform overactive bladder only smaller amounts are lost. However, the symptoms can vary in adolescents and adults. Both the complete leakage of the bladder and the loss of only small amounts of urine are possible. On the one hand, this depends on whether the patient is able to control and actively tense the sphincter at will. On the other hand, it is important how well and how quickly the patient can stabilize himself psychologically and control himself physically after a partial tension reduction in the sense of a kind of overflow incontinence has taken place in an emotionally charged situation.

Urological functional diagnostics

There is a completely normal basic diagnosis: urine sediment, physical examination including inspection of the lumbosacral region, orienting neurological status, sonography of the urinary organs and uroflowmetry are normal. Analogous to the other somatoform diseases, there are often indications of the presence of a psychosomatic illness based on the biographical anamnesis and behavior in practice.

Urethrocystoscopy, performed to rule out stress urinary incontinence, shows a smooth entry into the bladder with problem-free passage even into the proximal urethra. A physiological finding appears in the urinary bladder. The digital pelvic floor evaluation shows normal muscle tone, and there is also normal mobility of the urethra. Urination cannot be provoked by provoking a cough while lying down or standing. Accordingly, there is no muscular insufficiency of the sphincter, as is the cause of stress urinary incontinence. Typically, however, there is a limited ability to respond to the sphincter even under digital guidance, i. H. the patient is unable to achieve the desired contraction of the sphincter. So it is a limited perception and control of the pelvic floor. The urodynamics also shows a physiological measurement of the bladder and sphincter pressures, in particular a sufficient pressure transmission in the urethral pressure profile at rest and when a cough is provoked.

Dysfunctional coping with stress

Like the other somatoform micturition disorders, enuresis is assigned different functions for reducing psychosocial stress. Typically, the incontinence episodes occur during sleep, which is not characterized by the brain being switched off, but - on the contrary - by phases of increased activity in certain centers. While the inhibiting or controlling left half of the brain is at rest and thus functionally ceases to exist, the right half is now very active in the form of dreams, thus dealing with experiences and processing emotions.

Analogously to this, the daytime symptoms that appear in the course or sometimes also appear in isolation are then also manifested in moments that are occupied with negative emotions, i.e. H. in situations associated with fear, insecurity, resignation and excessive demands Are z. If, for example, helplessness and powerlessness are felt because the adequate reaction of the resistance does not seem permissible, the resulting anger and aggression can find its expression in the initiation of micturition. Has a person had to learn that in offensive situations the attempt of self-assertion with punishment or love
Withdrawal is answered, it may be that this person will piss his pants as a result of social conditioning in order to get their basic needs for autonomy and self-esteem increased in the short term.

Maturation disorder, negative self-image and abuse

Like the somatoform overactive bladder, enuresis is based on a disorder of maturation and self-esteem regulation. With both diseases, social insecurity, fears and a negative self-image are usually perceptible.

In adolescents and adults, enuresis is often found in neglect and deprivation, emotional exploitation and sexual abuse. The communicative or interactional functionality of the symptoms provides protection and the restoration of boundaries. The unspoken punishment of causing a guilty conscience makes relationships control. So someone who wets and wears a diaper loses his attractiveness as a sexual partner or is at least left alone.

Conclusion: Success through psychosomatic multimodal therapy

Like all psychosomatic micturition disorders, the treatment of enuresis also requires a combined approach of multimodal pelvic floor education to improve the body's own or self-perception and cognitive restructuring to eliminate psychosocial stress and self-esteem problems. The cornerstone is to create a motivating doctor-patient relationship that allows for relaxation, with which the basic needs are met, positive interpersonal experiences are made and thus self-esteem and social competence training for self-assertion is allowed. Every incontinence operation will not improve the problem, but usually worsen it - and then often result in a legal battle against the surgeon because of the personality behind the psychosomatic voiding disorder.

Literature from the author.

Private practice for urology and psychotherapy, Heidelberg
Outpatient rehabilitation center for urology and gynecology Heidelberg
Chair of the working group for psychosomatic urology and sexual medicine of the German Society for Urology

Conflicts of Interest: The author has not declared any

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