Development of control of urination and defecation involvesphysical and cognitive maturation and is strongly influenced by cultural norms, socioeconomic status, and practices within the United States and throughout the world. Inthe first half of the twentieth century, toilet mastery by 18months of age was the norm in the United States. Concernabout harsh toilet training and possible later psychologicaldistress led to professional endorsement of later toilet training. In 1962 Brazelton introduced the child-centered approach,which respects the child’s autonomy and pride in mastery.The invention of disposable diapers also facilitated later toilettraining. Social changes, including increased maternal workoutside of the home and group child care, also have influencedthis trend. Some families choose to wait until the child is older because the duration of the training period may be shorter.Toilet training usually begins after the second birthday andis achieved at about 3 years of age in middle-class white U.S.populations. Toilet training between 12 and 18 months of agecontinues to be accepted in lower-income families.
Prerequisites for achieving elimination in the toilet include the child’s ability to recognize the urge for urination and defecation, to get to the toilet, to understand the sequence of tasks required, to avoid oppositional behavior, and to take pride in achievement. The entire process of toilet training can take 6 months and need not be hurried. Successful parent-child interaction around the goal of toilet mastery can set the stage for future active parental teaching and training (e.g., manners, kindness, rules and laws, and limit setting).
Enuresis is urinary incontinence in a child who is adequately mature to have achieved continence. Enuresis is classified as diurnal (daytime) or nocturnal (nighttime). In the United States, daytime and nighttime dryness are expected by 4 and 6 years of age, respectively. Another useful classification of enuresis is primary (incontinence in a child who has never achieved dryness) and secondary (incontinence in a child who has been dry for at least 6 months).
Enuresis is a symptom with multiple possible etiologic factors, including developmental difference, organic illness, orpsychological distress. Primary enuresis often is associated with a family history of delayed acquisition of bladder control. A genetic etiology has been hypothesized, and familialgroups with autosomal dominant phenotypic patterns fornocturnal enuresis have been identified. Although most children with enuresis do not have a psychiatric disorder, stressfullife events can trigger loss of bladder control. Sleep physiology may play a role in the etiology of nocturnal enuresis, with ahigh arousal threshold commonly noted. In a subgroup ofenuretic children, nocturnal polyuria relates to a lack of anocturnal vasopressin peak. Another possible etiology is malfunction of the detrusor muscle with a tendency for involuntary contractions even when the bladder contains smallamounts of urine. Reduced bladder capacity can be associatedwith enuresis and is commonly seen in children who havechronic constipation with a large dilated distal colon, whichimpinges on the bladder.
Enuresis is the most common urologic condition in children.Nocturnal enuresis has a reported prevalence of 15% in 5-yearolds, 7% in 8-year-olds, and 1% in 15-year-olds. The spontaneous remission rate is reported to be 15% per year. The oddsratio of nocturnal enuresis in boys compared with girls is 1.4:1.The prevalence of daytime enuresis is lower than nocturnalenuresis but has a female predominance, 1.5:1 at 7 years of age.Of children with enuresis, 22% wet during the day only, 17%wet during the day and at night, and 61% wet at night only.
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