Home > International Dictionary of Psychoanalysis > Enuresis

Enuresis is incomplete, or total lack of, bladder control in children past the age of four to five years, when bladder control is normally achieved. It is considered primary when a child has never been consistently dry. In secondary nocturnal enuresis, bedwetting begins after a period of adequate bladder control and suggests regression due to such traumatic factors as separation, loss, or illness. Enuresis is distinguished from genuine organic urinary incontinence. Enuretic urination, as a rule, is nocturnal and involuntary. It may be also associated with daytime events.

As a disorder that attracts the interest of a number of medical specialists, enuresis has spawned a variety of hypotheses concerning its etiology. The deep sleep of the enuretic child has been implicated, though without evidence of any unusual sleeping habits, save increased resistance to specific waking stimuli. The bladder capacity of the enuretic child is usually normal, although in some cases an immature bladder has been demonstrated, and this can cause a nocturnal surge in bladder pressure. In a few cases, disorders (or delayed maturation) of circadian rhythms due to secretion of antidiuretic hormones may disrupt, or delay the development of, the normal relationship between diurnal and nocturnal production of urine, and this can produce functional nocturnal polyuria. Finally, studies of families and twins have established a genetic component.

Although psychological and environmental factors have often been investigated, a specific psychological profile for enuresis has not yet emerged. Complicating matters is that relevant factors differ according to whether the symptom is an isolated one or forms part of a more complex clinical picture and a definite psychopathology.

Freud emphasized the libidinal dimension of primary enuresis. Beginning with the case of Dora (1905e [1901]), he interpreted enuresis as a substitute for genital gratification, noting consistent links between enuresis and fire, a theme that he discovered in dreams as representative of frightening, aggressive, or erotic drives. As the gratification of an organic need, Freud suggested, urination counts as one of the autoerotic and infantile pleasures; the infant renounces it only with reluctance under the pressure of toilet training (1916-1917a [1915-1917]).

Even if this classical conception must be viewed today in connection with other considerations, psychotherapy of enuretic children often demonstrates the relevance of Freudian intuition. Gérard Schmidt and Michel Soulé (1985) stress the significance of primary enuresis in the libidinal economy of the enuretic child, together with various direct instinctual gratifications that indicate continued and persistent eroticization of urination. Gains in controlling secondary enuresis are correlated with reactions of the child's caregivers and the availability of other means of gratification.

The study of the psychological factors involved in enuresis must take into account several factors implicated in successful toilet training: (1) the gradual maturation of control over the somatic functions, with individual inborn variations; (2) the affective investment in excretory functions in different stages of libidinal development; and (3) interactions with the environment, ranging from the child's privileged relationship with its mother to familial and social customs concerning the child's acquisition of sphincter control.

GERARD SCHMIDT

See also: Eroticism, urethral; Institut Max-Kassowitz.