Goodbye to the diaper. Enuresis and sphincter control

Goodbye to the diaper

What are sphincters?

When studying human anatomy we find some muscles that are called sphincters. These muscles are usually ring-shaped or ring-shaped. When they contract, they usually open or close certain holes, through which body fluids or fluids circulate.

Some important sphincters of the human body are:

  • The urethral sphincter: It is a striated and voluntary muscular sphincter. It exists in both sexes: men and women. It is responsible for surrounding the membranous portion of the urethra. Its contraction prevents the exit of urine to the outside.
  • In the eye we find the sphincter of the iris that contracts and dilates the pupil.
  • The anal sphincter: Controls the exit of feces to the outside. There is an internal anal sphincter and an external anal sphincter. The first one has smooth muscle fibers and is totally involuntary. It is usually contracted and relaxes when feeling the pressure of gas or stool from the rectum. The second is made of striated muscle fibers and its contraction is voluntary. Between both sphincters the exit of the feces to the outside is controlled.
  • In the intestine the sphincter of Oddi allows bile and pancreatic secretions to the duodenum.

Toilet training classes.

There are many more sphincters, of different nature and varied functions. In this topic we will analyze the importance of the first two: urethral and anal. They are responsible for achieving correct and unaltered urination and defecation.

According to their shape and composition, sphincters are classified into two groups:

  • The anatomical ones are circular muscles often thickened to fulfill their valve function. They do this by contracting or relaxing their muscle fibers.
  • The functional ones are not properly speaking muscles. They do their job by extrinsic contraction of adjacent muscles.

Taking into account their form of contraction, we distinguish between sphincters:

  • Volunteers: The subject can contract or relax the sphincter according to his will. They are innervated by somatic nerves.
  • Involuntary: They are sphincters, whose control is beyond the will of the subject. Its innervation comes from the autonomic nervous system.

Toilet training after birth.

Toilet training after birth.

When a baby comes into the world they have no control over the sphincters related to urination (urethral sphincter) and defecation (external anal sphincter). We have already said that the internal anal sphincter is involuntary.

Throughout its first months of life, the baby must learn to control his toilet bowls. This is a slow and progressive process. It is directly related to the state of maturity of the muscles and nerves involved in urination and defecation.

Boy on urinal peeing.

Neuromuscular maturation.

Most experts agree that it is normal for a baby to acquire control of his bowels between eighteen and twenty-four months. The child first acquires control over defecation. Later it does it on the urination. At three or four years of age it is usual for him to control both sphincters without problems.

Everything seems to indicate that the baby is less comfortable with a stool-stained diaper than with a diaper wet with urine. This unpleasant sensation causes their maturation processes to be stimulated and defecation is the first function over which they acquire control. Learn to control it first during the day and then at night.

Later, it begins to control the emission of urine. The child notices and warns that he wants to urinate or that he is wet. First he manages to control his urine during the day. After some time he manages to do it also during the night.

Additional factors.

In addition to the aforementioned, neuromuscular maturation (involved nerves and muscles), there are other factors that can condition the advance or delay of sphincter control:

Attitude of the mother, family and caregivers.

  • The attitude of the parents, and fundamentally of the mother.
  • Attitude of babysitters, family members or other people who take care of the child and who are in charge of setting rules and limits .
  • If the caregivers or the mother have a cordial and affectionate attitude, they encourage the child to relieve themselves at the appropriate times, they will be able to accelerate their maturation process and therefore their toilet training.
  • Group activities, which take place in nurseries or nursery schools , can be of great help when they are cordial and do not imply pressure on the child.
  • On the contrary, we can consider negative attitudes, which delay the control of the sphincters: authoritarian attitudes, pressure exerted on the child, punishment and threats, teasing and insults when he is not able to control his excretory functions.

Bowel rhythm.

The child’s bowel rhythm can be of vital importance. Constipation often leads to hard stools, which make defecation painful.

If the child is constipated, he will try to avoid these painful moments at all costs. This will result in chronic constipation and poor stool control. In many cases it is necessary to resort to the use of enemas, to relieve digestive discomfort.

Diarrhea can also disrupt the maturation process. Thus we can see children who had reached almost total control over their defecations, which due to the urgency of diarrhea, become incontinent and regress in their development.

Statue of a urinating boy.

Psychological factors: Regressive attitudes.

Finally, we cannot forget about many psychological factors, which can cause the child to have regressive behaviors. In psychology the term regression is used to refer to activities that had been abandoned over the years, but to which the subject returns again, sometimes to attract attention and in others because he does not know how to face some real obstacle.

The most typical case is the arrival of a new brother.  In these cases, the whole family showers the newcomer with attention, sometimes forgetting the older brother. This usually reacts in a regressive way. It is not uncommon for him to show urinary or fecal incontinence again, when he had already passed this phase.

Teaching the child to control his sphincters.

“I want to pee”.

When children are able to walk quickly it is the right time to teach them how to control their urine, taking advantage of the moments when you start to say that you want to pee or that you have already peed.

It does not matter, if the child warns late, when he has already urinated. At that time, the diaper must be changed so that the child knows at all times the difference between being dry and being dirty or wet.

Most pediatricians and experts recommend summer as the time to get your child used to controlling urine. In this way, any leakage of urine will be less annoying than when it gets wet in winter, with more clothes and adverse temperatures.

Time to urinate.

It costs little work for mothers or caregivers to be aware of the schedules. Generally, the child tends to pee at certain times. Likewise, there is usually not much difference in the time that passes from one urination to the next.

Once the mother or caregiver knows the approximate times when the child needs to urinate or defecate, it is a good idea to suggest that the child go to the bathroom. Get him used to using the potty.

If the child has seen the activities of adults in the bathroom, he may prefer to use the toilet. Today there are countless gadgets that can be attached to the toilet to achieve this.

Avoid long stays in the bathroom.

Make sure that all these actions have a playful tone and are something festive for the child. Praise him if he succeeds, but do not scold him or punish him if he does not succeed.

If, once in the bathroom, too much time passes and the child does nothing, it is better to take him out of the toilet and let him play. Excessive time in the bathroom that is not accompanied by any physiological action can be experienced as punishment or seclusion “until I pee” or “until I poop.”

Boy pooping.

Infinite childhood curiosity.

In general, children are very curious, especially in matters such as poop-ass-pee. Therefore, there is nothing in particular that they like to enter the bathroom when it is occupied by the elderly. Nothing bad happens to let him in and see how the elderly use the toilet. He will learn to do it the same way and you will kill the bug of his insatiable curiosity.

Profitable games.

We have already said at the beginning that sphincters are muscles, and as such they have muscle tone. The stronger the sphincter has, the easier it will perform its functions.

You can teach children a game, which will undoubtedly be fun and beneficial at the same time.

Once in the bathroom, either on the potty or on the toilet, teach your children to cut off the stream of urine. By strong contraction of the urethral sphincter the stream of urine is cut off. With subsequent relaxation of the same, urination is resumed.

By repeating this action two or three times each time you go to urinate, you will ensure that your children acquire an enviable muscle tone and greater control over their urine.

Now, as we have repeated before, remember to congratulate him if he succeeds, but do not scold or discourage him if he is not able to do it.

Sometimes parents or caregivers sin excessively and want to do everything on their own without leaving the child the ability to learn. When the child goes to the bathroom, it is necessary to teach him how to raise or lower his clothes, to urinate or defecate. Once the child has learned how to do it, let him do it himself.

Sphincter disorders.

There are two main alterations that can appear when the child is not able to control his sphincters, being old enough to do so:

  • Enuresis is the lack of control when passing urine.
  • Encopresis is the lack of control when passing stool.

We are going to see these two alterations starting with the first one that usually appears most frequently.

Child with daytime enuresis.



If after four or five years the child is not able to control the emission of urine, we speak of enuresis. To apply this qualifier: There must be no medical reason that justifies the lack of control.

The American Psychiatric Association (APA) in the DSM-IV qualifies this concept a bit when considering enuresis:

“… Voluntary or involuntary urination, either during the day or at night, that wets the bed or clothes, that appears at least twice a week and that lasts for at least three months in a child of at least five years of age ”.

Types of enuresis.

Depending on the time of day in which the urine control failure occurs, we can say that there is: diurnal enuresis (lack of urine control during the day), nocturnal enuresis (lack of control at night) or mixed (lack of control 24 hours a day)

Enuresis can be constant, when it appears every day of the year, or intermittent, when it only appears on certain occasions.

The so-called primary enuresis is more frequent, which is one in which the child has never been able to control the emission of urine.

Although more rarely, secondary enuresis also appear, in children who have fully controlled the emission of urine, but on a bad day they urinate again.

It is frequent that the origin of secondary enuresis is conditioned by stressful situations for the child , distressing events, etc. We could point out among these situations the death of family members, the birth of a little brother or marital separations .

Frequency and epidemiology.

Enuresis is one of the disorders that most frequently appears in childhood. Many are the parents who have to face this problem. At this point, it is best not to dramatize the situation and turn to a professional to find out the origin of it.

Despite the high number of cases, there are no serious conclusive studies on the frequency in which it appears. This may be due to the fact that enuresis decreases with age and many studies have not specified the type of enuresis analyzed (daytime, nocturnal, primary, secondary ..)

Making a compilation of figures we can see these ranges for the different ages:

5 años >>>  6-32%

7 años >>>  8-28%

9 años >>>  5-24%

11 años >>> 3-17%

15 años >>> 1-4%

This disease occurs more frequently in girls, in low socioeconomic environments and in institutionalized children. Primary enuresis doubles in cases to secondary.

Child with nocturnal enuresis.

Causes of enuresis:

Different factors intervene in the appearance of enuresis:

  • Family history of bed-wetting: They can double or triple the chance of bed-wetting.
  • Maturational delay: It is more frequent in children with speech and language delay, as well as motor clumsiness.
  • Bladder dysfunction: Alteration of the volume of the bladder.
  • Although many authors point to deep sleep as a predisposing factor, the studies carried out have not confirmed this hypothesis.
  • Alteration of the sensations that trigger the mechanism to urinate.
  • Lack of nighttime rhythm of antidiuretic hormone (vasopressin) levels
  • Anatomical disorders of the urinary system.
  • Stressful situations: deaths, financial problems, changes of address, divorces .
  • Lack of training in bladder control.

How to act in a case of enuresis.

Attitude on the part of the parents.

As we have already seen, up to 1 or 2 out of every ten parents can have a case of enuresis in their children. The first of all is not to be unnecessarily alarmed, since enuresis in many cases evolves towards spontaneous healing, simply over the years.

It is important not to make comparisons between the enuresis child and his siblings, cousins, or friends.

When one night does not get wet, praise him. If he gets wet, do not punish or scold him. If he manages to link several nights, give him a special prize.

There are devices on the market, the so-called pis-stop, which at the first drops of urine emitted trigger an alarm, waking up the child and cutting off the emission of urine.

Involvement of the child with enuresis.

  • Avoid drinking a lot of fluids at night.
  • You should always urinate before going to bed.
  • Keep a daily log where you note if you have wet the bed.
  • It is important that the child takes charge of the maintenance of the bed. When he gets her wet, he should change the sheets and find dry pajamas.
  • The use of diapers is under discussion, since on the one hand it does not stain the bed, but on the other they prevent you from noticing the signs of imminent urination.
  • You should practice during the day to endure the urge to urinate. This will increase control over your bladder. If he does well, congratulate him and encourage him to continue in that direction.
  • The child can be awakened at night to urinate.
  • In all cases, when the child is over five years of age, it is inexcusable to take the child to his pediatrician or family doctor. Sometimes it will be necessary to take the child to a psychology consultation  (or in your city) to rule out certain pathologies.
  • The doctor, in some cases, will opt for pharmacological treatments such as desmopressin (Minurin), which must always be administered under strict medical supervision.

Encopresis – The importance of getting good habits.


What is encopresis?

We call encopresis the lack of control in the evacuation of stool that appears in children of at least four years of age.

Fortunately, encopresis is a much rarer disorder than enuresis, although it is also more serious and should always be studied by the pediatrician.

Causes of encopresis.

Among the factors that are pointed out in the medical literature, as predisposing to encopresis we find:

  • The constipation.
  • Lack of habits and schedules to defecate.
  • Situations of anxiety, depressive states or moments of stress, experienced by the child with special anguish.
  • Family problems: financial, work, bad relationships between parents.

Parents’ attitude.

Almost all the advice that we gave for the parents of a child with enuresis, are equally valid for cases of encopresis.

Involvement of the child.

The help and collaboration of the child is essential to achieve positive goals. I never tire of saying how important it is not to make him feel guilty, not make jokes on the subject, not punish him or make him the object of criticism.

  • The child should adopt the routine of going to the bathroom, at least twice, every day. One when you get up and another when you finish eating. You must sit for a few minutes until you see if you can have a bowel movement.
  • It is a good idea to plan the times that best suit your defecation habits. This way when you feel the need to go to the toilet, you can do it freely.
  • It is very useful to keep a daily chart, where you write down your activity, successes and failures.
  • You must be responsible for cleaning sheets or pajamas.
  • They should be encouraged and encouraged to take maximum interest in these activities.


Each child is different from the others, and will begin to control their toilet bowls when they are mature and capable. A controlling and strict attitude of parents can be counterproductive, in the same way that passivity on the part of parents is negative.

Both enuresis and encopresis are serious problems that must be treated by doctors and pediatricians, or eventually psychologists. If there is an inhibition, shame or reluctance on the part of the parents to go to the specialists, the situation usually becomes chronic, feelings of guilt appear in the parents for not having acted on time and this usually affects the child who feels guilty about everything which is related to your disorder.

If the pediatrician or GP confirms that there are no organic alterations, it will be time to choose a good psychologist  who can take care of the treatment and choose the most appropriate way to act.

Bibliographic references.

  • Castaño Recuero, G. (2016). How to control the sphincters
  • Enuresis –
  • Úbeda Sansano, MI, & Martínez García, R .. (2012). Nocturnal enuresis Pediatrics Primary Care ,  14 (Suppl. 22), 37-43. Link.
  • Ramírez-Backhaus, M., Arlandis Guzmán, S., García Fadrique, G., Martínez Agulló, Martínez García, R., & Jiménez-Cruz, JF. (2010). Nocturnal enuresis: A common disorder with a prevalence difficult to estimate. Actas Urológicas Españolas ,  34 (5), 460-466. Link.
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Alexa Clark specializes in Cognitive Behavioral Therapy. She has experience in listening and welcoming in Individual Therapy and Couples Therapy. It meets demands such as generalized anxiety, professional, love and family conflicts, stress, depression, sexual dysfunction, grief, and adolescents from 15 years of age. Over the years, She felt the need to conduct the psychotherapy sessions with subtlety since She understands that the psychologist acts as a facilitator of self-understanding and self-acceptance, valuing each person's respect, uniqueness, and acceptance.

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