Toilet Training

Robert S. Michel

doi:10.1542/pir.20-7-240

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Robert S. Michel, MD^*

^*Associate Professor of Pediatrics, University of Virginia Children’s Medical Center, Charlottesville, VA.

OBJECTIVES

After completing this article, readers should be able to:

List the age-appropriate factors related to toilet training.
Name the age by which the majority of American children are toilet trained.
Delineate what percent of 5-year-old children experience primary nocturnal enuresis despite daytime bladder control.
Describe antecedants to toilet training refusal.
Describe the potential consequences of stool withholding.

Introduction

Acquiring toileting skills is a nearly universal developmental milestone, but the path to toilet training has changed substantially over the past century. Parents need guidance in recognizing when their child is ready to acquire toileting skills, how to help their child acquire those skills, and how to address problems in toilet training. Problems may include toileting refusal, stool withholding, and constipation with or without encopresis. It is important to recognize that current views on toilet training are based on the physical and psychosocial development of the child, including culture differences, which should be noted.

Definition

A child has achieved bladder control when there no longer is involuntary leakage of urine. Enuresis (involuntary leakage of urine) is categorized as diurnal (daytime) versus nocturnal (during sleep) and primary versus secondary. Primary diurnal enuresis should be evaluated if the child is older than 48 months of age. Other indications for evaluation of primary diurnal enuresis at any age are concerns of dysuria, gross changes in the appearance or odor of the urine, or abnormalities in the urinary stream.

Secondary diurnal enuresis implies that bladder control has been consistent for at least 3 months. In the preschooler who recently acquired urinary control, diurnal enuresis should prompt a review of psychosocial stressors. Secondary diurnal enuresis always should be evaluated with a thorough history and physical examination. Common reasons for secondary enuresis include urinary tract infection and diabetes mellitus. Additional causes of diurnal enuresis include constipation, congenital or acquired neurogenic …