An Osteopathic Case Study of Adolescent Nocturnal Enuresis in Relation to Developmental Stages of Kidney Formation

A well-built 19-year-old male, towering physically over his mother, presented with the debilitating problem of persistent nocturnal enuresis (bed wetting), with episodes occurring most nights. Previous conventional treatment, including medication, had brought little to no relief, and both he and his family felt increasingly desperate to find a way forward.

This case study builds upon the themes explored in the previous two articles concerning kidney development and the osteopathic dialogue with the kidneys in treatment.

In particular, this case presentation appeared to reflect patterns associated with the embryological development of the kidneys, and the way these developmental stages continue to be expressed and mirrored throughout the phases of childhood development.

This case offers an opportunity to observe how these developmental processes may remain held within the organism, and how treatment can support their gradual unfolding and integration through the stages of healing.

Physical Presentation

The patient presented with a large, strongly built stature and physically towered over most people around him. Despite this, his facial appearance expressed markedly infantile qualities. The jaw and facial contours lacked clear definition, with rounded cheeks and a soft facial expression giving an overall childlike appearance. The abdomen was similarly rounded in presentation.

Posturally, the thorax demonstrated considerable rigidity both in standing posture and during movement. There was a lack of clarity and differentiation through the thoracolumbar transitional curve. The hips, elbows, and lower extremities demonstrated signs of hypermobility, although this existed alongside significant holding and guarding through the psoas musculature.

Vitality and Physiological Presentation

One of the first impressions during assessment was the markedly protective and vigilant state of the nervous system. Considerable time was required before a sense of safety and therapeutic trust could develop sufficiently for deeper physiological processes to become perceptible. In particular, the thoracolumbar and kidney region felt notably cold and guarded.

As the system gradually settled and became more receptive, the rhythms of the body became easier to perceive. In general, these rhythms appeared shallow and difficult to perceive. Breathing was held predominantly in an inspiratory pattern, with minimal excursion occurring through the respiratory diaphragm. Cranial rhythmic expression was similarly shallow and appeared biased toward the expiratory phase.

A generalised coolness was palpable throughout the kidney region, respiratory diaphragm, and abdomen.

Consciousness and Emotional Presentation

Despite his physically imposing stature, the patient’s posture and manner conveyed considerable shyness and vulnerability. Initially, he spoke very little during the consultation, with his mother answering most questions and often prompting his responses.

There was a quality of a “gentle giant” in his presentation — sensitive, withdrawn, and inwardly guarded.

His mother described a longstanding fear of the dark, alongside a profound anxiety surrounding the subject of death, both of which he himself acknowledged during the consultation.

Biographical Context

The patient came from a large family with several older siblings. The prevailing ethos within the family, particularly from the father, centred around hard work, endurance, and resilience. One older brother had joined the military, while the father himself had become physically unwell through prolonged overwork.

From an early age, the patient appeared to feel pressure to conform to this masculine ideal of strength and labour, despite his own gentler disposition and desire for more childlike activities, such as playing with tractors.

There was a strong sense that aspects of early childhood had been prematurely interrupted or pushed aside, resulting in a feeling of being thrust too early into a demanding and male-dominated environment before sufficient inner maturation and grounding had occurred.

Osteopathic Reasoning

From a physical perspective, aspects of the patient’s organisation appeared to remain held within the developmental qualities of the first seven-year phase of childhood, prior to the transition often described around the Rubicon period.

This revealed itself through a strong predominance of cranial organisation—characteristic of the earlier stages of development—with comparatively limited progression into the more rhythmic and metabolic maturation expressed through the thorax, limbs, and lower body.

The overall impression was one of retained childhood morphology, with a rounded and relatively undifferentiated bodily form, giving a more infantile quality to the patient’s physical presentation.

As discussed in the previous journals, the stages of kidney embryology—first emerging through the head, then the thorax, followed by the pelvis before ascending toward the definitive kidney region—are mirrored in the developmental phases of the growing child. During the first seven years, development is predominantly centred within the cranial and nervous system organisation. This is followed by maturation of the rhythmic system through the thorax, and later by the fuller development of the metabolic-limb system expressed through the pelvis and extremities.

Within this presentation, it appeared that this developmental progression had, in some way, been held back. Despite the patient’s physical size and age, there remained a strong predominance of the earlier cranial developmental organisation, with the later stages of rhythmic and metabolic maturation not yet being fully embodied or expressed.

Physiologically, there was a clear impression of shock, vigilance, and protective holding throughout the waking state. The organism appeared to maintain itself in a guarded cranial orientation—almost like a deer caught in headlights—as though unable to safely descend from the dominance of the head and nervous system into the rhythmic and metabolic processes of the thorax and abdomen.

The respiratory system reflected this pattern clearly. Breathing was held predominantly in inspiration, with minimal diaphragmatic excursion, giving the impression that the organism remained suspended in a preparatory or defensive state, unable to fully yield into the deeper rhythms of physiological regulation and restoration.

Emotionally and psychologically, similar themes emerged. The patient’s fear of darkness and death appeared significant within the osteopathic understanding of his presentation. Symbolically, these fears reflected an anxiety around surrendering conscious control and moving from the safety of waking consciousness into the more unconscious and vulnerable states associated with sleep, embodiment, and maturation.

In developmental terms, this may also be understood as a difficulty in fully moving beyond the earlier phases of childhood development—analogous to the closure of the cranial fontanelles and the gradual process through which the cranial system becomes more differentiated, organised, and contained within itself.

There was a palpable sense that part of the patient did not yet wish to leave the protected realm of childhood.

Biographically, this picture was further reinforced through the experience of growing up within a strongly masculine, work-oriented family environment. Expectations of endurance, productivity, and hardness appeared to have been impressed upon him before his own emotional and physiological organisation had fully matured enough to meet them.

The resulting picture was one of an organism caught in a chronic state of overwhelm and hypervigilance during waking life. During sleep, however, this highly activated nervous system appeared to swing into the opposite polarity: a profoundly unconscious state without sufficient bodily regulatory awareness and integration within the lower body.

From this perspective, the nocturnal enuresis could be understood as arising through several interacting processes.

The persistent anxious and inspiratory state likely contributed toward heightened physiological acidity and altered fluid regulation, compounded by reduced respiratory capacity to effectively balance acid-base dynamics due to the restricted diaphragmatic breathing pattern.

Within this heightened vigilance state everything was in a general state of contraction and holding. Only during sleep, does than the organism breath out and relaxation happens, resulting in the release if the held acidity and fluids of the organism which the kidneys than process and balance.

Simultaneously, the bladder appeared insufficiently integrated into conscious regulatory awareness during sleep. Urine accumulation and bladder emptying therefore occurred without adequate perceptual or neurological mediation.

From this perspective, the nocturnal enuresis was not simply a local bladder dysfunction, but an expression of a wider developmental and physiological pattern held throughout the organism.

Treatment

Part of the therapeutic process involved supporting the patient in gradually finding his own way into maturation, rather than being forced prematurely into externally imposed expectations.

The first stage of treatment was to establish trust within the nervous system and the adrenal response. This was approached through a holding yet affirming contact with the body, with particular focus on the kidney region itself—offering warmth, containment, and support.

Once this trust had been established, the intervention sought to work with the rhythms of the developmental stages reflected within the embryology of the kidneys, mirroring the movement from childhood into adolescence (as described in the previous journal).

The treatment began with the head and cranial rhythms, supporting the organism to feel sufficiently safe to descend out of a state of survival and into the rhythmic and metabolic aspects of awareness.

Attention was then brought to the mediastinum and thorax, helping awareness and breathing to centre through the heart and respiratory rhythms. The intention here was to support the organism in finding balance between inner and outer experience, allowing the patterns held within the nervous system to begin moving toward physiological processing.

From here, the treatment moved into the pelvis and sacrum. Through warmth, holding, and grounded contact, the patient was supported to feel safe, contained, and able to yield into deeper metabolic levels of awareness and relaxation.

The intervention then followed the psoas musculature upward, releasing the holding patterns through the pelvic diaphragm and ascending toward the renal fascia. Gentle contact was again established through the kidneys themselves, supporting the final stages of release and integration.

Finally, awareness was guided back toward the centre of the organism through the solar plexus, mediastinum, and heart region, helping the patient return into a more integrated and centred state.

This sequence was repeated four times during the treatment, allowing sufficient time for the organism to gradually unfold through each stage.

Following treatment, the patient reported feeling deeply relaxed and subsequently returned home and slept for several hours.

Treatment Outcome

Following the initial treatment, the patient developed a fever—something notably rare within his clinical history. This lasted approximately three days and was followed by increased mucus production through the lungs and upper respiratory tract.

Although there were still a small number of nocturnal episodes during the following week, their frequency was significantly reduced.

The second treatment followed the same therapeutic sequence. Over the subsequent weeks, gradual improvement became evident, with a marked reduction in episodes during the night.

Following the third treatment, the patient again entered a deeply relaxed state. The following day, however, he experienced a bout of diarrhoea lasting three to four days. During this same period, a large red eruption appeared over the chin area.

Despite this acute phase, this period also represented the longest duration without nocturnal episodes, extending over two weeks.

At this stage, several significant changes became evident. The red eruption over the chin, together with the diarrhoea, suggested a further awakening and integration of metabolic processes within the lower organism.

Physically, the patient’s postural pattern had begun to reorganise, with improved definition through the thoraco-lumbar transition. Both cranial and respiratory rhythms demonstrated greater breadth and coherence.

Equally important were the changes in behaviour and self-expression. The patient had begun attending appointments independently and was able to engage in fuller and more confident conversation.

Treatment continued on a monthly basis. Occasional episodes still occurred, though these could generally be related to periods of increased stress or emotional challenge during the day. Over the following months, the patient gradually became able to navigate challenging situations without triggering further episodes.

Follow-up reviews took place after three months, six months, and finally one year later, following an unrelated farming injury. By this stage, there had been no recurrence of nocturnal enuresis.

The patient had developed a more integrated posture, healthy respiratory breadth, and a more mature facial expression. Significantly, he was independently arranging his own appointments and engaging with the world with increased confidence and autonomy.

In essence, there was never anything “wrong” with the nocturnal enuresis in a purely pathological sense. There was no isolated dysfunction requiring correction. Rather, the therapeutic gesture was to support and guide the organism through interrupted stages of development—helping to integrate the physical, physiological, emotional, and biographical dimensions of experience into a healthier and more coherent rhythm.