Bedwetting

Bedwetting (Enuresis)

When a child empties the urinary bladder at an inappropriate time and place it is called incontinence. When incontinence happens at night while asleep it is called enuresis (or bedwetting). This is a common problem that affects more than 5 million children in the United States. This issue can be very frustrating for children, families and their physicians. But with patience most children can be treated effectively, today. The different causes of enuresis and possible treatment options are described for you.

What is enuresis?

Most children achieve some degree of daytime and nighttime bladder control by age four. Any kind of incontinence that occurs during sleep in a child who is five years old or older is called enuresis. About 20 percent of five-year-old children have at least occasional enuresis, but approximately 15 percent per year of these children will spontaneously grow out of their condition.
Enuresis is slightly more common in boys than girls. Up to 25 percent of all wetter’s are described as having secondary enuresis. This means that the child has had a period of time (typically six to 12 months) being dry during sleep. In contrast, children who have never been dry when they sleep are said to have primary enuresis. While some cases of secondary enuresis can be linked to a recent trauma or stress, their evaluation, treatment and response are generally no different than those with primary enuresis. In the past, when there were few treatment options, it was common to ignore or downplay the situation and hope for improvement with time. Today, with increasing opportunities for children to spend nights away from home (e.g., camps, sleepovers and overnight field trips), it has become a concern at an earlier age. It should be emphasized that the cause of all forms of incontinence, enuresis included, is almost never due to laziness or deliberate willfulness by the child. So, a parent should keep a supportive and understanding attitude. However, in a small number of situations, behavioral issues may play a significant role.

Common causes of enuresis
Experts now believe that enuresis in most cases is caused by combinations of the following three mechanisms:
1. Failure to arouse – the child does not wake up when the bladder is full or contracts spontaneously. In the majority of cases this is the primary cause, but one or both of the mechanisms listed below can also play a role.
2. Increased production of urine while asleep – the child’s kidneys make more urine during the night than can be stored within the child’s bladder. Sometimes this extra urine production is caused by a relative night-time lack of the hormone vasopressin, which tells the kidneys to decrease urine production.
3. Overactive bladder – the bladder tends to contract without being full leading to a smaller than normal capacity. This is the same mechanism as that for daytime incontinence (see below).
Furthermore, it should be noted that enuresis (and/or daytime incontinence) is very often inherited. It commonly "goes in the family" although this may not always be evident since it may skip generations and not all grandparents remember (or want to remember) that they were bedwetters when they were younger. Research has even revealed a specific gene that, if passed on to the next generation, causes enuresis through the mechanisms described above.

Enuresis and psychiatry/psychology
Bedwetting is not believed to be due to a learning disability or psychological issue. It can, however, become a source of problems if the stresses and pressures from the enuresis severely affect the child or his/her family. Children who have enuresis can develop fear of discovery by their friends and may suffer from teasing from siblings. They can become withdrawn and anxious. Family members, especially parents and guardians, are asked to be supportive and understanding. Remember that the child in nearly all of these cases cannot directly control what is happening. Although it may take longer than usual, children who are developmentally delayed can achieve control of their urination as long as their basic neurological function is normal.
Social stress such as a new sibling, sleeping alone, starting a new school, a family crisis, an accident or trauma can probably cause enuresis in children who are genetically predisposed to the condition, but the mechanism and the causes behind the wetting in these children is largely similar to that of other bedwetting children, and the treatment is also similar.

Enuresis and daytime incontinence
Daytime incontinence and enuresis can occur together in some children. In those children, both the day and nighttime wetting need to be addressed. Sometimes solving the daytime incontinence problem is emphasized first because the child can participate in daily activities more readily. During the day, the child is awake, alert and can assist in helping to stay dry. At night, the child is asleep and is unable to help directly in this response. The usual cause for daytime incontinence – or for combined day and night wetting – is that the bladder is "overactive". This means that it tends to contract and tries to empty without warning and without being full. This is not the child’s fault but it can be aggravated by bad toileting habits or by constipation. Constipation in children often occurs with symptoms of abdominal pain or fecal soiling rather than with the usual complaint of having "hard stools." In the latter case, the mechanism is probably that the stool-filled rectum compresses the bladder from behind and makes it irritable and prone to premature contractions. Thus, when there is day and night wetting it is often important to assess the toilet habits – both for urine and stool - of the child. The toileting habits of normal children are different from those of adults. Many adults urinate three to four times each day and it is not unusual for them to wait eight hours between urinations. Children cannot be evaluated with these same standards. Studies have shown that children normally urinate, or should urinate, more frequently. Many children will also exhibit "avoidance maneuvers." These are repetitive actions that the child performs to suppress an urge to urinate. Leg crossing and squeezing, squirming and heel sitting are all common examples. When these maneuvers are observed it strongly suggests that the child is trying to suppress an urge to urinate. Sometimes these actions become habitual and the child may do them without realizing it.

Uncommon causes of enuresis
Urinary Tract Infections
The presence of a urinary tract infection can lead to wetting. In these cases there is usually daytime wetting and not just enuresis. The infection irritates the bladder wall, which can lead to painful voiding, urinary frequency and feelings of urgency. The bladder becomes irritated and can cause the child to wet suddenly. A urine culture is needed to diagnose an infection.
Structural or Anatomical Problems
In most cases when enuresis is associated with an anatomic abnormality, there will either be a history of urinary tract infection or a history of persistent, continuous day and nighttime urinary incontinence. If either of these two findings is noted, X-ray tests will frequently be performed to rule out an underlying anatomical abnormality.

Neurological Problems
Storing and emptying urine from the bladder is a complicated process. It involves the central nervous system, which helps to coordinate the action of the bladder and its muscle groups. Children with a history of injury or disease of the brain, spinal cord or the nerves leading to the bladder can have enuresis, but they usually have daytime incontinence and other neurological issues as well. Examples include brain and spinal cord trauma or surgery, radiation therapy of the brain and spina bifida. These are among the most complicated cases that require a thorough urological evaluation

Kidney Disease
In rare cases, disorders that affects the kidneys’ ability to concentrate urine may lead to enuresis due to a very large urine production. These children are very thirsty, they usually need to drink every night as well and they often have additional symptoms such as stunted growth and poor appetite.

Hormonal Disorders
Diabetes is caused by a lack of the hormone insulin which is essential for our ability to take care of the sugar we get through food and drink. In untreated diabetic patients the sugar is lost in the urine which, in turn, leads to a loss of lots of water as well. In this manner, some children with diabetes may have enuresis as one of their symptoms at the start of their illness. But they have other symptoms as well: excessive thirst, weight loss, nausea, stomach ache. Diabetes can be diagnosed rapidly with a urine and blood sample and insulin treatment should, of course, start immediately. A very rare cause of enuresis is a severe lack of the hormone vasopressin that is produced by the hypothalamus – a small organ located just below the base of the brain. These children may produce huge amounts (usually 6 liters or more) of urine every day, and consequently need to drink very often both during the day and night.

How is enuresis treated?

There are several treatments that are recommended for enuresis, some effective and some not. They include modifications in fluid intake, toilet habits, the use of wetting alarm devices and medications. While they can be used alone, they are oftentimes administered in combination.

Methods without proven effect
Stopping fluids before bedtime. All parents of bedwetting children have tried this, and it usually does not help a significant number of children. We recommend that instead of this strategy the child is asked to take one or two extra glasses of water in the morning or at lunchtime and then in the evening drink to quench thirst only.
Scheduled night waking. The child is taken to the bathroom and is asked to urinate during the night by a parent or family member. This can also be done more than once during the night. Many families try this approach on their own before seeking medical attention. While it can be effective in the short term, it is hard to carry out in the long term. It is labor intensive and does not work consistently. Sometimes the child will be wet soon after going to bed or after having been taken to the bathroom. Consequently, we do not recommend this strategy.
Bladder training exercises. Among men and women who suffer from various forms of incontinence, pelvic muscle exercises can be helpful. Usually adults are asked to hold a full bladder and try to interrupt their stream consciously. An example is the female who has had several children and who now spurts some urine whenever she strains when she carries a heavy load or when coughing. This situation usually does not apply to children. Children who hold their urine deliberately during the daytime may not help their situation. Rather than "stretching out the bladder," using these techniques in children promotes delaying of normal urination and may lead to subsequent urgency, daytime wetting and even urinary tract infections. Thus, this strategy is also not recommended. We do, however, recommend that the physician look for signs of constipation and, if present, treat the child with dietary advice and – if needed – laxatives.
Alternative therapies. Homeopathy, herbal remedies and chiropractic practices have all been tried, but have no proven effect whatsoever. Some research on acupuncture and hypnotherapy has, however, given encouraging results and may prove useful in the future.
Enuresis alarms. Wetting alarms are small electronic devices that are composed of two components. One part is a sensor that attaches to the pajamas or underwear. The sensor is connected to the second part; an electronic alarm that is attached to the child's clothing near the shoulder or clipped to the waist. The alarm unit may also be put on the bedside table, wirelessly connected to the sensor. When the sensor becomes moist, the alarm is triggered. Some of the alarms also offer a vibration mode that makes a loud sound as well as vibrates. When the alarm triggers, the child attempts to get up and go to the bathroom while the bladder is almost full. It usually requires an adult to help, since most bedwetting children sleep very deeply and do not wake by themselves in the beginning of the alarm treatment. The main advantage of an alarm is that it is not a medication and has no side effects. Also it has a low relapse rate after the device is stopped, and thus is the only truly curative treatment we have today. If it is used correctly the chances of success are approximately 75% after 1-2 months of continuous treatment. Its major disadvantages are that it cannot be used discretely for sleepovers and campouts and that it requires hard work and commitment from the parents. It will disturb siblings who share bedrooms. Finally, most health insurance plans will not pay for these alarm devices that can cost $60 to $120 each.
Desmopressin acetate (DDAVP). The human body naturally produces a hormone called vasopressin that causes the body to make a reduced volume of urine. It is produced when the body is trying to conserve water. Athletes, for example, secrete more vasopressin into their bloodstream when they are playing because they are losing water from sweating. It was found that most people increase their secretion of vasopressin naturally when they sleep. That is part of the reason why most people sleep through the night without having the need to get up to urinate. In many children with nocturnal enuresis, this surge of vasopressin is absent. The hormone has been analyzed and synthesized as the drug, desmospressin, and is available as a pill or nasal spray or as an under the tongue preparation. Because it works by decreasing the volume of urine produced, it must be used in conjunction with a moderate fluid restriction program. Its primary advantage is that when it works, it can work very well, making it a confidence booster on sleepovers and campouts. It can be used discretely and is usually covered by most health insurance plans. The main disadvantages are that less than half of the treated children respond completely to the drug but if it helps it works as long as it is taken. Still, desmopressin remains one of the first-line therapies against enuresis.
Other medications. Drugs that act on the bladder muscle, such as oxybutynin and tolterodine, are often effective against daytime incontinence, combined with bladder training. It is thus logical that they may also be useful in enuresis, when this is caused by bladder over activity. This has now been shown to be true in several studies, but not all children are helped and at times the medication has to be combined with desmopressin to be fully effective. The most common side effect in children is constipation, which, in itself, may cause the incontinence or enuresis to reappear.

Frequently asked questions:

Does bedwetting improve with age?

Most children can outgrow bedwetting. It is thought nearly 100 percent of one-year-olds wet the bed. By age five, this percentage drops to around 20 percent and by age 10 it is around 5 percent. By puberty, this rate is approximately 1 percent. It is important to understand that given time, most children will ultimately overcome their enuresis. The urgency to act early in today’s world is that many children have expectations that their parents and grandparents did not have in the past. In addition to sleepovers and overnight school trips, there are more extracurricular activities like scouting campouts, and specialty camps (i.e. computer, swimming, hockey) being offered to younger children.

Does bedwetting run in families?

Yes. It has been found that if one or both parents have a history of bedwetting, the risk that their child will be a bed wetter is several times greater than the general population.

How is enuresis treated?

Methods without proven effect

Stopping fluids before bedtime. All parents of bedwetting children have tried this, and it usually does not help a significant number of children. We recommend that instead of this strategy the child is asked to take one or two extra glasses of water in the morning or at lunchtime and then in the evening drink to quench thirst only.
Scheduled night waking. The child is taken to the bathroom and is asked to urinate during the night by a parent or family member. This can also be done more than once during the night. Many families try this approach on their own before seeking medical attention. While it can be effective in the short term, it is hard to carry out in the long term. It is labor intensive and does not work consistently. Sometimes the child will be wet soon after going to bed or after having been taken to the bathroom. Consequently, we do not recommend this strategy.
Bladder training exercises. Among men and women who suffer from various forms of incontinence, pelvic muscle exercises can be helpful. Usually adults are asked to hold a full bladder and try to interrupt their stream consciously. An example is the female who has had several children and who now spurts some urine whenever she strains when she carries a heavy load or when coughing. This

Does bedwetting improve with age?

Does bedwetting run in families?

Yes. It has been found that if one or both parents have a history of bedwetting, the risk that their child will be a bed wetter is several times greater than the general population.

Does my child need further testing?

In most cases, there is no need to perform testing like X-rays and other imaging techniques, or urodynamic studies. Conditions that may need more detailed evaluation include:
• combination of day and nighttime wetting
• urinary tract infection
• constipation and/or bowel accidents
• difficulties with the urinary stream and flow
• history of recent neurological injury or disease
Your urologist or pediatrician will decide what tests if any are needed after speaking with you and examining your child.
Will the use of absorbent pants and other diaper-like products delay my child from developing control of toileting and continence?
The use of absorbent pants has not been shown to prevent or delay the later development of toileting and continence. They do help to decrease social friction between child and parents by making fewer demands for laundry and decreasing the embarrassment caused by wet bed sheets.