Mother checking her sleeping child who sometimes has bedwetting problems.
Nighttime bedwetting is called nocturnal enuresis or enuresis. Most children out grow bedwetting by the age of five, but many children at age seven (5% – 15%) continue to experience problems becoming continent – staying dry at night. Many of these children will stop bedwetting in their late childhood or teen years, but some will continue to experience enuresis into adulthood (0.5% – 1% in adults). Rarely, adults who did not previously experience enuresis will begin to experience bedwetting. A sudden onset of enuresis in adulthood can be a warning sign of serious health issues like diabetes, a urinary tract infection (UTI) or neurologic conditions and so a healthcare professional should be quickly consulted.
Some children also experience daytime wetting. Daytime wetting affects one in 75 children age three years and older. By the age of seven, approximately three percent (3%) of girls and two percent (2%) of boys continue to experience daytime wetting at least once a week. This following discussion is focused on nighttime bedwetting only.
Possible Causes of Bedwetting
The cause of enuresis is unknown, although there seems to be a strong genetic or family link. Often one or both parents of a child with enuresis also experienced nighttime bedwetting during their childhood. The child will often outgrow bedwetting at about the same age that the parent did, which is reassuring for all to know. The child’s physician will consider all the potential causes for a child’s enuresis, including the genetic link. The many potential causes may include, but are not limited to, the following possibilities:
The human body produces a hormone called vasopressin to hold onto water. Most people produce a larger amount of vasopressin at night, which causes urine to become more concentrated (that is why urine is generally a darker tint of yellow in the morning). Sometimes children with enuresis do not produce the needed extra amount of vasopressin at night, resulting in the body producing more urine than the bladder can hold throughout the night.
Constipation (not having regular bowel movements) is actually quite common with young children. When it happens often on a regular basis it is said to be chronic. Chronic constipation can contribute to enuresis.
Many individuals with enuresis are described as “very deep” or “very heavy” sleepers. They do not awaken when the urge to urinate strikes. Some children have sleep disorders such as sleep apnea or sleep walking. If these sleep problems exist, having them treated by a sleep specialist will often improve or halt the enuresis.
Some children will begin wetting the bed as the result of new psychological stresses in their life. These stresses can come from traumatic or benign events. Starting class at a new school, moving to a new home, the loss of a friend or family member, or the arrival of a new sibling, are common examples of such events.
Enuresis can be a symptom of an anatomic abnormality (birth anomaly) or other health condition. This is one of the reasons it is important to seek treatment for your child from an interested and knowledgeable healthcare professional.
It is believed that some children may simply have smaller bladders that are unable to hold the usual amount of urine. Some children may grow out of bedwetting as they and their bladders grow. This was a popular theory several decades ago, but recent research suggests that this is not a major cause of enuresis in children.
It is common for children with conditions such as ADD, ADHD, depression, and autism to experience enuresis, so there may be a link between these conditions and bedwetting. Research is ongoing in this area.
Because most enuresis is thought to be influenced by genetics, at least in part, prevention is not possible. Parents’ efforts are better placed in providing a supportive and understanding environment for children as they learn to control their bladder and bowel during both the day and the night.
Parents need to try to keep in mind that most children stop wetting the bed by the age of five, but bedwetting even after the age of five is common. When bedwetting does become a problem and medical help is sought, it is important for parents to honestly answer questions about their own medical history, including bedwetting — this will help the doctor determine if the enuresis is related to genetics, or possibly some other condition.
Because psychological stress can play a role in some cases, it also may be helpful to seek professional guidance during times of change in your child’s life, including the birth of a sibling, death of a pet or family member, or a move to a new home or school.
It is important not to punish a child for wetting the bed. Bedwetting is not a child’s fault. No child enjoys wetting his/her bed. Instead, parents need to accept that it is a medical condition and the child has little, if any, control.
Medical Evaluation
A primary care physician or pediatrician will need to do a thorough medical history of the child. There will need to be documentation of all lower urinary tract symptoms along with drinking habits, bowel symptoms and any previous treatments that have been tried. The child will also need to have a physical exam. Frequency/volume charts of urination and bladder diaries are extremely valuable for the physician’s evaluation. Some diagnostic tests may also need to be done to help reach a diagnosis and a management program for the child.
Treatment and Management Options for Bedwetting
There is no one treatment option for enuresis that has a 100% cure rate, which means there will probably have to be a bit of experimenting to find what works best for each child’s situation. A treatment program for enuresis will most likely involve several methods of therapy, used in sequence or in combination. The treatment program will take time, and there may be short-term failures and relapses. The sooner parents see a doctor with their child, the sooner they can start working to determine what might be causing the enuresis and what can be done to help their child. The following are some options that the doctor may discuss with the parents:
Helping a child get more sleep may help them to have drier nights. Trying an earlier bedtime for a while may make a noticeable difference (This may also work with adults who experience enuresis).
Because of the close anatomical and functional relationship between the lower gastrointestinal tract and the bladder, if constipation has been diagnosed, it must be treated before and throughout any incontinence therapy for the child.
The child should avoid fluids for about two hours before bedtime. No one should ever go to bed thirsty, so the child may drink some water if necessary. Also, the child should avoid foods containing a lot of liquid before bed, such as fruits, popsicles, etc. Healthy water intake should occur between 8 a.m. and 4 p.m. Drinking plenty of water during the day will help promote the normal expansion and holding capacity of urine in the bladder. Timed voiding (going to the bathroom to pee) during the daytime should occur with intervals not being more than two to three hours apart.
Help the child avoid bladder irritants, especially before bed, such as citrus juices, chocolate, and anything with caffeine.
Try waking the child up at regular intervals throughout the night to have them empty their bladder before it becomes full to the point of leakage. This is a common older approach and is called “night waking.” It may not necessarily work: some children will be wet before he/she is awakened or the child may wet after being taken to the bathroom.
This child is using a moisture alarm at night to help with bedwetting issues.
There has been great success with the use of alarms that awaken the child as soon as they begin urinating during the night. A personal alarm has a sensor, which is tucked into the underwear or in a mat on which the child lies (a pad and bell alarm). The other end is attached to the pajama top or shirt. When wetting occurs, the alarm will both sound off and/or vibrate. Some alarms also include lights. Alarm therapy is curative in 60% of children. Alarms have no side effects and the lowest relapse rate, but not every insurance plan will cover the cost. These usually require a long-term commitment as they take three to four months to prove effective. It can be stopped after 14 consecutive dry nights. Motivation and support is crucial for success. If recurrence of enuresis occurs, re-introduction of the alarm therapy is usually successful.
Biofeedback therapy, which sometimes can be done with video games that provide the child with immediate feedback on how well they are learning to control their pelvic muscles, is a new therapy that is reporting promising results.
A medication may be prescribed, most often desmopressin. It is also known by the acronym DDAVP. This medication is used to try to reduce the amount of urine produced by the body at night. About 70% of children respond to this medication, but it does have a high recurrence rate once a child stops taking the drug. This drug can be used in combination with the alarm therapy. Typically, a child will take the drug for 3-6 months with a 1-month break to see if the child can now stay dry at night.
Absorbent Products
While a child is experiencing enuresis, parents may want to use disposable and/or reusable extra absorbent underwear and bed pads. Using absorbent products for older children is controversial: some claim that the use of “diaper-like products” hurts the child’s self-esteem by making him or her feel like a baby; others claim that the use of absorbent products gave their child a renewed sense of control over the condition. The use of diapers or pull-on style products has not been shown to delay gaining of control. Parents should go shopping with their child for pajamas that will conceal the product. Many of these products are available from several national distributors on Continence Central.
Resources
The International Children’s Continence Society has detailed guidelines for the diagnosis and treatment of the basic problems associated with multiple forms of childhood incontinence, including enuresis. They also have clinically useful resource materials. These resources can be found on their website at (www.i-c-c-s.org).
Education and Resources for Improving Childhood Continence (www.eric.org.uk) is another resource for parents, professionals, and children regarding bedwetting. This website features message boards for both parents and the children. This is a non-profit agency based in England that is dedicated to improving the lives of children and young people with ongoing continence problems.
Medical Reviewer: Julian Hsin-Cheng Wan, MD
Julian Hsin-Cheng Wan, MD
Dr. Wan is the Reed Nesbit Professor of Urology, Department of Urology, University of Michigan Medical School, with a specialty in pediatric urology. He describes his interest as follows: “My particular areas of interest in pediatric urology are in how basic practical issues and concerns can be addressed so as to best serve the needs of our patients and families. Great strides are being made today in understanding the fundamental genetic, biochemical, or molecular basis for many of the conditions which affect our patients, and it is hoped that someday in the future these developments will lead to a significant cure or treatment. In the meanwhile we must still have practical therapies which can be applied today.” Dr. Wan received his MD from the University of Michigan in 1985. He did his residency at the University of Michigan Medical Center, 1990, Ann Arbor, Michigan, United States and did his fellowship in Reconstructive and Pediatric Urology in 1992 at the University of Michigan Medical Center.