Bedwetting (enuresis) is the involuntary discharge of urine during sleep. It is called bedwetting after the age by which bladder control should have been established. In children, voluntary control of urination is usually present by the age of five. Nevertheless, nocturnal enuresis is present in about 15 to 20 percent of otherwise healthy 5-year-old children, 7 percent of healthy 7-year-olds, 5 percent of healthy 10-year-olds, 2 to 3 percent of 12 to 14-year-olds and 1 to 2 percent of normal children at age 15. Enuresis is slightly more common in boys than in girls and occurs more frequently in the first born child.
Enuresis is the involuntary voiding of urine at least twice a month in a child age five or older. Children vary markedly in the age at which they are physiologically ready to awaken from sleep aware of the need to urinate. This hinders their ability to hold their urine throughout the night.
If the child has never been totally dry for a year, the condition is known as primary enuresis. Eighty-percent of children who wet their bed suffer from primary enuresis.
Secondary enuresis is when a child has had a dry period of at least a year before the appearance of the problem. The child invariably urinates during the first third of the night and remembers nothing of the occurrence.
Although in 1 percent of cases, enuresis continues into adulthood, most children are continent by adolescence. Aside from wet pajamas, enuresis itself causes no direct impairment of the child’s life, but social ostracism by peers (at sleepovers and camp, for example), and anger and rejection by parents can damage self-esteem.
For most children, there is no disease that causes bedwetting, and a true organic cause is identified in only about 2 to 3 percent of children with the condition.
A number of factors may contribute to enuresis:
- Genetic factors
- A family history of enuresis
- Delayed maturation
- A stressful life event, such as the birth of a sibling, the first week of school or a parent’s going away
- Delayed arousal from sleep
- Small functional bladder capacity
- Chronic constipation can irritate the bladder, which results in frequent urination.
- Sleep apnea (periods of non-breathing during sleep) decreases oxygen levels. This may make a child less responsive to the sensation of a full bladder and less likely to wakeup when they need to urinate.
- Urinary tract infection
- High urine production during the night
Behavioral therapy is the first approach to night-time bedwetting. There are several standard ways of helping your child learn to be dry at night. However, before you start such a program, you need to make sure your child is “ready”. Specifically, your child should be able to understand how to do what you are asking him to do and be motivated to do so. He should not be forced behavior changed. Punishment for bedwetting at night can hurt your child and should not be used.
Bedwetting takes time to resolve. Be patient with your child and avoid expressing anger, frustration or hostility. There will be periods of progress followed by relapses. If you are feeling like the family is becoming overwhelmed dealing with bedwetting, family counseling may be appropriate.
General behavioral approaches – setting the stage for change
- Children should urinate just before going to bed; remind the child to get up at night to do so if they feel the need to
- Bathroom needs to be easily accessible and have a light on; you can also place a potty in the child’s room
- Don’t use diapers anymore at night; you can place a plastic cover over the mattress to protect it
- If an accident occurs, have the child change into pajamas (leave them out the night before for easy access) and place dry towels over the wet spot; this way you can avoid remaking the bed in the middle of the night
- In the morning have the child strip and remake the bed and take a shower
- Do not allow siblings to “tease” the child
- Have a small reward for dry nights. This results in improvement almost three-quarters of the time. Let the child help you pick the reward in advance. A token or a sticker is a great idea.
Managing your child’s fluid intake
- Keep track of how much fluid your child drinks in a day. He should receive no more than 20% (1/5) of it in the evening.
Training your child to wake up
- You can have your child “rehearse” getting up to go to the bathroom. He can do this by going and lying down in his bed when he feels the need to urinate during the day. The child pretends to sleep and thinks to himself, “It’s time to wake up and go to the bathroom, you need to get up NOW.”
Other approaches you can use with your physician’s advice
- Bladder training involves helping your child increase his bladder capacity.
- Night wet alarms. These can remind a child to wake up when urine is passed into the bed. Children should be motivated. It is a good idea to try other approaches above before working with a physician to use an alarm system.
Medications that can be used under a physician’s supervision.
Every year, about 15 percent of bedwetters become dry without treatment. If an organic cause has been ruled out, it should be made clear that there is no medical need to treat the child. If medical treatment is indicated, there are usually three types of medication prescribed.
DDAVP (desmopressin acetate) is a medication approved by the Food and Drug Administration for use with enuresis. Research shows that one cause of bedwetting is a deficiency in the secretion of antidiuretic hormone (ADH) during sleep. (ADH causes the body to produce less urine.) DDAVP, a synthetic version of the hormone, raises nighttime ADH levels and thereby decreases urine production. It is effective regardless of whether or not the child is ADH-deficient. Because DDAVP comes in a nasal spray, the drug is absorbed into the bloodstream much faster than broken down in the stomach, like a pill.
DDAVP is odorless, tasteless and considered safe. Except for an occasional headache or irritation of the nasal passages, children do not seem to suffer side effects. The medicine can work after the first dosage of a single spray in each nostril. The drug is expensive and it does not always work.
Imipramine (Tofranil) is a relatively inexpensive trycyclic antidepressant that has been used for bedwetting for about 30 years. It is not known exactly how it works, but it may relax the bladder, decrease the depth of sleep in the last third of the night, and increase bladder capacity (taken one hour before bedtime). Mild reactions can include nervousness, insomnia, gastrointestinal disturbances, fatigue and sensitivity to sunlight. Parents must be very careful to keep imipramine out of the reach of children, as it can be toxic in large doses and an overdose can be fatal.
Anti-spasmodic drugs, such as oxybutynin chloride (Ditropan), can be useful for daytime wetting. They reduce the frequency of bladder contractions, delaying the urge to urinate. Side effects include drowsiness, dry mouth and constipation.
If the child develops “new” bedwetting after having achieved night time dryness, you should consult with you physician. This could be a sign of anxiety or stress, diabetes, bladder infection or a seizure.
If you believe that family tension or problems are causing your child to develop bedwetting, discuss obtaining a referral for counseling for the family and your child for this problem.
Are there any tests that need to be done?
Is the child’s enuresis primary or secondary?
If it is stress related, should a specialist or therapist be consulted?
What type of treatment or modification do you recommend?
How effective is this treatment? Are there any alternative treatments?