What Is Enuresis? What Is Nocturnal Bedwetting?

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Main Category: Urology / Nephrology
Also Included In: Pediatrics / Children's Health;  Sleep / Sleep Disorders / Insomnia
Article Date: 04 Nov 2009 - 3:00 PDT

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Nocturnal enuresis, also known as nocturnal bedwetting or night-time incontinence is an inability to control urination during sleep, often referring to people who are old enough to be able to exercise urinary control. It is a common childhood condition, especially among young children. According to pediatricians, nocturnal bedwetting is one of the most common reasons parents ask for medical help. Most experts say that childhood bedwetting under the ages of 5 or 6 is normal; the child may still be undergoing the development of bladder control

In most countries an average girl will remain dry at night by the age of six, and boys by the age of 7. By the age of 10 years 95% of children stay dry at night. Adult bedwetting, according to the National Health Service (NHS), UK is between 0.5% and 2%.

There are two main types of enuresis:

• Nocturnal enuresis - this is bedwetting. Urination during sleep. 75% of cases are boys.
• Diurnal enuresis - this is daytime wetting. This is more common in girls than boys.

According to Medilexicon's medical dictionary:

Enuresis is urinary incontinence during sleep.

Nocturnal enuresis is classed in two ways:

• PNE (primary nocturnal enuresis) - the child has not yet had a prolonged dry period.
• SNE (secondary nocturnal enuresis) - the child is bedwetting again after a prolonged dry period (usually 6 months or more)

Experts stress that nocturnal enuresis is simply a developmental delay, and not, as many people wonder, primarily an emotional problem or physical illness. Only about 1 or 2 in every 20 bedwetting cases that reach a doctor are linked to a specific medical condition.

If a close relative, such as a parent or sibling had nocturnal enuresis, there is a greater chance the child will have it as well.

Bedwetting is sometimes linked to childhood stress, such as bullying, marital problems, or domestic violence.

The embarrassment and worry by the child himself/herself and how the parents react to soggy sheets, may sometimes trigger a cycle of bedwetting-embarrassment-worry-and more bedwetting. Parents should know that bedwetting is common and is part of normal development. The child should be comforted and encouraged to think that everything is OK, and not made to feel guilty or embarrassed.

What are the signs and symptoms of enuresis?

A symptom is something the patient reports and feels, while a sign is something other people, including a doctor may detect. For example, a headache may be a symptom, while a rash may be a sign.

The signs of bedwetting are straightforward; the child urinates in bed during sleep.

Parents should not be concerned if the child is aged up to six years (perhaps seven years for boys). If by this age the bedwetting is occasional, and the intervals or wet episodes are tending to get longer, the child is probably developing normally.

If the child has SNE - after a long dry period bedwetting starts to become regular again - and is over 6 or 7 years of age, the parent may want to consider talking to their GP (general practitioner, primary care physician).

Doctors say that in most cases the bedwetting is not the problem, but rather how the child or family member reacts to bedwetting. In other words, the child's or family member's reaction to bedwetting determines whether or not it is a problem.

What are the causes of enuresis?

Humans who do not wet their beds, stay dry for two reasons:

• A anti-diuretic hormone is produced during sleep which reduces urine production. The hormone is called AVP (arginine vasopressin). At about sunset each day the human body starts releasing ACP, which reduces kidney urine output. The bladder is less likely to get full during the night. Most children develop this hormone cycle between the ages of 2 and 6 years - some may take longer. The longer a child takes, the more likely they will continue bedwetting for longer.
• If the bladder is full during sleep, the person wakes up to go to the toilet. Most children develop this ability at about the same time as when the AVP hormone cycle starts. If the child is a very deep sleeper, or if the nerves around the bladder are not yet developed enough (or a combination of the two), it may take a while before he/she wakes up when the bladder is full.

During the process of becoming dry at night, a child develops these processes (hormone cycle and waking up when the bladder is full). Experts say some hereditary factors may influence when these two processes become completely active.

In some cases the child's bladder may not have developed enough - it is still too small and cannot hold much urine.

Persistent constipation can increase the risk of bedwetting.

A child whose parents did not have nocturnal enuresis has only a 15% risk developing the condition. When both parents were bedwetters as children, the probability for the child is 77% (for just one parent, the risk is 44%). Genetic studies reveal that bedwetting is linked to the genes on chromosomes 13q and 12q, and possible two others.

Extreme stress can cause bedwetting, such as bullying, a death in the family, sexual abuse, or domestic violence.

Caffeine, which exists not only in coffee but many fizzy drinks, increases urine production.

In extremely rare cases there might be a link to a food allergy. Experts say further research is needed to confirm the existence of a link.

How is enuresis diagnosed?

Parents should only seek medical help if there is compelling evidence that there may be a health problem, or the child's is extremely distressed.

The GP (general practitioner, primary care physician), usually the first person the child will see, will ask questions regarding the frequency of bedwetting, the child's fluid intake before bedtime, how the child is coping emotionally and mentally, and whether there may be anything, such as bullying which may be worrying the child.

The doctor may also ask the parent whether he/she or/and the other parent was a bedwetter as a child.

The doctor will also check the child's medical history and look out for any incidents of urinary tract infection.

The doctor may carry out a physical examination. If the he/she suspects there may be a structural (anatomical) problem, imaging scans may be ordered.

A urine test may be ordered to rule out possible underlying medical conditions linked to bedwetting, such as diabetes.

What is the treatment for enuresis?

If the doctor has ruled out a physical abnormality or underlying disease, they will advise the parents to wait and offer the child comfort and support. In the vast majority of cases the problem will resolve without treatment.

In the UK, treatment is most definitely not recommended for children under the age of 5 years, and is only considered for children between 5 and 7 if the impact on the child is significant, or the child, parent and doctor believe they are old enough to cope with treatment.

If the child is over the age of 7 and the bedwetting occurs frequently, and the problem is having a significant impact on the child (and the family), then treatment may be considered.

Enuresis alarms - this is a tiny sensor which is attached to the child's underwear. As soon as it senses wetness it makes a noise and wakes up the child. After a while the child will eventually most likely wake up automatically when his/her bladder is full. Some sensors vibrate as well.

Medication - desmopressin tablets are sometimes prescribed. The doctor may recommend this medication if the child is going away for a few days, perhaps a sleepover, a school trip, or camping. Desmopressin makes the kidneys produce less urine during the night. It is very important that the child and parents follow the doctors instructions carefully.

Absorbent underwear - these may reduce embarrassment and give the child some control over his/her bedwetting.

Dealing with bedwetting

While normal fluid intake during the daytime is essential for good health, cut out all caffeinated drinks during the afternoon/evening.

A couple of hours before bedtime encourage the child to drink less. But make sure his/her daily total fluid intake is adequate.

Before falling asleep the child should have emptied his/her bladder.

Going to the toilet at night should be stress-free and easy. If the child is afraid of the dark, have a dim light on in the hall.

Have a waterproof sheet to protect the mattress.

If the child is older and is able to make their own bed. Offer them the choice of doing so if they wake up in the night and their bed is wet. Make sure they have a clean set of sheets, etc., nearby, and a laundry basked to place the wet linen.

Be neutral, matter-of-fact about bedwetting. If it occurs and the child wakes you up at night, comfort them, remake the bed, and put them to sleep normally. Do not make a big thing of it. Say everything is and will be OK and that it is not a big deal.

Written by Christian Nordqvist


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