What Is Enuresis? What Is Nocturnal Bedwetting?

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

email to a friend   printer friendly   view / write opinions   rate article

Bedwetting is a common childhood condition. It occurs when there is an accidental loss of urine during sleep. Bedwetting is also known as nocturnal enuresis or nighttime incontinence. It is normal in children who are under five years old. At this age, nighttime bladder control may not be established.

Bedwetting is the most common pediatric-health issue. Studies show that parents become worried too quickly because they expect children to stay dry too early. Most girls can stay dry by age six and most boys stay dry by age seven.

According to Medilexicon's medical dictionary, Enuresis is "urinary incontinence during sleep."

Bedwetting is often caused by an overactive bladder, but it can be the result of problems with the development of the bladder. It can also be due to a neurological disorder (disorders of the brain and nervous system).

There are two types of bedwetting:

• Primary nocturnal enuresis: persistent, involuntary bedwetting during sleep in a child aged five or over.
• Secondary nocturnal enuresis: in some cases bedwetting comes back after a dry period of at least six months.

It is often linked to a stressful event, such as bullying at school, or the divorce of a child's parents.

Bedwetting can be a disruptive and stressful condition. When a child wets the bed, it is important for the parents to know that the child has no control over it. They should not be punished since this can have harmful psychological effects, such as lowering their self-esteem.

A child usually wets the bed because the amount of urine that they produce is more than their bladder can hold. They do not wake up even though their bladder is full.

Bedwetting usually stops when the child gets older, because:

• Their bladder capacity increases
• They learn to wake up when their bladder is full
• They produce less urine at night

Almost all children stop wetting the bed, often without treatment. Approximately 1% will continue to wet the bed into adulthood.

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.

Bed-wetting is characterized by involuntary urination at night.

By age four, most kids are fully toilet trained. However, there is no precise date for developing complete bladder control. By age five, bed-wetting remains a problem for only about 15 percent of children. Between 8 and 11 years of age, fewer than 5 percent of children are still bed-wetting.

In some cases, bed-wetting may indicate an underlying condition that needs medical attention.

Get medical advice if:

• Child still wets the bed on a regular basis after age five or six.
• Child starts to wet the bed after a period of being dry at night.
• Bed-wetting is accompanied by painful urination, unusual thirst, pink urine or snoring.

What are the causes of enuresis?

The causes of bed-wetting are not clear, but various factors may play a role:

A hormone imbalance. During childhood, some children do not produce enough anti-diuretic hormones (ADH) to slow nighttime urine production.

A small bladder. The child's bladder may not be developed enough to hold urine produced during the night.

Child is unable to recognize a full bladder. If the nerves that control the bladder are slow to mature, a full bladder may not rouse the child from sleep, especially if the child is a deep sleeper.

Chronic constipation. A lack of regular bowel movements may lead to reduced bladder capacity, which can cause bed-wetting at night.

Congenital abnormalities (present at birth) such as an ectopic ureter.

Diabetes. For a child who is usually dry at night, bed-wetting may be the first sign of diabetes. Other signs and symptoms may include passing large amounts of urine at once, increased thirst, fatigue and weight loss.

Fluid intake. Bedwetting may simply be caused by drinking too much fluid.

Neurological disorders such as spina bifida (a condition that affects the development of the spine and nervous system).

Overactive bladder. This is when the bladder squeezes out urine before it is full. It often causes urge incontinence.

Sleep apnea. In some cases, bed-wetting is a sign of obstructive sleep apnea, a condition in which the child's breathing is interrupted during sleep. Other signs and symptoms may include snoring, frequent ear and sinus infections, sore throat, and daytime drowsiness.

Stress. Stressful events (such as the arrival of new baby in the family, starting a new school, sleeping away from home..) may trigger bed-wetting. It is a sign that the child is upset or worried.

Urinary tract infection. A urinary tract infection can make it difficult for a child to control urination. Signs and symptoms may include bed-wetting, daytime accidents, frequent urination and pain during urination.

What are the risk factors of enuresis?

A risk factor is something which raises the likelihood of developing a disease or condition. For example, obesity increases the risk of developing diabetes type 2; therefore, obesity is a risk factor for diabetes.

Several factors have been associated with an increased risk of bed-wetting, including:

Attention-deficit/hyperactivity disorder (ADHD). Bed-wetting is more common in children who have ADHD.

Family history. If both of a child's parents wet the bed as children, their child has an 80 percent chance of wetting the bed, too.

Gender. It can affect anyone, but is more common in boys.

How is enuresis diagnosed?

Seek medical advice if:

• Child is wetting the bed at night (nocturnal enuresis) on a regular basis.
• Child is feeling distressed about their bedwetting.

Assessing nocturnal enuresis

During medical evaluation, these questions will be asked:

• How often does bedwetting occur?
• How much fluid does the child drink before going to bed?
• How well are the parents and the child coping with the problem?
• Is there anything bothering or worrying the child, (such as being teased or bullied)?
• Has the child had a urinary tract infection (UTI) or any other health conditions?

Ruling out underlying conditions

To find out whether the child's bedwetting is linked to a current infection or health condition, the doctor will carry out a physical examination. Depending on the circumstances, urine tests may be done to check for signs of an infection or diabetes. Sometimes a blood test may be ordered. If the doctor suspects an anatomical abnormality or other problems, the child may need X-rays or other imaging studies of the kidneys or bladder.

What is the treatment for enuresis?

Most children outgrow bed-wetting on their own. If there is a family history of bed-wetting, the child will probably stop bed-wetting around the age the parent stopped bed-wetting.

Generally, treatment depends on the child's reaction to bed-wetting and its impact on the family. If bothered or embarrassed, he or she may be more motivated to try additional treatments. The decision to go ahead with treatment should be made jointly by the child's parents and the child. The type of treatment will depend on the child's situation, such as their age and previous bedwetting history, as well as any underlying conditions that may be causing it. Treatment for bedwetting is not recommended for children under five.

Moisture alarms or Enuresis alarms

Enuresis alarms are considered to be the best form of long-term treatment for bedwetting. This is usually preferred to the use of a medication.

They are small, battery-operated devices and are available without a prescription at most pharmacies. A moisture-sensitive pad is connected to the child's pajamas or bedding. When the pad senses wetness, the alarm goes off. Ideally, the moisture alarm sounds just as the child begins to urinate and in time to help the child wake-up. If the child is a heavy sleeper, another person may need to listen for the alarm.

It often takes at least two weeks to see any type of response and up to twelve weeks to stop enuresis. Moisture alarms are highly effective, carry a low risk of relapse or side effects, and may provide a better long-term solution than medication does. Over time, an enuresis alarm can help the child to recognize when their bladder is full and it is time to wake up to go to the toilet.

After fourteen consecutive dry nights with increased fluid intake, the child can stop using the enuresis alarm. If bedwetting reoccurs after stopping the use the alarm, start using it again.

Medication

In some cases, medication may be prescribed to stop bed-wetting. There are various types of medication:

Slow nighttime urine production. The drug desmopressin acetate (DDAVP) boosts levels of a natural hormone (anti-diuretic hormone, or ADH) that forces the body to make less urine at night. Although DDAVP has few side effects, the most serious is a seizure. This can happen if the medication is accompanied by too many fluids. For this reason it is advised not use this medication on nights when the child has had a lot of fluids. A short course of desmopressin may be prescribed for a child if they need to spend some nights away from home, for example if they are going on holiday abroad or on a school trip.

The bladder. If the child has a small bladder, an anticholinergic drug such as oxybutynin (Ditropan) or hyoscyamine (Levsin) may help reduce bladder contractions and increase bladder capacity. Side effects may include dry mouth and facial flushing.

Child's sleeping and waking pattern. The antidepressant imipramine (Tofranil) may provide bed-wetting relief by changing a child's sleeping and waking pattern. The medication may also increase the amount of time a child can hold urine or reduce the amount of urine produced. Imipramine has been associated with mood changes and sleep problems. Caution is essential when using this medication, because an overdose could be fatal. This medication is generally recommended only when other treatments have failed.

Oxybutynin is not recommended, because it has been found to be ineffective in treating bedwetting that is not caused by bladder instability.

Sometimes a combination of medications is most effective. However, frequent bed-wetting resumes when the medication is stopped. If the child's bedwetting does not improve after trying individual treatments, a combination of treatments, such as an enuresis alarm and desmopressin may be recommended. However, there is no evidence to confirm whether combining treatments produces a more effective outcome.

Absorbent Underwear

Diapers or pull up absorbent underwear are commonly used by all ages of bedwetters. Protective underwear may reduce embarrassment and make cleanup easier. This can reduce stress on both the bedwetter and caregivers. Absorbent underwear can be especially beneficial for children wishing to attend sleepovers or campouts. It reduces emotional problems caused by social isolation and embarrassment in front of peers.

Dry bed training

Dry bed training consists of a strict schedule of waking the child at night, attempting to condition the child into waking by himself/herself. However, studies show this training is ineffective by itself.

What are the complications of enuresis?

The guilt and embarrassment a child feels about wetting the bed can lead to low self-esteem. However, bed-wetting without a physical cause does not pose any health risks.

Bedwetting children face problems ranging from being teased by siblings, being punished by parents, and being afraid that friends will find out.

The amount of psychological harm depends on whether the bedwetting harms self-esteem or development of social skills. Important factors are:

• Anger, punishment, and rejection by caregivers
• How long the child has been wetting
• How much the bedwetting limits social activities (sleep-overs, campouts...)
• The degree of the social ostracism by peers
• The number of failed treatment attempts

Rashes on the bottom and genital area may appear if the child sleeps in wet underwear. To prevent a rash, help the child rinse his or her bottom and genital area every morning.

How to prevent enuresis?

A few changes at home may help:

Limit fluid intake in the evening. Around 8 ounces (about a quarter of a liter) in the evening is generally enough. Some experts recommend for children to have 40 percent of their liquids between 7 a.m. and noon, another 40 percent between noon and 5 p.m. and just 20 percent of their daily fluids after 5 p.m. However, do not limit fluids if the child is participating in sports practice or games in the evenings.

Avoid beverages and foods with caffeine in the evening. Caffeine may increase the need to urinate. Limit cola or snacks that have caffeine, such as chocolate, in the evening.

Routine before bedtime. Urinating at the beginning of the bedtime routine and then again just before falling asleep. The child should know it is alright to use the toilet during the night if needed. Use small night lights so that the child can easily find the way between the bedroom and bathroom. Ensure that the child has easy access to the toilet at night.

Encourage regular urination throughout the day. During the day and evening, suggest that the child urinate once every two hours, or at least enough to avoid a feeling of urgency.

Treat constipation. Doctor may recommend an over-the-counter stool softener if needed.

Use waterproof covers on the mattress and duvet, and absorbent, quilted sheets. After a bedwetting, use cold water or mild bleach to rinse bedding and nightclothes and then wash them as usual.

Change bedding. Following a bedwetting, older children may wish to change their bedding at night to minimize disruption and embarrassment. Keep clean bedding and nightclothes available for them.

Attitude. To minimize the child's embarrassment, show a neutral attitude to bedwetting. Do not blame the child for wetting the bed. Take positive steps.

No punishment. Do not punish the child for wetting the bed. Doing so can make things worse by humiliating them and lowering their self-esteem.

Use a reward system. Such as a star chart to encourage positive behavior. Reward the child for behavior that helps to stay dry at night, such as drinking plenty of fluids during the day, or getting up to use the toilet at night.

Alternative medicine

In some cases, trying alternative therapies to treat bed-wetting, such as hypnosis and acupuncture, appear to be somewhat effective. However, currently there is no evidence to support the use of other therapies.

Acupuncture. The insertion of fine needles in specific parts of the body. Results of multiple studies have found that acupuncture is effective for some children.

Chiropractic. Chiropractic therapy suggests that if the spine is out of alignment, normal bodily functions will be affected. However, convincing evidence is lacking regarding the use of chiropractic for the treatment of bed-wetting.

Diet. It is believed that certain foods adversely affect bladder function and that removing these foods from the diet could help decrease bed-wetting. There is limited research and more study is needed.

Homeopathy and herbs. Some people are interested in homeopathic remedies and herbal products. However, none of these has been proven effective in clinical trials. Always check with a doctor before giving it to a child. Some of the ingredients may interact with other medications the child is taking.

Hypnosis. Hypnosis coupled with suggestions of waking up in a dry bed or visiting the toilet in the night may help some children stay dry throughout the night.

A child's bed-wetting is involuntary; therefore it is unfounded to punish them. Parents have to be patient and work through the problem together with the child.

Celebrate effort. Do not punish or tease the child for wetting the bed. Instead, praise the child for following the bedtime routine and helping clean up after accidents.

Child's feelings. If the child is stressed or anxious, encourage him or her to express those feelings.

Child's help. Perhaps the child can get involved in the cleaning up. Taking responsibility for bed-wetting may help the child feel more control over the situation.

Preparation for easy cleanup. Cover the child's mattress with a plastic cover, use absorbent underwear at night to help contain the urine, keep extra bedding and pajamas handy.

With patience, reassurance, encouragement and understanding, your child will overcome bed-wetting.

Written by Stephanie Brunner (B.A.)


Copyright: Medical News Today
Not to be reproduced without permission of Medical News Today