What Is Bedwetting?
Bedwetting, or nocturnal enuresis, refers to the unintentional passage of urine during sleep. Enuresis is the medical term for wetting, whether in the clothing during the day or in bed at night. Another name for enuresis is urinary incontinence.
For infants and young children, urination is involuntary. Wetting is normal for them. Most children achieve some degree of bladder control by 4 years of age. Daytime control is usually achieved first, while nighttime control comes later.
The age at which bladder control is expected varies considerably.
- Some parents expect dryness at a very early age, while others not until much later. Such a time line may reflect the culture and attitudes of the parents and caregivers.
- Factors that affect the age at which wetting is considered a problem include the following:
- The child's gender: Bedwetting is more common in boys.
- The child's development and maturity
- The child's overall physical and emotional health. Chronic illness and/or emotional and physical abuse may predispose to bedwetting.
Bedwetting is a very common problem.
- Parents must realize that enuresis is involuntary. The child who wets the bed needs parental support and reassurance.
Bedwetting is a treatable condition.
- While children with this embarrassing problem and their parents once had few choices except waiting to "grow out of it," there are now treatments that work for many children.
- Several devices, treatments, and techniques have been developed to help these children stay dry at night.
What Causes Bedwetting?
While bedwetting can be a symptom of an underlying disease, the large majority of children who wet the bed have no underlying illness. In fact, a true organic cause is identified in only a small percentage of children who wet the bed. However, this does not mean that the child who wets the bed can control it or is doing it on purpose. Children who wet the bed are not lazy, willful, or disobedient.
There are two types of bedwetting: primary and secondary. Primary bedwetting refers to bedwetting that has been ongoing since early childhood without a break. A child with primary bedwetting has never been dry at night for any significant length of time. Secondary bedwetting is bedwetting that starts again after the child has been dry at night for a significant period of time (at least six months).
In general, primary bedwetting probably indicates immaturity of the nervous system. A bedwetting child does not recognize the sensation of the full bladder during sleep and thus does not awaken during sleep to urinate into the toilet.
The cause is likely due to one or a combination of the following:
- The child cannot yet hold urine for the entire night.
- The child does not waken when his or her bladder is full. Some children may have a smaller bladder volume than their peers.
- The child produces a large amount of urine during the evening and night hours.
- The child has poor daytime toilet habits. Many children habitually ignore the urge to urinate and put off urinating as long as they possibly can. Parents are familiar with the "potty dance" characterized by leg crossing, face straining, squirming, squatting, and groin holding that children use to hold back urine.
Secondary bedwetting can be a sign of an underlying medical or emotional problem. The child with secondary bedwetting is much more likely to have other symptoms, such as daytime wetting. Common causes of secondary bedwetting include the following:
- Urinary tract infection: The resulting bladder irritation can cause lower abdominal pain or irritation with urination (dysuria), a stronger urge to urinate (urgency), and frequent urination (frequency). Urinary tract infection in children may in turn indicate another problem, such as an anatomical abnormality.
- Diabetes: People with type I diabetes have a high level of sugar (glucose) in their blood. The body increases urine output as a consequence of excessive blood glucose levels. Having to urinate frequently is a common symptom of diabetes.
- Structural or anatomical abnormality: An abnormality in the organs, muscles, or nerves involved in urination can cause incontinence or other urinary problems that could show up as bedwetting.
- Neurological problems: Abnormalities in the nervous system, or injury or disease of the nervous system, can upset the delicate neurological balance that controls urination.
- Emotional problems: A stressful home life, as in a home where the parents are in conflict, sometimes causes children to wet the bed. Major changes, such as starting school, a new baby, or moving to a new home, are other stresses that can also cause bedwetting. Children who are being physically or sexually abused sometimes begin bedwetting.
- Sleep patterns: Obstructive sleep apnea (characterized by excessively loud snoring and/or choking while asleep) can be associated with enuresis.
- Pinworm infection: characterized by intense itching of the anal and/or genital area.
- Excessive fluid intake.
Bedwetting tends to run in families. Many children who wet the bed have a parent who did, too. Most of these children stop bedwetting on their own at about the same age the parent did.
What Are Risk Factors for Bedwetting?
Risk factors for the development of enuresis include
- male gender and family history;
- medical conditions such as abnormal anatomy or function of the kidneys, bladder, or neurologic system;
- sleep apnea;
- chronic constipation;
- sexual abuse;
- excessive fluid intake before bedtime;
- urinary tract infection; and
- some medications (for example, caffeine).
What Symptoms May Be Associated With Bedwetting?
Most people who wet their beds, wet only at night. They tend to have no other symptoms other than wetting the bed at night.
Other symptoms could suggest psychological causes or problems with the nervous system or kidneys and should alert the family or health-care provider that this may be more than routine bedwetting.
- Wetting during the day
- Frequency, urgency, or burning on urination
- Straining, dribbling, or other unusual symptoms with urination
- Cloudy or pinkish urine, or blood stains on underpants or pajamas
- Soiling, being unable to control bowel movements (known as fecal incontinence or encopresis)
Frequency of urination is different for children than for adults.
- While many adults urinate only three or four times a day, children urinate much more frequently, in some cases as often as 10-12 times each day.
- "Frequency" as a symptom should be judged in terms of what is normal for that particular child.
- Equally important, "infrequent voiding" (less than three times urinating/day) can be a sign of other underlying problems.
Fecal impaction may present as constipation. Both fecal impaction and constipation cause straining, which can injure the nearby urinary sphincters, muscles that control flow of urine out of the body.
- Fecal impaction occurs when feces becomes so tightly packed in the lower intestine (colon) and rectum that passing a bowel movement becomes very difficult or even impossible. When the stool is passed, it is often a painful experience.
- The hard, tightly packed feces in the rectum can press on the bladder and surrounding nerves and muscles, interfering with bladder control.
- Neither fecal impaction nor constipation is unusual in children.
- A strict bowel regimen utilizing dietary modification and/or over the counter medications can often alleviate bedwetting.
Sleep Apnea in Children
Sleep apnea is one of the sleep-related breathing disorders. These are disorders which include snoring on one end of the spectrum, and obstructive sleep apnea (OSA) on the other end. It is an extremely serious sleep pathology in which the child will struggle to breathe and possibly stop breathing due to enlarged tonsil and adenoid tissues that obstruct the child's upper airway.
What Specialists Treat Bedwetting?
Routine evaluation and management of both primary and secondary enuresis should be in the domain of a pediatrician or family practice physician. If a complex cause for the child's enuresis is determined or if routine therapies are not helpful, a consultation with a pediatric urologist would be in order.
When Should a Child Seek Medical Care for Bedwetting?
The decision of when to involve your health-care professional is variable and is most commonly based on how the situation is affecting the child, as well as the parents. If the child displays only nighttime wetting without any other symptoms, then the decision about when to seek medical treatment is up to the family.
- It is probably a good time to seek medical help when the child is 5-7 years of age.
- Referral to a specialized enuresis clinic is likely not needed for most children with no other symptoms. This is a reasonable problem for the child's pediatrician to handle.
A child should be checked without delay for an underlying medical problem if he or she develops any other physical or behavioral symptoms.
What Exams and Tests Assess Bedwetting?
The health-care provider will ask many questions about the child's symptoms and about many other factors that can contribute to bedwetting. These include the following:
- The pregnancy and birth
- Growth and development, including toilet training (both urine and stool)
- Medical conditions. Specific attention is focused on the following:
- Wetness of underwear: indicates day and nighttime enuresis
- Palpating stool in the abdomen: indicates possible constipation or other obstruction
- Excoriation of genital or vaginal area: possible scratching due to pinworms
- Poor growth and/or high blood pressure: possible kidney disease
- Abnormalities of the lower spine: possible spinal cord abnormalities
- Poor urinary stream or dribbling: possible urinary abnormalities
- Medications, vitamins, and other supplements
- Family history if one or both parents were enuretic, approximately one-half to three-quarters of their offspring may also wet the bed. Identical twins are twice as likely to both be enuretic when compared to fraternal siblings.
- Home and school life: recent stress, how this problem is affecting the child and family, any attempts at therapy which have been tried
- Toilet habits: Record a voiding diary (daytime pattern and volume of urine, to determine bladder volume) and stool diary (to evaluate for constipation).
- Nighttime routines
- Diet, exercise, and other habits: Is there caffeine intake?
There is no medical test that can pinpoint the cause of primary enuresis. Secondary enuresis more commonly reflects underlying pathology and thus warrants laboratory and possibly radiologic evaluation.
- A routine urine test (urinalysis) usually is performed to rule out any urinary tract infection or kidney disease.
- An X-ray or ultrasound of the kidneys and bladder may be done if a physical problem is suspected. Occasionally, MRI examination of the lower spine/pelvis is indicated.
Generally, medical professionals divide bedwetting into uncomplicated and complicated cases.
- Uncomplicated cases consist of only bedwetting with no other symptoms, a normal urinary stream, and no daytime urination complaints or soiling. These children have a normal physical exam and urinalysis findings.
- Complicated cases may be any of the following: wetting in relation to another disease or condition, problems urinating, soiling or daytime urinary incontinence, or urinary tract infections. These children require further evaluation.
Children who have complicated bedwetting may be referred to a specialist in urinary tract problems (urologist) for further evaluation.
What Are Treatments for Bedwetting?
Bedwetting is typically seen more as a social disturbance than a medical disease. It creates embarrassment and anxiety in the child and sometimes conflict between parents. The single most important thing parents can and should do is to be supportive and reassuring rather than blaming and punishing. Primary nocturnal enuresis has a very high rate of spontaneous resolution.
The many treatment options range from home remedies to drugs, even surgery for children with anatomical problems.
- Underlying medical or emotional conditions should first be ruled out.
- If there is an underlying condition, it should be treated and eradicated.
- If bedwetting persists once these steps are taken, however, there is considerable debate as to how and when to treat.
Treatment of uncomplicated bedwetting is not appropriate for children younger than 5 years of age.
- Because a majority of children 5 years and older spontaneously stop bedwetting without any treatment, many medical professionals generally choose to observe the child until age 7.
- The age at which to treat, then, depends on the attitudes of the child, the parents/caregivers, and the health-care provider.
Are There Home Remedies for Bedwetting?
Here are some tips for helping your child stop wetting the bed. These are techniques that are most often successful.
- Reduce evening fluid intake. The child should try to not take excessive fluids, chocolate, caffeine, carbonated drinks, or citrus after 3 p.m. Routine fluids with dinner are appropriate.
- The child should urinate in the toilet before bedtime.
- Set a goal for the child of getting up at night to use the toilet. Instead of focusing on making it through the night dry, help the child understand that it is more important to wake up every night to use the toilet.
- A system of sticker charts and rewards works for some children. The child gets a sticker on the chart for every night of remaining dry. Collecting a certain number of stickers earns a reward. For younger children, such a motivational approach has been shown to provide significant improvement (14 consecutive dry nights) in most children with a low relapse rate (two wet nights out of 14).
- Make sure the child has safe and easy access to the toilet. Clear the path from his or her bed to the toilet and install night-lights. Provide a portable toilet if necessary.
- Some believe that you should avoid using diapers or pull-ups at home because they can interfere with the motivation to wake up and use the toilet. Others argue that pull-ups help the child feel more independent and confident. Many parents limit their use to camping trips or sleepovers.
The parents' attitude toward the bedwetting is all-important in motivating the child.
- Focus on the problem: bedwetting. Avoid blaming or punishing the child. The child cannot control the bedwetting, and blaming and punishing just make the problem more frustrating for all.
- Be patient and supportive. Reassure and encourage the child often. Do not make an issue out the bedwetting each time it happens.
- Enforce a "no teasing" rule in the family. No one is allowed to tease the child about the bedwetting, including those outside the immediate family. Do not discuss the bedwetting in front of other family members.
- Help the child understand that the responsibility for being dry is his or hers and not that of the parents. Reassure the child that you want to help him or her overcome the problem. If applicable, remind him that a close relative successfully dealt with this same issue.
- The child should be included in the clean-up process.
To increase comfort and reduce damage, use washable absorbent sheets, waterproof bed covers, and room deodorizers.
Self-awakening programs are designed for children who are capable of getting up at night to use the toilet, but do not seem to understand its importance.
- One technique is to have the child rehearse the sequence of events involved in getting up from bed to use the toilet during the night prior to going to bed each night.
- Another strategy is daytime rehearsal. When the child feels the urge to urinate, he or she should go to bed and pretend he or she is sleeping. He or she should then wait a few minutes and get out of bed to use the toilet.
Parent-awakening programs can be used if self-awakening programs fail. These programs should only be used at the child's request. Interruption of sleep should be a last resort.
- The parent should awaken the child, typically at the parents' bedtime.
- The child must then locate the bathroom on his or her own for this to be productive. The child needs to be gradually conditioned to awaken easily with sound only.
- When this is done for seven nights in a row, the child is either cured or ready for self-awakening programs or alarms.
Bedwetting alarms have become the mainstay of treatment.
- A majority of children stop bedwetting after using these alarms for 12-16 weeks.
- Some children start wetting the bed again when the alarm is discontinued (relapse). However, the positive response to reinstating the alarm system is rapid due to the behavioral conditioning experienced during the first treatment cycle. With persistence, this method works for a majority in the long run.
- These alarms take time to work. The child should use the alarm for a few weeks or even months before considering it a failure.
- There are two types of alarms: audio and tactile (buzzing) alarms.
- The principle is that the wetness of the urine bridges a gap in the sensor, which in turn sets off the alarm. The sensor is placed either on the child's underwear or bed pad.
- The child then awakens, shuts off the alarm, finishes urinating in the toilet, returns to the bedroom, changes clothes and the bedding, wipes down the sensor, resets the alarm, and returns to sleep.
- Alarms are preferred over medications for children because they have no side effects.
- It is generally believed that all children 7 years and older should be given a trial of an alarm.
- For the alarm to be effective, the child must desire to use it. Both the child and parents need to be highly motivated.
Beware of devices or other treatments that promise a quick "cure" for bedwetting. There really is no such thing. Stopping bedwetting is, for most children, a matter of patience, motivation, and time.
What Is the Medical Treatment for Bedwetting?
After an organic cause has been ruled out, there is no medical urgency to treat the child. Bedwetting tends to go away by itself. Discuss the treatment options with your child's health-care provider; together you can decide whether treatment is right for your child.
Several drug therapies are available.
- These are typically reserved for children who have not stayed dry by using the alarms.
- Adults with bedwetting often take medications. They may have to stay on the medication indefinitely.
- The drugs do not work for everyone, and they can have significant side effects.
- The two drugs have been approved by the U.S. Food and Drug Administration (FDA) specifically for bedwetting are desmopressin (DDAVP) and imipramine (Tofranil). Others, which are not specifically approved for bedwetting, are oxybutynin (Ditropan, Urotrol) and hyoscyamine (Cystospaz, Levsin, Anaspaz).
Medical opinion is divided on using drugs to treat bedwetting. Many believe that, since the child will outgrow the bedwetting anyway, the risks outweigh the benefits of taking the drugs.
Surgery for Bedwetting
Certain underlying medical or physical conditions may require surgery.
What Medications Treat Bedwetting?
Desmopressin acetate (DDAVP) is a synthetic form of antidiuretic hormone (ADH), a substance that occurs naturally in the body and is responsible to limiting the formation of urine.
- It has been in use for the treatment of bedwetting for about 10 years and is generally the first medication prescribed.
- This drug imitates ADH in the body, which is secreted by the brain; it increases the concentration of the urine and reduces the amount of urine formed. It is recommended to be taken just before going to bed.
- Its main use is for children who have not been helped by an alarm. It is also used as a stopgap measure to help children attend camps or sleepovers without embarrassment.
- DDAVP comes as a pill and is taken before bedtime. Side effects are uncommon but include headache, runny nose, nasal stuffiness, and nosebleeds. A previously manufactured nasal spray form is generally not used since it is more likely to be associated with potentially severe side effects.
- The dose is adjusted until effective. Once it is working, the dose is tapered if possible. About 25% of children with enuresis will have total dryness with desmopressin, while approximately 50% will have a significant decrease in bedwetting. When compared with alarm devices, however, approximately 60% of patients will return to bedwetting when DDAVP administration is stopped.
Imipramine is a tricyclic antidepressant that has been used to treat bedwetting for about 30 years.
- How it works is not clear, but it is known to have a relaxing effect on the bladder and to decrease the depth of sleep in the last third of the night.
- Initial cure rates range from 10%-60%, and it has a relapse rate of up to 80%.
- Side effects tend to be rare with correct dosage, but nervousness, anxiety, constipation, and personality changes have been reported.
- It can have toxic side effects if taken improperly or as an accidental overdose. Deaths have been attributed to accidental overdoses - most commonly associated with abnormal heart-rhythm patterns.
- It may be combined with desmopressin if desmopressin alone is not effective.
Oxybutynin and hyoscyamine are medications that reduce unwanted bladder contractions. They help relieve daytime urgency and frequency in addition to uncomplicated bedwetting. Their side effects include dry mouth, drowsiness, flushing, heat sensitivity, and constipation.
Is Bladder Training Effective for Bedwetting?
Bladder training exercises: These are useful for adults with bedwetting or other types of urinary incontinence. They do not usually work for children. A recent review of complementary and alternative medicine (CAM) therapies (for example, acupuncture, hypnosis, etc.) for bedwetting shows little encouragement for the use of these modalities.
What Follow-up Is Necessary After Treatment of Bedwetting?
For a child with an underlying medical or emotional cause for the bedwetting, the health-care provider will recommend an appropriate treatment for the underlying condition.
- If the treatment recommendations of the provider are followed closely, the bedwetting will stop in most cases.
- Keep in mind that for some underlying conditions, such as anatomical problems or emotional problems, the treatment may be complex and take some time.
Children with uncomplicated bedwetting usually "grow out of it" on their own.
- If you decide to try treatment, try to follow the recommendations of the child's health-care provider.
- Relapse rates can be high, but retreatment is typically successful.
- Your child's health-care provider will monitor the child's progress periodically. How often depends on how quickly the bedwetting improves and your comfort level with that rate.
- Commitment and motivation are needed if the treatment is to be successful.
What Is the Prognosis for Bedwetting?
Bedwetting can damage the child's self-image and confidence. The best way to prevent this is to be supportive. Parents should reassure the child that bedwetting is a common problem and that they, the parents, are confident that the child will overcome the problem. If there is a family history of bedwetting (for example, the child's father), the child should be informed to help lessen any stigma.
Every year, a significant percentage of school-aged children who wet the bed become dry without specific treatment.
It is difficult to estimate the effectiveness of treatment, but cure rates range from 10%-60% with drugs to 70%-90% with alarms and parent awakening.
- Nearly all bedwetting problems can be cured with single or combination therapy.
- Some people do, however, need to have long-term drug therapy.
Bedwetting Support Groups and Counseling
American Foundation for Urologic Disease
1000 Corporate Blvd. Suite 410
Linthicum, MD 1090
National Association for Continence
62 Columbus Circle
Charleston, SC 29403
National Kidney Foundation
30 East 33rd St., Suite 1100
New York, NY 10016
The Simon Foundation for Continence
PO Box 815
Wilmette, IL 60091
Where Can People Find More Information on Bedwetting?
National Kidney and Urologic Diseases Information Clearinghouse, National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), National Institutes of Health, http://www.niddk.nih.gov/
The Simon Foundation for Continence, http://www.simonfoundation.org/
Urology Health.org - Public information Web site produced by the American Urological Association and the American Foundation for Urologic Disease, http://www.urologyhealth.org/