Pediatric Nocturnal Enuresis (Bedwetting)

Nocturnal enuresis, or bedwetting, is a common problem of childhood. Bedwetting is not a serious medical disorder, but it can be very difficult to live with. Wetting the bed may interfere with a child’s socialization and it can lead to significant stress within the family.1 This review, while not exhaustive, will describe the main causes and treatments for bedwetting.

Definitions

Nocturnal enuresis refers to the involuntary passage of urine during sleep. The frequency of wetting that is necessary to be considered enuretic varies among authors. The American Psychiatric Association defines enuresis as wetting two or more times per week for at least three consecutive months in children over the age of five.2 The World Health Organization defines enuresis as wetting twice per month (under 7 years) or once per month (over 7 years).3 Primary nocturnal enuresis is defined as bedwetting in an individual who has never been dry for six consecutive months. Secondary nocturnal enuresis is defined as bedwetting in an individual who was dry for six consecutive months and then started wetting again. A small percentage of bedwetters have wetting episodes when they are awake. Diurnal enuresis, or incontinence, are the terms used to describe this situation.

Prevalence and Natural History

Nocturnal enuresis affects approximately 5 million children in the United States.4 In population-based cross-sectional studies on children between 6 and 12 years of age, a prevalence of 0.2-9.0% (daytime incontinence)44-46, 1.5-2.8% (combined daytime and nighttime incontinence)45,47,48, and 1.5-8.9% monosymptomatic nocturnal enuresis49, respectively, have been reported.50 It is well known that nocturnal enuresis resolves over time. Every year 15% of those suffering from bedwetting become dry without treatment.5 The following table illustrates what percentages of children have nocturnal enuresis as a function of age.

Percentage of Children That Wet the Bed According to Age:

Age ................... Percentage
5-year-olds ................... 20%
6-year-olds ................... 12%
7-year-olds ................... 10%
8-year-olds ................... 7%
9-year-olds ................... 6%
10-year-olds ................... 5%
11-year-olds ................... 4%
12-year-olds ................... 3%
13-year-olds ................... 2-1/2%
14-year-olds ................... 2%
15-year-olds ................... 1-1/2%
16-year-olds ................... 1%

 

From Bennett H.J. Waking Up Dry: A Guide to Help Children Overcome Bedwetting. Elk Grove Village, IL: American Academy of Pediatrics. All rights reserved. Used with permission.

Background

Psychological Considerations

The most difficult aspect of nocturnal enuresis is its effect on a child’s self-esteem.6,7 Bedwetting can be a source of embarrassment for children causing them to refrain from certain age-appropriate activities such as sleepovers. Parents may become frustrated with their child’s wetting because it is a drain of time, energy, and money.8 Some parents punish their children in response to their bedwetting.

How Urination Occurs

Urine is produced by the kidneys and travels through tubes called the ureters to the bladder for storage (see figure 1). The bladder is a muscular sac that holds urine until it is ready to be released into the urethra, the tube that connects the bladder to the outside of the body. The bladder is emptied when the urinary sphincter relaxes and the detrusor muscle (within the bladder wall) contracts. The relaxed sphincter acts like an open door that allows the urine to leave the body. For successful urination, both the detrusor muscle contraction and sphincter relaxation must occur at the same time. This process is not under voluntary control.

The communication between the nerve and muscle groups that link the bladder and the brain is very complicated, thus explaining the different ages at which children become dry.

The following timetable shows the development of bladder control:

  • Ages birth-18 months: The child is unaware of bladder filling or emptying.
  • Ages 18-24 months: The child has a conscious sensation of bladder emptying.
  • Ages 2-3: Most children develop the ability to voluntarily stop urination and develop appropriate toileting skills.
  • Ages 3-5:  Most children have achieved urinary control and are dry both day and night.

Learning to Become Dry At Night

Most children become dry at night between 3 and 5 years of age. Children attain nighttime dryness in two ways. First, if the bladder sends a signal to the brain saying that it is filling up with urine, the brain sends a signal back telling the bladder to relax so it can hold more urine. Second, if the bladder cannot hold all of the urine until morning, it continues to signal the brain until the child wakes up and goes to the bathroom. Bedwetting occurs because of a delay in learning one or both of these skills.10

Causes of Nocturnal Enuresis

Although there are many factors that contribute to nocturnal enuresis, most children do not have a disease process that explains their bedwetting.

Genetic Considerations

Formal studies have documented the importance of heredity in enuresis. The risk of a child having nocturnal enuresis is 44% and 77% if one or both parents, respectively, wet the bed as children.11

Reduced Bladder Capacity

Children with nocturnal enuresis often have a small bladder capacity compared to their peers.12 Children with small bladders urinate more often during the day and sometimes have to run to the bathroom to avoid having accidents. When these children sleep at night, their bladders are less able to hold all of their urine until morning. Interestingly, when children with small bladders are examined under anesthesia, their bladders are normal in size. This means that the bladder is not anatomically smaller, but the child has the sensation that the bladder is full before it really is. The medical term for this condition is a small functional bladder capacity.

Increased Nighttime Urine Production

The brain releases a hormone at night called vasopressin that reduces the amount of urine the kidneys make. (It does this by reabsorbing water from the urine back into the bloodstream.) Decreased urine production at night allows an individual to sleep till morning without having to urinate. Although the research in this area is inconclusive, it appears that some children wet the bed because they do not make enough of this hormone.13

Arousal Disorder

For many years, it was thought that children wet the bed in deep states of sleep. However, recent research has shown that children wet the bed in all sleep states.14 These studies have demonstrated that some children do not respond to their internal bodily signals while they sleep. Children with nocturnal enuresis are unable to arouse from sleep when the bladder reaches its maximum capacity.15

Constipation

Most parents pay little attention to the frequency or consistency of their children’s stools once they are toilet trained. As a result, constipation is an under recognized cause of bedwetting.10 If a child has a lot of stool in his rectum, it may push against the bladder. This can “confuse” the nerve signals that go from the bladder to the brain. A full rectum may also reduce how much urine the bladder can hold or how well the bladder empties when a child urinates. Treatment of constipation alone can either reduce or cure bedwetting.16

Psychological Factors

Although children may develop secondary enuresis after an episode of emotional stress, psychological problems do not cause primary nocturnal enuresis.10 Examples of stressful situations that can trigger bedwetting include moving to a new home, changing schools, the death of a loved one, or being sexually abused. The wetting usually resolves when the stress passes.

Sexual Abuse

Sexual abuse may be a factor in children with bed-wetting issues who may have previously outgrown the issue.  Other signs that might point out sexual abuse could be chronic urinary tract infections, discharge due to a sexually transmitted infection, vaginal itching or pain, frequent visits to the school nurse, or bedwetting that resurfaces.51

If you find physical signs that you suspect are sexual abuse, have the child examined immediately by a professional who specializes in child sexual abuse. Sexual Assault Nurse Examiners (SANEs) are registered nurses who have specific training in physical examinations for sexual assault victims.  Go to www.sane-sart.com to learn more.  Children's Advocacy Centers provide child-friendly, safe places for abused children and their families to seek help.  Contact the National Children's Alliance at www.nca-online.org or call 1-800-239-9950.

Medical Conditions That Cause Nocturnal Enuresis

Less than 3% of children with nocturnal enuresis have a medical disorder that underlies their wetting, and a careful medical history, examination, and urine analysis will uncover these problems. Bedwetting has been reported with sleep apnea,17 sickle cell disease,18 urinary tract infections,19 diabetes,20 and neurological problems.21 Medical disorders are more likely to present with secondary nocturnal enuresis.

Treatment

What To Do If A Child Has Nocturnal Enuresis

Before discussing the treatment of nocturnal enuresis, there are two important things to keep in mind. First, children do not wet the bed on purpose. Second, most pediatricians do not consider bedwetting to be a problem until a child is at least six years of age.10

Communicate With The Doctor

A recent study showed a significant communication breakdown between parents and doctors on this issue.22 While 80% of parents want healthcare providers to discuss bedwetting, most feel uncomfortable initiating the discussion themselves. Furthermore, 68% of parents said their children's doctor has never asked about bedwetting at routine visits. Therefore, parents need to be more proactive by asking for help if they have a child who is wet at night.

How To Tell If A Child Is Motivated To Become Dry

There is no magic age when children are ready to work on their wetting, however, most children show some concern about the problem by the time they are 6- to 7-years-old.

There are five signs parents can look for to see if their child is ready to work on becoming dry:

  • He starts to notice that he is wet in the morning and doesn’t like it.
  • He says he does not want to wear pull-ups anymore.
  • He says he wants to be dry at night.
  • He asks if any family members wet the bed when they were children.
  • He does not want to go on sleepovers because he is wet at night.

Steps Parents Can Take To Help Children Feel Better About Themselves

There are a number of things parents can do to reduce the stress associated with nocturnal enuresis.23

  • Remind children that bedwetting is no one’s fault.
  • Let children know that lots of kids have the same problem.
  • Do not punish or shame children for being wet at night.
  • Make sure the child’s siblings do not tease him about wetting the bed.
  • Let children know if anyone in the family wet the bed growing up.
  • Maintain a low-key attitude after wetting episodes.
  • Reinforce any efforts the child makes to help with his wetting, e.g. stripping the bed or helping parents carry wet bedding to the laundry room.
  • Praise the child for success in any of the following areas: waking up at night to urinate, having smaller wet spots, having a dry night.

Use Information That Children Understand

Although there is a lot of information available on bedwetting, there are few sources that present the material in a child-friendly way.10 For example, while it is easy for adults to appreciate what it means that 5 million children in the United States have nocturnal enuresis, this number is too big for children to understand. The following example is a more effective way to communicate this information to children: The average professional baseball stadium holds 50,000 fans. Therefore, if you invited 5 million children to see a professional baseball game, you would need 100 stadiums to find them all seats. Using school-based statistics is another way to help children understand how common bedwetting is 10% of elementary school and 3% of middle school children have nocturnal enuresis. Parents can apply these statistics to their own circumstances. For example, if an 8-year-old attends a school with 480 children, his parents can reassure him that there are 48 kids in the school that have the same problem he does.

Should Parents See a Specialist?

In most cases, a child’s regular healthcare provider will be able to treat his bedwetting. However, if parents are not getting the help they need in this setting, there are a number of specialists that have an interest in bedwetting. Pediatric urologists are surgeons that specialize in the urinary tract. They are experts in bedwetting and spend a lot of their time helping children become dry. Urologists are particularly skilled helping children with complicated types of wetting. Pediatric nephrologists are pediatricians that specialize in kidney problems. They also know a lot about wetting problems. Child psychologists and child psychiatrists also treat children with nocturnal enuresis.

What To Expect At the Doctor’s Office

No one has studied how doctors approach bedwetting on a day-to-day basis, though in many cases the problem is probably brought up at routine checkups. However, because so much needs to be addressed at annual physicals, this may not be the ideal time to address the problem. Some doctors prefer to tackle bedwetting during separate visits where it can be addressed in more detail.10 In addition to obtaining a medical history, healthcare providers will examine the child and get a urine analysis. Blood tests and radiologic procedures are not routinely needed for the diagnosis and treatment of nocturnal enuresis.24

Effective management of nocturnal enuresis improves a child’s self-esteem.6 Treatment options will vary depending on the child’s age, the frequency of wetting, the impact on the family, and any symptoms that may be associated with the bedwetting.10 Both pharmacological and behavioral treatments exist. To better combat the problem, a combination of treatment modalities may be used if necessary. Unless an underlying medical cause is identified, primary and secondary bedwetting are treated the same way.25 The most important aspect of treatment is determining if the child is motivated to become dry. This is especially true for behavioral management.26 If it is determined that a child is not motivated to become dry, treatment should be postponed or simplified until the child is ready.10

Practical Management Tips

In addition to a treatment program, there are practical measures that parents can use to make it easier to live with bedwetting.

  • Mattress Covers: When a child wets the bed, urine can soak through the sheets and into the mattress. Over time, the mattress will begin to smell like urine. To prevent this from happening, parents should protect the mattress with a waterproof cover. Mattress covers protect the top and sides of the mattress or encase it completely. Parents can buy mattress covers at department stores or from medical supply companies that sell bedwetting products. Cheap mattress covers may crack or leak, so try to find one that is well made.
  • Absorbent Briefs: This product is a form of modified underwear that is built to absorb liquid, preventing leakage through to clothes or sheets. Both reusable and disposable products are available.
  • Odor Protection: Bedrooms can pick up a urine smell even if parents take care of wet beds promptly. The easiest way to handle odors is with room freshener. There are many types available, but they all work by putting a pleasant smell in the air. Room fresheners can be purchased at pharmacies and grocery stores. Another way to handle urine smells is to use a product that eliminates odors instead of masking them. These products come as sprays and solid odor absorbers and are available from medical supply companies.

Making It Easier to Deal with Wet Bedding

One way to make mornings easier is to put a protective pad on a child’s sheets. These products are called underpads, and they come in two basic styles: reusable and disposable. Reusable underpads have cloth on one side and a waterproof backing on the other. Disposable underpads have absorbent material on one side and a thin plastic layer on the other. The reusable type costs more to begin with, but they are less expensive over time because you wash them over and over. Disposable underpads are more expensive over time because they are used once and thrown away. Although they cost more in the long run, disposable underpads are easier to use because they do not have to be washed.

Underpads are sold in most pharmacies and from medical supply companies that carry incontinence products. Medical supply companies usually have a bigger selection and are less expensive because you buy things in bulk. Pharmacies have the advantage of being close to home.

Behavioral Treatment

  • Restricting Fluids:Limiting a child’s fluid intake after dinner is designed to reduce his urine production at night. This is accomplished by asking the child to refrain from overdrinking between dinner and bedtime. Although there is little data to support this approach, many parents find it an easy way to treat bedwetting. If parents choose this option, it is important not to severely restrict the child’s fluid intake because children may view this as a punishment, and it can lead to hostility within the family. Instead of restricting fluids, some authors prefer to have children meet their liquid needs by drinking more during the day.27
  • Nighttime Waking (Lifting): One of the techniques parents use to help children stay dry is to take them to the bathroom a few hours after they go to sleep. This technique is called lifting because in many cases children barely wake up and walk “zombie-like” to the bathroom. Some authors believe that lifting makes bedwetting worse because it conditions the bladder to empty at the same time each night rather than allowing the child to learn how to recognize a full bladder while he is asleep.28 Other authors see lifting as a simple measure that parents can use until a child becomes dry on his own or is ready to start a bedwetting program.10 There is some data showing that lifting can help children become dry at night.29 This is a basic intervention that should be included with any bedwetting program.10 It consists of the following elements: Encourage the child to take some responsibility for his bedwetting such as urinating appropriately before bed and putting underwear in the laundry basket. Give the child positive reinforcement and rewards for dry nights. This is done by encouraging the child make a calendar to monitor his progress and by giving him stickers for dry nights.30
  • Bladder Therapy: Bladder therapy has evolved over time. In the past, doctors recommended something called bladder-stretching exercises. These exercises consisted of holding back urine as long as possible during the day. The goal of this treatment was to enlarge the child’s bladder since many bedwetters have a small bladder capacity. Although a child's bladder capacity can increase with this approach, the change is not accompanied by a significant reduction in bedwetting and most children relapse after the exercises are discontinued. Most bedwetting experts no longer recommend bladder stretching for the following reasons: First, it is very difficult for children to hold back their urine when they need to go. Second, there is little research to support the efficacy of this approach. Third, some children who repeatedly hold back their urine may develop a “voiding dysfunction” in the future.10 (Voiding is the medical term for urinating.) Current bladder therapy focuses on having children pay more attention to bladder function.32,33 This approach encourages children to increase their fluid intake during the day, to think about the sensation of a full bladder, to respond to their bladder at the first signal, and to fully empty their bladder each time they have to go.
  • Enuresis Alarm: The enuresis alarm is a device that awakens a child from sleep when he wets the bed. Enuresis alarms have two basic parts: a wetness sensor that detects urine and an alarm unit that buzzes after the child wets the bed. A few models also have the ability to vibrate when they go off. This is a helpful feature because some children are more likely to wake up if they feel a vibration at the same time that the alarm starts to buzz. Bedwetting alarms come in three styles: wearable alarms, wireless alarms, and bell-and-pad alarms. The enuresis alarm is the most effective treatment for bedwetting with cure rates approaching 75%.4 When a child wets at night, the urine in his underpants turns on the alarm, creating a loud sound. When the alarm goes off it wakes the child up so he can go to the bathroom and finish urinating in the toilet. After weeks of hearing the alarm, the child learns to pay attention to his bladder signals and wakes up before wetting the bed. Over time, most children stop waking up at night to pee. This happens because the bladder learns to hold all of its urine until morning. Although effective, the enuresis alarm requires a lot of work on the part of the child and parents.34 It involves frequent waking up at night and can take three months to work. Consequently, this may not be the best option for every child and family.26 However, studies have not only demonstrated the alarm’s efficacy, but also a lower relapse rate when compared with other treatments.
  • Psychotherapy: Psychotherapy is a treatment option for children with secondary enuresis due to a change or traumatic event in their life or for those experiencing a significant problem with self-esteem because of their bedwetting.
  • Pharmacological Treatment: There are a small number of medications that doctors use to treat bedwetting. Medication is taken before bedtime and can be used alone or in combination with behavioral treatment.26 The effects of drug therapy are not long lasting and most children often relapse when medication is stopped. For this reason, healthcare providers generally recommend medication for short-term use or to control a child’s symptoms if other measures have failed.
    • Desmopressin: Desmopressin is a manufactured form of the hormone, vasopressin. It acts by making the kidney produce less. The drug helps 50% of patients who take it, though recent studies have shown it is more effective in older children who have a normal bladder capacity. Desmopressin is a safe medication when used as directed.36 It is important to restrict fluids after dinner when taking desmopressin to prevent lowering the sodium (salt) in a child’s blood.
    • Imipramine: Imipramine was originally developed as a treatment for depression, but doctors discovered that patients who took the drug sometimes had trouble emptying their bladders. This motivated researchers to study the medication with nocturnal enuresis. Imipramine helps 40% of those who take it. A major concern, however, is the fact that the line between an effective dose and toxic dose is small. In the United Kingdom, imipramine is one of the most common causes of fatal poisoning in young children.38 Children have also died from accidental overdose due to magical thinking.39 Some authors do not think Imipramine is safe enough to use in a benign condition such as nocturnal enuresis.
    • Oxybutynin: Oxybutynin is an anticholinergic medication that is usually prescribed for individuals with an overactive bladder. People with this condition get uncontrolled bladder contractions that cause frequent urination and an urgent need to empty their bladders without much warning. Children with an overactive bladder typically wet the bed more than once per night and often have daytime wetting as well. Oxybutynin is not an effective treatment for bedwetting by itself. However, when used in conjunction with the bedwetting alarm or desmopressin, it may relax the bladder enough to make those treatments more successful.

Other Treatment Modalities

There are a number of pharmacological and behavioral therapies that are not a part of standard enuresis management because they have only been investigated in small studies. Examples of these interventions include tolterodine, atomoxetine, acupuncture, and hypnosis. The Cochrane Database recently published comprehensive reviews of these studies.

Conclusion

Bedwetting is a common and embarrassing problem that can greatly affect children and families. It is neither the fault of the child nor the parent. Despite the frustrations that families have to endure, many parents do not raise the issue with their healthcare providers. The most important thing to remember is that with care and perseverance, nocturnal enuresis is a problem that can be successfully treated.

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Author: Howard Bennett, MD. Contributing author: Katie Koval