PEDIATRIC BEDWETTING | CAUSES AND TREATMENTS
Learn about the causes and treatment options for pediatric bedwetting, and practical steps you can take to help your child stay dry at night.
While not a serious medical disorder, bedwetting can have far-reaching effects on both the child and on the family. Wetting the bed may interfere with a child’s socialization and it can lead to significant stress within the family. Patience and understanding, two things that are often in short supply in the middle of the night, are keys to figuring out how to best resolve this issue.
Perhaps the most difficult aspect of nocturnal enuresis is its effect on a child’s self-esteem. 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.
Although there are differences of opinion on what constitutes bedwetting as a condition, a child with primary nocturnal enuresis is defined as someone who has never been dry for 6 consecutive months. The good news is that this problem does resolve itself over time. Every year, 15% of those dealing with bedwetting become dry without treatment. The chart proves this out:
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%
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.
One of most important things to keep in mind about urination is that the process is not under voluntary control. The individual parts and nerves of the urinary system must work in unison for successful urination to occur. As the bladder muscles contract, the urinary sphincter relaxes, allowing urine to flow into the urethra and exit the body.
The communication between the nerve and muscle groups that link the bladder and the brain is very complicated, and explains 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 years: Most children develop the ability to voluntarily stop urination and develop appropriate toileting skills.
- Ages 3-5 years: Most children have achieved urinary control and are dry both day and night.
Although there are many factors that contribute to nocturnal enuresis, most children do not have a disease process that explains their bedwetting. However, formal studies have shown that the risk of a child having nocturnal enuresis is heavily influenced by heredity. If one parent wet the bed as a child, their child is 44% more likely to do so as well. If both parents had nocturnal enuresis, the likelihood increases to 77%.
Reduced Bladder Capacity. Another contributing factor may be physical. Children with nocturnal enuresis often have a small bladder capacity compared to their peers. When these children sleep at night, their bladders are less able to hold all of their urine until morning.
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 a child 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.
Arousal Disorder. Some children suffer from arousal disorder or the inability to respond to the body signals that it is time to urinate. In addition, studies have demonstrated that children do experience nocturnal enuresis.
Constipation. If a child has a lot of stool in his or her rectum, it may push against the bladder. This can “confuse” the nerve signals, causing the bladder to believe it is fuller than it might be. A full rectum may also reduce how much urine the bladder can hold and how well the bladder empties when a child urinates. Parents are often surprised that by treating constipation, bedwetting is sometimes reduced or even cured.
Psychological Factors. Although children may develop secondary nocturnal enuresis after an episode of emotional stress, psychological problems do not cause primary nocturnal enuresis.
Sexual Abuse. Sexual abuse may be a factor in children with bedwetting issues who had 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.
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 such as Sexual Assault Nurse Examiners (SANEs). These registered nurses 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.
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 6 years of age.
COMMUNICATE WITH THE DOCTOR
Parents must be proactive and bring bedwetting to the attention of the pediatrician. No one knows your child better than you do. So speak up. Everyone involved will be relieved you did.
In most cases, a child’s regular healthcare provider will be able to treat bedwetting. However, if you are not getting the help you 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
Some doctors prefer to tackle bedwetting during separate visits where it can be addressed in more detail.1 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.
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. 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.
The most important aspect of treatment is determining if the 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
HOW PARENTS CAN HELP
There are a number of things parents can do to reduce the stress associated with nocturnal enuresis:
- 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, or having a dry night
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.
- Restricting Fluids. Limiting a child’s fluid intake after dinner is designed to reduce his urine production at night. Although there is little data to support this approach, many parents find it an easy way to treat bedwetting.
- 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. There is some data showing that lifting can help children become dry at night.
- Bladder Therapy. 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. Available in a variety of models, all alarms work on the premise of waking a child if the wetness sensor detects urine.
- Psychotherapy. 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.
There are a small number of medications that doctors use to treat bedwetting.
- Desmopressin. This helps the kidneys produce less urine.
- Imipramine. This medication boasts a 40% success rate but also has a fine line between an effective dose and toxic dose.
- Oxybutynin. Oxybutynin is not an effective treatment for bedwetting by itself, but when used in conjunction with the bedwetting alarm or desmopressin, it may relax the bladder enough to make those treatments more successful.
Bedwetting is neither the fault of the child nor the parent. No one should feel ashamed or embarrassed. What is key is to speak with your physician and develop a plan to resolve this issue. Being proactive, using reinforcement and full commitment can help remedy this situation.