Enuresis ("Bedwetting")

Inappropriate wetness in children is a common problem. Wetting is a symptom and not a disease in itself. Many different causes can share this symptom and it can be a frustrating problem for children, families and their physicians. With patience and a thorough physical exam, most children today can be treated effectively. Read on to learn more about the different types and possible treatment options.

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What is enuresis?

Most children achieve some degree of daytime and nighttime bladder control by age four. Usually daytime control is achieved before nighttime wetting control. Over time, children are able to control urination at night. About 20 percent of five-year-old children wet their beds. About 15 percent of these children will spontaneously be able to control their urination.

Though some studies suggest a slight predisposition in boys to have enuresis, there is no clear-cut difference between the sexes. Up to 25 percent of all wetters are described as having secondary enuresis. This means that the child has had a period of time (typically six to 12 months) being dry. In contrast, children who have never been dry are said to have primary enuresis. While some cases of secondary enuresis can be linked to a recent trauma or stress, their evaluation, treatment and response are generally no different than those with primary enuresis. In the past, when there were few treatment options, it was common to ignore or downplay the situation and hope for improvement with time. Today, with increasing opportunities for children to spend nights away from home (e.g., camps, sleepovers and overnight field trips), it has become a concern at an earlier age. It should be emphasized that the cause of all forms of enuresis is almost never due to laziness or deliberate willfulness by the child. So, a parent should keep a supportive and understanding attitude.

Urinary tract infection: The presence of a urinary tract infection can lead to wetting. The infection irritates the bladder, which can lead to urinary frequency and feelings of urgency. The bladder becomes irritated and can cause the child to wet suddenly. A urine culture is needed to diagnose an infection. When an infection has been found, it is common to conduct studies to look for an anatomical problem in the urinary tract that may have led to the infection.

Structural or anatomical problems: In most cases when enuresis is associated with an anatomic abnormality, there will either be a history of urinary tract infection or a history of persistent, continuous day and nighttime urinary incontinence. If either of these two findings is noted, X-ray tests will frequently be performed to rule out an underlying anatomical abnormality.

Neurological problems: Storing and emptying urine from the bladder is a complicated process. It involves the nervous system, which helps to coordinate the action of the bladder and its muscle groups. Children with a history of injury or disease of the brain, spinal cord or the nerves leading to the bladder can have enuresis. Examples include brain and spinal cord trauma or surgery, radiation therapy of the brain and spina bifida. These are among the most complicated cases and require a thorough urological evaluation.

Day and night enuresis: Day and night wetting can occur together. In those who wet day and night, both the day and nighttime wetting need to be addressed. Sometimes solving the daytime problem is emphasized first because the child can participate in the treatment more readily. During the day, the child is awake, alert and can assist in helping to keep dry. At night, the child is asleep and is unable to help directly. When there is day and night wetting it is often important to assess the toilet habits of the child. The daytime wetting may occur because of poor toilet habits, constipation or both. The toilet habits of normal children are different from those of adults. Many adults urinate three to four times each day and it is not unusual for them to pass eight hours between urinations. Children cannot be evaluated with these standards. Studies have shown that children normally urinate more frequently. Urinating up to 10 to 12 times by children between pre-school to early elementary school age is common. Few young children (under age eight years) urinate four or fewer times each day. Similarly, constipation in children often occurs with symptoms of fecal soiling rather than with the usual complaint of having "hard stools." Many children will also exhibit "avoidance maneuvers." These are repetitive actions that the child performs to suppress an urge to urinate. Leg crossing and squeezing, squirming and heel sitting are all common examples. When these maneuvers are observed it strongly suggests that the child is trying to suppress an urge to urinate. Sometimes these actions become habitual and the child may do them without realizing it.

Day-only enuresis: Children who wet only when awake have day-only enuresis. Because daytime control usually precedes nighttime control, this situation strongly suggests while the child is awake, some aspect of his or her life is making wetting more likely to occur. As noted above, the most common underlying cause is poor daytime toilet habits. A detailed history is often useful. Sometimes a diary of all urinations and bowel movements helps to see if there are any patterns to the accidents. An example is the boy who was wet only during the day, and when a thorough history and diary were obtained, it was found that the child was wet when he would play video games. To play longer, he did not use the "pause" feature of the game and learned to ignore the warning signals his full bladder was sending to his brain. Soon he was no longer noticing the early warning signs and was responding only to the late ones. Ultimately, he was often too late in responding and became wet. Correcting these habits improved the wetting.

Giggle incontinence: The complete or partial loss of bladder control that occurs with laughing or giggling while awake is referred to as giggle incontinence. It is a condition, which is well known enough to spawn the phrase "I laughed so hard that I wet my pants." It is most often seen in adolescent girls but can also occur in boys. There is no specific cause and the treatment is aimed at prevention with proper emptying of the bladder. It is usually a self-limiting condition that improves with age and maturity. 

Nocturnal enuresis (classic bedwetting): Experts believe this condition is caused by any combination of the following:

• Failure to arouse — the child does not wake up when the bladder is full.
• Increased production of watery urine during sleep — the child produces more urine during sleep than can be handled by the child's bladder.
• Size and volume mismatch — the child's bladder capacity has not caught up with the volume being produced.

Bedwetting is not believed to be due to a learning disability or psychological issue. It can, however, become a source of problems if the stresses and pressures from the enuresis severely affect the child or his/her family. Children who have nocturnal enuresis can develop fear of discovery by their friends and may suffer from teasing from siblings. They can become withdrawn and anxious. Family members, especially parents and guardians, are asked to be supportive and understanding. Remember that the child in nearly all of these cases cannot directly control what is happening. Although it may take longer than usual, children who are developmentally delayed can achieve control of their urination as long as their basic neurological function is normal.

Social stress such as a new sibling, sleeping alone, starting a new school, a family crisis, an accident or trauma can cause enuresis. Children who were previously able to control their urination may develop wetting after some dramatic event in their life, although the event may not necessarily be a "bad" event. In cases where the child had excellent control previously, continence usually returns although it may take weeks to months. Support, reassurance and patience by the parents are very important.

How is enuresis treated?

There are several treatments for enuresis. They include modifications in fluid intake, toilet habits, the use of wetting alarm devices and medications. While they can be used alone, they are commonly used in combination.

Stopping fluids before bedtime: All drinking of fluids is stopped one to two hours before bedtime. This is usually not effective by itself, but is a part of nearly every program. Fluids rich in sugar and caffeine promote urination in some children. Curtailing the intake of fluids rich in these substances is sometimes helpful. Remember that foods that may not seem to be fluids may actually be mostly water. Fruit, bowls of ice cream or cereal with milk and other "juicy" snacks are sometimes overlooked. They should be considered fluids and avoided before bedtime.

Scheduled night waking: The child is taken to the bathroom and is asked to urinate during the night by a parent or family member. This can also be done more than once during the night. Many families try this idea on their own before seeking medical attention. While it can be effective in the short term, it is hard to carry out in the long term. In some families where one or more adults work later shifts, they can take the child to the bathroom. It is labor intensive and does not consistently work. Sometimes the child will be wet soon after going to bed or after having been taken to the bathroom.

Bladder training exercises: Among men and women who suffer from various forms of incontinence, pelvic muscle exercises can be helpful. Usually the adults are asked to hold a full bladder and try to interrupt their stream consciously. An example is the woman who has had several children and who now spurts some urine whenever she strains when she carries a heavy load or when coughing. This situation usually does not apply to children. Children who hold their urine deliberately during the daytime may not help their situation. Rather than "stretching out the bladder," using these techniques in children promotes delaying of normal urination and may lead to subsequent urgency and daytime wetting.

Wetting alarms: Wetting alarms are small electronic devices that are composed of two components. One part is a sensor that attaches to the pajamas or underwear. The sensor is connected to the second part; an electronic alarm that is attached to the child's clothing near the shoulder or clipped to the waist. When the sensor becomes moist, the alarm is triggered. Some of the alarms also offer a vibration mode that makes a loud sound and vibrates. When the alarm triggers, the child attempts to get to the bathroom while the bladder is almost full. It usually requires an adult to help the child. The main advantage of an alarm is that it is not a medication and has no side effects. It also has a low relapse rate after the device is stopped. Its major disadvantages are that it cannot be used discretely on sleepovers and campouts. It may disturb siblings who share bedrooms. It does not always work in many children who may be heavy sleepers. Finally, most health insurance plans will not pay for alarm devices that can cost $60 to $120 each.

Medications: Several medications are commonly prescribed for the treatment of nocturnal enuresis. Some of these drugs have very serious side effects. They should never be used without the supervision of a physician. The medications may be used alone or often in combination with each other and with other treatments. The drugs include:

Desmopressin acetate (DDAVP): The human body naturally produces a hormone called vasopressin that causes the body to make less volume of urine. It is produced when the body is trying to conserve water. Athletes, for example, secrete more vasopressin into their bloodstream when they are playing because they are losing water from sweating. It was found that most people increase their secretion of vasopressin naturally when they sleep. That is part of the reason why most people sleep through the night without getting up to urinate. So, in the morning, the bladder contains urine that is more concentrated. In many children with nocturnal enuresis, this surge of vasopressin is absent. The hormone has been analyzed and synthesized as the drug, desmospressin, and is available as a pill or nasal spray. Because it works by decreasing the volume of urine produced, it must be used in conjunction with a fluid restriction program. Its primary advantage is that when it works, it can work very well, making it a confidence booster on sleepovers and campouts. It can be used discretely and is usually covered by most health insurance plans. The main disadvantages are that not every child will respond and the relapse rate can approach 50 percent.

Imipramine: This medication was for many years the only drug available for the treatment of nocturnal enuresis. Originally designed as an antidepressant, it was found to have an effect on nocturnal enuresis. It must be prescribed carefully and is usually given according to the child's age and weight. It must be stored carefully in a safety container. An overdose can lead to dangerous and potentially fatal irregular heart rhythms. Any suspected overdose of imipramine should be treated as an emergency.

Other medications: Oxybutynin and hyoscyamine are other medications which are sometimes used to treat nocturnal enuresis. They work by affecting the smooth muscle layers that line the wall of the bladder. These drugs act on the muscles to slow down their ability to contract; thereby causing the bladder to relax. Primary side effects include flushing with occasional heat sensitivity, dry mouth and constipation. These medications usually do not effectively work alone to treat nocturnal enuresis but may be helpful in children who also have daytime wetting.

Alternative therapies: Acupuncture, herbal remedies, chiropractic and hypnosis have all been tried as therapies. There are no scientific data that these methods have any consistent benefit in the treatment of enuresis.

Does bedwetting improve with age?

Most children can outgrow bedwetting. It is thought nearly 100 percent of one-year-olds wet the bed. By age five, this percentage drops to around 20 percent and by age 10 it is around 5 percent. By puberty, this rate is less than 1 percent. It is important to understand that given time, most children will ultimately overcome enuresis. The urgency to act is that today many children have expectations that their parents and grandparents did not have to meet. In addition to sleepovers and overnight school trips, there are more extracurricular activities like scouting campouts and specialty camps (i.e. computer, swimming, hockey) being offered to younger children.

Does bedwetting run in families?

It has been found that if one or both parents have a history of bedwetting, the risk that their child will be a bedwetter is several times greater than the general population.

There are some adults with bedwetting. Some are helped by medication and may have to stay on medication indefinitely.

In most cases, there is no need to perform testing like X-rays and other imaging techniques. Conditions that may need more detailed evaluation include:

• combination of day and nighttime wetting
• urinary tract infection
• constipation and/ or bowel accidents
• difficulties with the urinary stream and flow
• history of recent neurological injury or disease

Your urologist will decide if tests are needed after speaking with you and examining your child.

The use of absorbent pants has not been shown to prevent or delay the later development of toilet control. They do help decrease social friction between child and parents by making less laundry and decreasing the embarrassment caused by wet bed sheets.

Reviewed May, 2003

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Glossary Terms

abnormality:
	A variation from a normal structure or function of the body.
bladder:
	The bladder is a thick muscular balloon-shaped pouch in which urine is stored before being discharged through the urethra.
bladder control:
	The ability to control the timing of urination. Also referred to as continence.
bowel:
	Another word for intestines or colon.
constipation:
	A condition in which a person has difficulty eliminating solid waste from the body and the feces are hard and dry.
continence:
	The ability to control the timing of urination or a bowel movement.
contract:
	To shrink or become smaller.
culture:
	Biological material grown under special conditions.
enuresis:
	Urinary incontinence not caused by a physical disorder. Involuntary discharge of urine during sleep at night. Bedwetting beyond the age when bladder control should have been established.
flushing:
	Fitting two things so they are completely level and form an even surface.
gene:
	The basic unit capable of transmitting characteristics from one generation to the next.
hormone:
	A natural chemical produced in one part of the body and released into the blood to trigger or regulate particular functions of the body. Antidiuretic hormone tells the kidneys to slow down urine production.
incontinence:
	Loss of bladder or bowel control; the accidental loss of urine or feces.
infection:
	A condition resulting from the presence of bacteria or other microorganisms.
ions:
	Electrically charged atoms.
neurologic:
	Pertaining to the nervous system.
neurological:
	Pertaining to the nervous system.
nocturnal enuresis:
	Bedwetting at night.
pelvic:
	Relating to, involving or located in or near the pelvis.
radiation:
	Also referred to as radiotherapy. X-rays or radioactive substances used in treatment of cancer.
radiation therapy:
	Also referred to as radiotherapy or radiation. X-rays or radioactive substances used in treatment of cancer.
secretion:
	Process of producing a substance from the cells and fluids within a gland or organ and discharging it.
spina bifida:
	A condition at birth in which part of the vertebral bodies (or back bones) fail to seal off completely and some part of the spinal cord protrudes through this opening. This condition is often associated with bladder and bowel control problems as well as lack of control of voluntary movement in the lower body.
stent:
	With regard to treating ureteral stones, a tube inserted through the urethra and bladder and into the ureter. Stents are used to aid treatment in various ways, such as preventing stone fragments from blocking the flow of urine.
stool:
	Waste material (feces) discharged from the body.
urinary frequency:
	Urination eight or more times a day.
urinary incontinence:
	Inability to control urination.
urinary tract:
	The system that takes wastes from the blood and carries them out of the body in the form of urine. Passageway from the kidneys to the ureters, bladder and urethra.
urinary tract infection:
	Also referred to as UTI. An illness caused by harmful bacteria, viruses or yeast growing in the urinary tract.
urinate:
	To release urine from the bladder to the outside. Also referred to as void.
urine:
	Liquid waste product filtered from the blood by the kidneys, stored in the bladder and expelled from the body through the urethra by the act of urinating (voiding). About 96 percent of which is water and the rest waste products.
urine culture:
	Sample of urine for diagnostic purposes.
urologist:
	A doctor who specializes in diseases of the male and female urinary systems and the male reproductive system. Click here to learn more about urologists. (Download the free Acrobat reader.)
vas:
	Also referred to as vas deferens. The cordlike structure that carries sperm from the testicle to the urethra.
vasopressin:
	A hormone produced by the pituitary gland that causes narrowing of the arteries and raises blood pressure. Also reduces the volume of urine excreted by the kidneys.

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