What Is Nocturnal Enuresis (Bedwetting)?

Female Urinary Tract

Male Urinary Tract

When children urinate without control while they sleep, it is called nocturnal enuresis. It's also known as bedwetting.

Most children can control their bladder during the day and night by the age of 4. About 10% of children age 6 or 7 still can't stay dry, as they have day or nighttime "accidents." If a child experiences bladder control problems during sleep after the age of 7, it's worth looking into. Your health care provider can help.

Nocturnal enuresis is common for more than 5 million children in the U.S. It is slightly more common in boys than girls. This issue can be frustrating for children, parents and health care providers. As children spend more nights away from home (at camps, sleepovers and field trips), it is more imperative tolook for solutions. With patience and tools for treatment, most children will stop bedwetting.

There are two types of nocturnal enuresis. The testing, care and treatment for both types are very similar:

  • Primary nocturnal enuresis describes children who never achieved dry nights since potty training (typically these children have no accidents during the day time)

  • Secondary nocturnal enuresis is when a child achieved consistent dry nights for at least six months but has now started bedwetting again. Mostly, this type of bedwetting is related to a stressful event (e.g. birth of a sibling, parent divorce, etc.). Eating disorders and some medicines can cause secondary bedwetting.

Contact your pediatrician if your child is experiencing either of these types of nocturnal enuresis

How Does the Urinary System Work?

Urine is liquid waste from your body. Urine forms when the kidneys clean your blood. The "urinary tract" includes the organs in your body that make, store and remove urine.

Normally, the kidneys make about 1½ to 2 quarts of urine each day in an adult; less in children. Urine travels from the kidneys to the bladder through the ureters (the tubes that join them). The bladder has the job of storing and releasing urine. The muscular neck of the bladder stays closed in order to store urine. The urethra is the tube that carries urine from the bladder, out of the body. This area is kept closed with sphincter muscles.

The brain works with the bladder to control when to release urine. Once you are ready to release urine (i.e.: in a toilet), the brain sends a signal to the bladder. Then the bladder muscles contract. This pushes urine out of the bladder, through the urethra. The sphincter muscles open, and urine is released out of the body.

At first, infants release urine in an uncontrolled way by a simple reflex. As infants grow, several things develop to allow them to gain control over the way their bladder empties:

  • The bladder grows to hold more urine volume with age. 
  • By age 2-3 years, the child gains control over the sphincter and pelvic floor muscles. When they squeeze these muscles, children can hold the flow of urine until they reach to a toilet. 
  • The brain matures with age to allow children to relax or squeeze these muscles at all times. This is when they become "toilet trained." 
  • By age 7, 90% of children can control their bladder both day and night. If they have to use the bathroom at night, they will wake up and go.



What are Common Causes of Enuresis (Bedwetting)?

Being lazy or willful is almost never a reason for a child's loss of bladder control. In a small number of cases, behavior may play a role. No matter the causes, parents need to be patient and supportive. Bedwetting is caused by a combination of things:

Family history (genetics)

Bedwetting can be inherited. The "bedwetting gene" is strong among families. Half of all children who have this problem had a parent who also struggled with bedwetting. This percent increases to 75% if both parents had enuresis. Close relatives (aunts, uncles and grandparents) may also share this gene, though you may not know it. A child without a family connection has only a 15% chance of bedwetting.

Slow development of brain-bladder control

Children who wet their beds are often described as "deep sleepers." Deep sleep affects the way the bladder communicates with the brain. Instead of waking up to use the toilet, the child's pelvic floor muscles relax and empty while the child sleeps. This brain-bladder control will develop naturally over time, or speed up with treatment.

Smaller than expected bladder capacity

Some children who have enuresis have bladders that can only hold a small amount of urine. This condition does not allow the child to sleep through the night without wetting the bed.

Making too much urine while asleep

Your child's kidneys may make too much urine at night, and the bladder may not be able to hold it all. Normally, the brain produces a hormone called "antidiuretic hormone (ADH)" which slows the kidney's urine production. It helps make less urine at night. When the brain does not make enough ADH or when the kidney stops responding to it, more urine is produced. The child will either have to wake up several times during the night to urinate or wet the bed. Caffeinated and carbonated drinks may also cause the kidneys to produce more urine. .

Type 1 diabetes (insulin dependent diabetes mellitus or "sugar diabetes") is caused by a lack of the hormone insulin. This hormone helps manage the sugar we get through food and drink. In untreated patients with type 1 diabetes, sugar is lost in the urine. This leads to a great loss of water. Some children with type 1 diabetes may have bedwetting as a symptom at the start of their illness.]

Sleep disorders

Some children have sleep disorders such as sleepwalking or obstructive sleep apnea (OSA). With OSA, less oxygen from poor breathing will cause the heart to produce "atrial natriuretic peptide (ANP)." This substance will cause the kidneys to produce extra urine at night.

Constipation

The rectum lies behind the bladder. If constipation causes stool to store in the rectum, it will push on the bladder. This limits the way the bladder can hold urine, causing leaks.

Stress

Any form of stress can lead to bedwetting problems. If the stress from bedwetting itself affects your child or your family, it can make things worse. Children who wet the bed often fear being discovered and teased by their friends or siblings. Emotionally, a child can become withdrawn and nervous. Children with learning disorders or attention problems generally feel more stressed. These children commonly have bedwetting issues. Be aware of social stresses that can affect bedwetting, such as:

  • A new brother or sister
  • Sleeping alone
  • Starting a new school
  • A family crisis
  • An accident or trauma



How is Enuresis (Bedwetting) Diagnosed?

You'll know if a child has enuresis if he/she is over the age of 6, and often wakes to a wet bed. You and your health care provider will want to learn the cause of the bedwetting.

Your child's pediatrician will ask about how often this happens, and about other symptoms. Before your appointment, try to keep track of your child's bathroom habits in a bladder diary. Include information such as:

  • How often does your child urinate during the day and at night? 
  • How often does he/she pass stool and how hard or soft is the stool? 
  • Does your child drink fluids before bed?

If your health care provider needs more information, your child may have a:

  • Urine culture & urinalysis: Urine tests are used to check for infection, unwanted blood and other elements in the urine.
  • Blood test: Blood tests can check the kidney and thyroid, cholesterol levels and the presence of anemia, diabetes or hormone problems.
  • Bladder scan: This type of ultrasound shows how much urine is still in the bladder after urinating.
  • Urodynamic testing: These tests check to see how well the lower urinary tract stores and releases urine. 
  • Cystoscopy: During this test, the doctor inserts a narrow tube with a tiny lens into the bladder to check for a tumor or other more serious conditions.


How is Enuresis (Bedwetting) Treated?

There are many treatments for bedwetting, some work better than others. Often, treatment starts with simple changes like:

  • Reducing the amount of fluids your child drinks 1-2 hours before bed
  • Creating a schedule for bathroom use (changing toilet habits)
  • Wetting alarm devices
  • Prescription Drugs

These strategies may be tried one at a time, or together.

The following strategies have not been shown to help:

  • Stopping food and fluid intake
  • Night waking
  • Pelvic muscle exercises 
  • Alternative therapies

Reducing the amount of fluids your child drinks 1-2 hours before bed

Begin by encouraging your child to drink 1 or 2 extra glasses of water in the morning or at lunchtime. Then in the evening, your child should only drink to quench thirst. Try to prevent drinking 1 to 2 hours before bed. Also, limit or stop your child from drinking caffeinated and carbonated drinks like soda. 

Creating a schedule for bathroom use (changing toilet habits)

Bladder training is a way to set a bathroom schedule with your child. For example, have your child sit on the toilet five times each day and before bed, even if he/she says he/she doesn't have to go.

Bedwetting (enuresis) alarms

Bedwetting alarms have a special sensor that detects moisture in a child's pajamas or Pull-Ups® training pants. It triggers a bell or buzzer to go off with wetness. The child wakes with the alarm and tries to get up to go to the bathroom before having an accident. An adult will need to help, since most children who wet the bed sleep very deeply and do not wake up by themselves at first. The alarm works by "conditioning" a child to wake when it's time to urinate. This is behavioral-type therapy that is known to be very successful.

Bedwetting alarms work with a sensor in the child's pajamas or underwear that links to an electronic alarm. The alarm is either attached to the child's clothing near the shoulder or clipped to the waist. The alarm unit may also be wireless, and placed on the counter. When the sensor becomes moist, the alarm is triggered. Some alarms also have a vibration mode that shakes the device. The alarm wakes the child so he or she can get to the bathroom to urinate or finish urinating.

Success for alarm therapy depends on parents understanding that this is a learning process. There are stages that a child and parents must go through for best results. Without patience, parent and child frustration will lead to quitting. Please try not to give up.

In the first and second stage of therapy, parents must wake up with the alarm and then wake the child from bed. The child then gets up, goes to the toilet, and tries to urinate for couple of minutes. they should then clean themselves in the shower, change their bed sheet or put on new pull up. The parent should be supportive and help. Then the child will turn the alarm back on, and go back to bed. In the third stage of therapy, the child should be able to wake on his or her own when their bladder feels full. Once the child successfully reaches this stage, parents should ask the child to use the device for 2-3 more weeks to reinforce this behavior.
Everyone at this stage should feel proud and relieved.

Tips for success:

  • Choose 3-4 months when a simple home routine can be made for treatment.
  • Agree with the child on a date when therapy will begin.
  • Perform a few drills with the alarm during the day so the child knows what to expect and what to do. 
  • Keep a calendar in the child's room to monitor progress.
  • Do not punish your child for accidents. Punishment is counterproductive. Instead, offer rewards for cooperating with therapy and completing tasks.

Advantages:

  • Not a prescription medication, so there are no side effects
  • Low rate of recurrence after device is stopped upon successful treatment
  • If used the right way, the chances of success are about 75% after 1 to 2 months of nonstop alarm treatment. 

Disadvantages:

  • They require hard work and commitment from parents
  • They are not good for sleepovers.
  • They disturb siblings who share a bedroom
  • Many health plans do not pay for these devices, and they cost around $100

Drugs

Desmopressin acetate (DDAVP)

Desmopressin is made from the hormone "vasopressin".

In normal conditions, vasopressin is produced by the kidneys when the body tries to conserve water. For example, athletes secrete more vasopressin when they are active and sweating. Most people have naturally higher levels of vasopressin during sleep. That is part of the reason why we can sleep through the night without needing to pass urine. In many children with enuresis, this hormone surge is absent. DDAVP is available as a pill. It can be given an hour before going to bed for a period of 3-6 months, with a one week break. Because it works to decrease the volume of urine made, it is used with a schedule of drinking less fluid.

Advantages:

  • When it works, it works very well
  • Can boost confidence on sleepovers 
  • Can be used privately 
  • The cost is usually covered by most health plans

Disadvantages:

  • This drug works on less than half of the treated children 
  • The child's body can adapt with time and stop responding to the drug

Oxybutynin and Tolterodine

These prescription drugs stop the bladder from having spasms with overactive bladder symptoms. It is helpful when a child has small bladder capacity, by increasing that capacity.

Advantages:

  • The drug can be combined with desmopressin to become more effective. The medication is safe and well tolerated by children.

Disadvantages:

  • The drug doesn't work for everyone. It may 
  • Common side effects include dry mouth, constipation, and facial flush. If constipation becomes a problem, be aware that this can make bedwetting worse.

Imipramine

Imipramine is an anti-depressant medication that has been used for many years to treat children with bedwetting. It does not mean that depression is a cause for bedwetting. It is not clear how imipramine helps in this case, but it is believed to improve the child's sleep patterns and bladder capacity. Side effects can include irritability, insomnia, drowsiness, reduced appetite, and personality changes. Overdose can be deadly. This drug must be used and stored safely.

Finally, your health care provider should look for signs of constipation. Treatment with dietary advice and laxatives may be recommended. This may help with your child's bedwetting issue.

Treatments That Are Not Recommended

Stopping all food and fluids before bedtime

Many parents think that if their child stops eating and drinking several hours before bed, it will help reduce or eliminate the bedwetting. However, this rarely helps. It's a good idea to stop drinks 1-2 hours before bed and to always limit caffeinated and carbonated sodas. However, if a child is hungry or thirsty, it is okay to provide small amounts of food and water. (Note: Limiting drinks is needed for treatment with vasopressin drugs.)

Scheduled night waking

Before seeking medical care, many parents try waking a child during the night to take him/her to the bathroom. Some families try this more than once during the night. While it can be helpful in the short term, it is hard to continue over time. It is hard on family members and does not always work. Sometimes the child will still wet the bed

Pelvic floor muscle exercises

Adults with bladder control problems may find help with pelvic muscle exercises, like the Kegel. During these exercises, adults are asked to hold a full bladder and try to stop their urine stream. This effort does not usually help children. Children who hold their urine on purpose during the day may lead to problems with urgency, daytime wetting and even UTIs.

Alternative therapies

Homeopathy, herbal cures and chiropractic practices have not been found to help with children's bedwetting.



After Treatment

Coping with Bedwetting

With treatment, a child who is struggling with bedwetting can find long-term relief. Most often, in time, this problem will end.

However, bedwetting can be extremely stressful for families. Several things can help you cope as you decide how to manage a child's bedwetting:

  • Remember, bedwetting is not the child's fault. Avoid punishing or teasing your child. 
  • Encourage regular bathroom visits during the day. Your child should try to go at least 5 times per day and just before bed.
  • Your child should have at least one bowel movement each day. Stool should be well formed and soft. Ask your pediatrician how to improve bowel health, if necessary.
  • Avoid foods high in sugar, carbonated and caffeinated beverages in children.
  • Drinking should take place mostly during the day, just sips 1-2 hours before bed.
  • Have your child wear Pull-Ups® training pants when your child sleeps outside the home.
  • To help manage bedwetting: use a mattress protector, washable/ disposable products and room deodorizers. 
  • After an accident, wash the child and use petroleum jelly to prevent skin chafing.
  • Keep a calendar to write down how well a treatment is working. 
  • Remember that enuresis ends on its own for most children (rate of about 15% per year)!


More Information

Frequently Asked Questions

Does bedwetting decrease with age?

Yes. Nearly all one-year-olds wet the bed. By age 5, this drops to around 20% and by age 10 it is about 5%. By puberty, this rate is about 1%. It is important to understand that with time, most children will overcome bedwetting.

Does my child need further testing?

In most cases, there is no need for x-rays, or other imaging or urodynamic studies. Your urologist or primary care doctor will decide what tests, if any, are needed after speaking with you and examining your child.

Conditions that may need more testing include:

  • Combined daytime and nighttime wetting
  • UTI
  • Constipation and/or bowel accidents
  • Difficulties with urinary stream and flow
  • Recent neurological injury or disease
  • Physical findings that suggest an underlying neurological condition. (For example, hair tufts at the base of the spine with spina bifida occulta, or shaking, and blurred eyesight with multiple sclerosis.)

Will using absorbent pants and other diaper-like products delay my child's control?

The use of absorbent pants does not prevent or delay toileting and continence control. These products can help reduce stress for children and parents. They can help reduce wet clothing and bedding at night, and prevent embarrassment.

Questions to Ask Your Health Care Provider:

  • What is causing my child to wet the bed?
  • When should this problem be addressed? 
  • Will he or she outgrow wetting the bed? When? 
  • Are there other tests my child can take to see if his/her bedwetting is because of a hormone problem or infection?
  • What treatments are available, and which do you recommend?
  • How long will treatment take? 
  • What are the pros and cons for each treatment option? 
  • What do I have to do to help my child be successful? 
  • Should my child follow any food or drink restrictions?