Bedwetting Authors: Vinaya Gavini, M.D., F.A.AP. & Rachel Lethorn, M.S., PAC, ATC What is bedwetting? Bedwetting during the night, also known as nocturnal enuresis, is the term used for the involuntary release of urine during sleep. Bedwetting is considered common in children until at least age 6. In the United States 5-7 million children wet the bed. About 15-20% of 5-year-old children still wet the bed at night. Also, nocturnal enuresis is more common in boys than girls. What causes Bedwetting? The urinary system in children with bedwetting usually works just fine. There may be a mix-up in the signals from the brain going to the bladder indicating nervous system immaturity. Bedwetting commonly runs in families. There is a 44% chance of enuresis if one parent had enuresis. Also, the chances increase to 77% if both parents had enuresis. There are two types of bedwetting: primary and secondary enuresis. Primary enuresis includes those children who have never had a dry night for any significant length of time. Secondary enuresis means bedwetting that starts up after the child has had dry nights for at least 6 months. The main causes of primary enuresis include one or a combination of the following:
Secondary enuresis typically is caused by an underlying medical or emotional problem including:
How do I know if my child has a problem? Children develop bladder control at different ages as they grow older and their bodies and brains mature . Most children no longer urinate in their sleep by age 6. However, those that do will naturally stop at the rate of 15% of cases per year starting at age 5. Treatment before the age of 5 is not necessary. If your child is still having problems after this age, it may be a good time to seek medical help. You do not have to wait for your child to outgrow bedwetting. There are now safe, effective techniques to treat nocturnal enuresis. How do I help my child? Children with bedwetting may have lower self-esteem and confidence. It is important to treat nocturnal enuresis to help them get over this problem. Children can suffer many psychosocial issues if this problem is ignored. Parents also need to be supportive and reassure their child that bedwetting is a common problem. Treatment approaches include a variety of behavioral changes, medications and alarm devices. Each child responds differently to the various treatments, so many methods may need to be attempted. First, underlying medical conditions should be ruled out or treated and eradicated. It is important to know that the child who wets the bed cannot control it and is not doing it on purpose. Parents should not punish their child for wetting the bed. Exams and Tests Urine and/or blood test may be ordered by your practitioner to make sure there is no urinary tract infection, diabetes or kidney disease. However, there is no medical test that can definitively find a cause for enuresis. If the child is older than 5 years and has no other symptoms other than wetting the bed at night, then this is considered an uncomplicated case of enuresis. These uncomplicated cases have many treatment options. Treatment Options
Medicines may be prescribed if behavior therapy has not worked. Medicines are not a cure, but can buy some time. DDAVP (Desmopressin acetate) is a synthetic version of the antidiuretic hormone (ADH). This medicine comes in a tablet or nasal spray form. This is the most commonly prescribed medicine for enuresis. The effectiveness ranges from 38-55%. This medicine helps the kidneys to produce less urine. Reported side effects include headache, nausea, and vomiting. Other side effects include water intoxication if a large amount of water is ingested after taking it. The main complaint with this medication is the frequent relapse rate after the drug is stopped. Oxybutin (Ditropan) is another medicine that can be useful in treating enuresis in some children. It works by relaxing the bladder’s smooth muscle, increasing bladder capacity, and delaying the initial desire to void. The medicine comes in a liquid and tablet form. The side effects include dry mouth, constipation, and decreased ability to sweat. Imipramine (Tofranil) is a tricyclic antidepressant medication sometimes used for enuresis. This medicine helps the bladder to hold more urine by decreasing contractility of the bladder and increasing the outlet resistance. Side effects include nervousness, anxiety, constipation and personality changes.
Bedwetting alarms help the child achieve nighttime dryness by conditioning him to stop the flow of urine when sleeping. A loud noise sounds at the first drop of urine, awakening both the child and parent. Over time, the child will learn to sense the need to wake up in response to a full bladder and to contract the pelvic floor muscles to inhibit the flow of urine. Bedwetting alarm therapy offers the possibility of sustained improvement of enuresis and should be considered for every bedwetting child. Alarms are 70-90% successful in children after 4-6 months of use. Bedwetting alarms are preferred over medication, because there are no side effects. Although, the alarm does take time to work. The child should use an alarm device for weeks to months before considering it a failure. There are audio (beeping) and tactile (buzzing) alarms. The bedwetting alarm is not an alarm clock. It consists of a small, wearable plastic alarm box that attaches to the shoulder area and a moisture sensor that attaches to snug-fitting underwear. When the child is aroused, that parent can walk him to the bathroom to urinate. Over time, the child will learn to do this independently and sleep dry all night. Use of a bedwetting alarm requires time, patience, and motivation of both parent and child. Permanent dryness is more likely if alarm therapy is used for at least 2 consecutive weeks of dryness, followed by every other night for 2 more weeks while maintaining dryness. If the child is still wet after a minimum of 3 months of consecutive use, alarm therapy can be discontinued and considered unsuccessful. Bedwetting alarms offer the most effective permanent treatment for bedwetting. Combination of alarm therapy and DDAVP is reported to result in dryness not achievable with either therapy alone. Making Sense of all the Different Alarms Unlike an alarm clock, which arbitrarily awakes the child to urinate in the toilet at a particular time or his parent at certain times, the bedwetting alarm responds to the child’s biological need to urinate. The timing and amount of urine will vary from one night to the other. Bedwetting alarms are a mainstay in enuresis treatment, and they are an easy first step for parents to employ. A wearable alarm consists of a sensor, an alarm unit, and a cord that connects the two. The sensor is attached to the area of his underwear or pajamas that will receive the first drop of urine. It senses moisture and makes a noise loud enough to wake up the child and parent. With parent’s help at first, the child will get up and go to bathroom. After a few months of using the alarm and cultivating the habit of going to bathroom, his brain will begin to understand the feeling of a full bladder. The child gradually develops the habit of waking up to urinate before the alarm goes off. A bell-and-pad alarm has a cord connecting the alarm unit to a plastic mat (pad), and the mat sitting under a bed-sheet. When a child wets, the urine leaks onto the pad and sets off the alarm. This type of unit requires a large amount of urine to trigger the alarm. If the child rolls off the pad or doesn’t wet a large amount of urine, the alarm won’t sound. Some children may find the size and texture of alarm uncomfortable. A wireless alarm consists of a special underwear with sensor strips sewn in place, a small transmitter snapped to the underpants on the waist, and a remote alarm. Moisture triggers the transmitter to sound an alarm that is plugged into the wall. The child or parent must walk to the wall alarm to turn it off, therefore having some one to get out of bed. Its use is, however, limited by fact that the special underwear must fit properly and be ready each night. An ideal alarm is the one that works every time it is used . It must be attached in the correct place on his clothing, and it must remain attached all night. The key to success is choosing the right alarm. Although most alarms sense moisture and respond by making a sound and/or vibration, there are many differences in the various models. Choosing the Right Alarm for You and Your Child The criteria to be used while choosing and purchasing an alarm include its usability, comfort, sensor, durability, sound, turnoff facility, warranty, and cost.
Key Points
References Enuresis (Bed-Wetting) ( American Academy of Family Physicians October 2003) http://familydoctor.org/366.xml Bedwetting (eMedicine Health Jan 2005) http://www.emedicinehealth.com/articles/8783-1.asp Urinary Incontinence in Children (National Kidney and Urologic Diseases Information Clearinghouse April 2004) http://kidney.niddk.nih.gov/kudiseases/pubs/uichildren/index.htm Enuresis (eMedicine: Article by WM Lane M Robson, MD, November 2004) http://www.emedicine.com/ped/topic689.htm Treating Nighttime Enuresis in Children: A Best Practice (American Family Physician February 2002) http://www.aafp.org/afp/20020215/tips/14html Wet-Stop 2 Enuresis Alarm by Palco Labs (Pediatrics Warehouse January 2005) http://www.pediatricswarehouse.com/enuresisalarms.html Bedwetting (Medline Plus, October, 2003) http://www.nlm.nih.gov/medlineplus/ency/article/001556.htm Nocturnal Enuresis (Family Practice Notebook.com October 2004) http://www.fpnotebook.com/PED100.htm Mercer, CPNP, R. (2004). Seven Steps to Nighttime Dryness: A Practical Guide for Parents of Children with Bedwetting. Maryland: Brookeville Media. Call or Visit VINAYA K. GAVINI, M.D. for consultation and treatment at: |
