Soggy sheets and pajamas and an embarrassed child are a familiar scene in many homes. But don’t despair. Bed-wetting isn’t a sign of toilet training gone bad. It’s often just a normal part of a child’s development.Bed-wetting is also known as nighttime incontinence or nocturnal enuresis. Generally, bed-wetting before age 7 isn’t a concern. At this age, your child may still be developing nighttime bladder control.
If bed-wetting continues, treat the problem with patience and understanding. Bladder training, moisture alarms or medication may help reduce bed-wetting.
What is Bedwetting?
What Causes Bedwetting?
Common causes of secondary bedwetting include the following:
What Are Risk Factors for Bedwetting?
- male gender and family history;
- medical conditions such as abnormal anatomy or function of the kidneys, bladder, or neurologic system;
- sleep apnea;
- chronic constipation;
- sexual abuse;
- excessive fluid intake before bedtime;
- urinary tract infection; and
- some medications (for example, caffeine).
What Symptoms May Be Associated With Bedwetting?
- Wetting during the day
- Frequency, urgency, or burning on urination
- Straining, dribbling, or other unusual symptoms with urination
- Cloudy or pinkish urine, or blood stains on underpants or pajamas
- Soiling, being unable to control bowel movements (known as fecal incontinence or encopresis)
- While many adults urinate only three or four times a day, children urinate much more frequently, in some cases as often as 10-12 times each day.
- “Frequency” as a symptom should be judged in terms of what is normal for that particular child.
- Equally important, “infrequent voiding” (less than three times urinating/day) can be a sign of other underlying problems.
- Fecal impaction occurs when feces becomes so tightly packed in the lower intestine (colon) and rectum that passing a bowel movement becomes very difficult or even impossible. When the stool is passed, it is often a painful experience.
- The hard, tightly packed feces in the rectum can press on the bladder and surrounding nerves and muscles, interfering with bladder control.
- Neither fecal impaction nor constipation is unusual in children.
- A strict bowel regimen utilizing dietary modification and/or over the counter medications can often alleviate bedwetting
What Specialists Treat Bedwetting?
When Should a Child Seek Medical Care for Bedwetting?
- It is probably a good time to seek medical help when the child is 5-7 years of age.
- Referral to a specialized enuresis clinic is likely not needed for most children with no other symptoms. This is a reasonable problem for the child’s pediatrician to handle.
What Exams and Tests Assess Bedwetting?
Growth and development, including toilet training (both urine and stool)
Medical conditions. Specific attention is focused on the following:
- Wetness of underwear: indicates day and nighttime enuresis
- Palpating stool in the abdomen: indicates possible constipation or other obstruction
- Excoriation of genital or vaginal area: possible scratching due to pinworms
- Poor growth and/or high blood pressure: possible kidney disease
- Abnormalities of the lower spine: possible spinal cord abnormalities
- Poor urinary stream or dribbling: possible urinary abnormalities
Medications, vitamins, and other supplements
Family history if one or both parents were enuretic, approximately one-half to three-quarters of their offspring may also wet the bed. Identical twins are twice as likely to both be enuretic when compared to fraternal siblings.
Home and school life: recent stress, how this problem is affecting the child and family, any attempts at therapy which have been tried
Toilet habits: Record a voiding diary (daytime pattern and volume of urine, to determine bladder volume) and stool diary (to evaluate for constipation).
Diet, exercise, and other habits: Is there caffeine intake?
There is no medical test that can pinpoint the cause of primary enuresis. Secondary enuresis more commonly reflects underlying pathology and thus warrants laboratory and possibly radiologic evaluation.
- A routine urine test (urinalysis) usually is performed to rule out any urinary tract infection or kidney disease.
- An X-ray or ultrasound of the kidneys and bladder may be done if a physical problem is suspected. Occasionally, MRI examination of the lower spine/pelvis is indicated.
Generally, medical professionals divide bedwetting into uncomplicated and complicated cases.
- Uncomplicated cases consist of only bedwetting with no other symptoms, a normal urinary stream, and no daytime urination complaints or soiling. These children have a normal physical exam and urinalysis findings.
- Complicated cases may be any of the following: wetting in relation to another disease or condition, problems urinating, soiling or daytime urinary incontinence, or urinary tract infections. These children require further evaluation.
Children who have complicated bedwetting may be referred to a specialist in urinary tract problems (urologist) for further evaluation.
What Are Treatments for Bedwetting?
General PrinciplesBedwetting is typically seen more as a social disturbance than a medical disease. It creates embarrassment and anxiety in the child and sometimes conflict between parents. The single most important thing parents can and should do is to be supportive and reassuring rather than blaming and punishing. Primary nocturnal enuresis has a very high rate of spontaneous resolution.
The many treatment options range from home remedies to drugs, even surgery for children with anatomical problems.
- Underlying medical or emotional conditions should first be ruled out.
- If there is an underlying condition, it should be treated and eradicated.
- If bedwetting persists once these steps are taken, however, there is considerable debate as to how and when to treat.
- Because a majority of children 5 years and older spontaneously stop bedwetting without any treatment, many medical professionals generally choose to observe the child until age 7.
- The age at which to treat, then, depends on the attitudes of the child, the parents/caregivers, and the health-care provider.
Are There Home Remedies for Bedwetting?
- Reduce evening fluid intake. The child should try to not take excessive fluids, chocolate, caffeine, carbonated drinks, or citrus after 3 p.m. Routine fluids with dinner are appropriate.
- The child should urinate in the toilet before bedtime.
- Set a goal for the child of getting up at night to use the toilet. Instead of focusing on making it through the night dry, help the child understand that it is more important to wake up every night to use the toilet.
- A system of sticker charts and rewards works for some children. The child gets a sticker on the chart for every night of remaining dry. Collecting a certain number of stickers earns a reward. For younger children, such a motivational approach has been shown to provide significant improvement (14 consecutive dry nights) in most children with a low relapse rate (two wet nights out of 14).
- Make sure the child has safe and easy access to the toilet. Clear the path from his or her bed to the toilet and install night-lights. Provide a portable toilet if necessary.
- Some believe that you should avoid using diapers or pull-ups at home because they can interfere with the motivation to wake up and use the toilet. Others argue that pull-ups help the child feel more independent and confident. Many parents limit their use to camping trips or sleepovers.
The parents’ attitude toward the bedwetting is all-important in motivating the child.
- Focus on the problem: bedwetting. Avoid blaming or punishing the child. The child cannot control the bedwetting, and blaming and punishing just make the problem more frustrating for all.
- Be patient and supportive. Reassure and encourage the child often. Do not make an issue out the bedwetting each time it happens.
- Enforce a “no teasing” rule in the family. No one is allowed to tease the child about the bedwetting, including those outside the immediate family. Do not discuss the bedwetting in front of other family members.
- Help the child understand that the responsibility for being dry is his or hers and not that of the parents. Reassure the child that you want to help him or her overcome the problem. If applicable, remind him that a close relative successfully dealt with this same issue.
The child should be included in the clean-up process.
To increase comfort and reduce damage, use washable absorbent sheets, waterproof bed covers, and room deodorizers.
Self-awakening programs are designed for children who are capable of getting up at night to use the toilet, but do not seem to understand its importance.
- One technique is to have the child rehearse the sequence of events involved in getting up from bed to use the toilet during the night prior to going to bed each night.
- Another strategy is daytime rehearsal. When the child feels the urge to urinate, he or she should go to bed and pretend he or she is sleeping. He or she should then wait a few minutes and get out of bed to use the toilet.
- The parent should awaken the child, typically at the parents’ bedtime.
- The child must then locate the bathroom on his or her own for this to be productive. The child needs to be gradually conditioned to awaken easily with sound only.
- When this is done for seven nights in a row, the child is either cured or ready for self-awakening programs or alarms.
Bedwetting alarms have become the mainstay of treatment.
- A majority of children stop bedwetting after using these alarms for 12-16 weeks.
- Some children start wetting the bed again when the alarm is discontinued (relapse). However, the positive response to reinstating the alarm system is rapid due to the behavioral conditioning experienced during the first treatment cycle. With persistence, this method works for a majority in the long run.
- These alarms take time to work. The child should use the alarm for a few weeks or even months before considering it a failure.
- There are two types of alarms: audio and tactile (buzzing) alarms.
- The principle is that the wetness of the urine bridges a gap in the sensor, which in turn sets off the alarm. The sensor is placed either on the child’s underwear or bed pad.
- The child then awakens, shuts off the alarm, finishes urinating in the toilet, returns to the bedroom, changes clothes and the bedding, wipes down the sensor, resets the alarm, and returns to sleep.
- Alarms are preferred over medications for children because they have no side effects.
- It is generally believed that all children 7 years and older should be given a trial of an alarm.
- For the alarm to be effective, the child must desire to use it. Both the child and parents need to be highly motivated.
What Is the Medical Treatment for Bedwetting?
- These are typically reserved for children who have not stayed dry by using the alarms.
- Adults with bedwetting often take medications. They may have to stay on the medication indefinitely.
- The drugs do not work for everyone, and they can have significant side effects.
- The two drugs have been approved by the U.S. Food and Drug Administration (FDA) specifically for bedwetting are desmopressin (DDAVP) and imipramine (Tofranil). Others, which are not specifically approved for bedwetting, are oxybutynin (Ditropan, Urotrol) and hyoscyamine (Cystospaz, Levsin, Anaspaz).
- Medical opinion is divided on using drugs to treat bedwetting. Many believe that, since the child will outgrow the bedwetting anyway, the risks outweigh the benefits of taking the drugs.
Surgery for Bedwetting
What Medications Treat Bedwetting?
- It has been in use for the treatment of bedwetting for about 10 years and is generally the first medication prescribed.
- This drug imitates ADH in the body, which is secreted by the brain; it increases the concentration of the urine and reduces the amount of urine formed. It is recommended to be taken just before going to bed.
- Its main use is for children who have not been helped by an alarm. It is also used as a stopgap measure to help children attend camps or sleepovers without embarrassment.
- DDAVP comes as a pill and is taken before bedtime. Side effects are uncommon but include headache, runny nose, nasal stuffiness, and nosebleeds. A previously manufactured nasal spray form is generally not used since it is more likely to be associated with potentially severe side effects.
- The dose is adjusted until effective. Once it is working, the dose is tapered if possible. About 25% of children with enuresis will have total dryness with desmopressin, while approximately 50% will have a significant decrease in bedwetting. When compared with alarm devices, however, approximately 60% of patients will return to bedwetting when DDAVP administration is stopped.
- How it works is not clear, but it is known to have a relaxing effect on the bladder and to decrease the depth of sleep in the last third of the night.
- Initial cure rates range from 10%-60%, and it has a relapse rate of up to 80%.
- Side effects tend to be rare with correct dosage, but nervousness, anxiety, constipation, and personality changes have been reported.
- It can have toxic side effects if taken improperly or as an accidental overdose. Deaths have been attributed to accidental overdoses – most commonly associated with abnormal heart-rhythm patterns.
- It may be combined with desmopressin if desmopressin alone is not effective.