Bedwetting

Bedwetting (enuresis) is the involuntary loss of urine (wetting) beyond the age when a child is expected to be toilet trained. This is generally considered to be by seven years of age for nighttime control.

Nocturnal enuresis is a very common problem. It occurs in about 15 to 20 percent of children five years old, 5 to 10 percent of children ten years old, and 1 to2 percent of children fifteen years old. Each year 10 to 15 percent of these children will become dry at night. About 25 to 30 percent of children who are initially dry at night will develop nighttime wetting.

Causes of bedwetting

We do not know exactly what causes enuresis. There may be several reasons your child may wet the bed, including:

  • Maturational delay: Many believe there is a delay in the maturation of the central nervous system. If the child is not aware of the sensation that his/her bladder is full while asleep and does not awaken to urinate, wetting will occur.
  • Genetic factors: Enuresis tends to run in families. Recently, scientists identified the gene that is associated with bedwetting in some children.

    The chances your child will wet are:
    • 15 percent if neither parent wet as a child
    • 40 percent if one parent wet as a child
    • 70 percent if both parents wet as children
  • Too much urine production at night: Normally, the body produces a hormone, called antidiuretic hormone or ADH that makes the body produce less urine at night. Studies have shown that some children who wet the bed do not make enough of this hormone. If the child does not make enough ADH, he/she may make more urine than the bladder can hold. If the child does not recognize that the bladder is full and wake up, wetting will occur.
  • A small bladder capacity: The bladder is unable to hold all the urine it produces.
  • Difficulty waking up from sleep. Although many parents report their children are very "sound sleepers", most studies have shown children who wet have normal sleep patterns. Children with enuresis do have difficulty waking up, which may indicate an arousal problem rather than a sleep problem.
  • Recent stress: such as a move, new school or sibling, death or a divorce in the family.
  • Medical problem: Although most children do not have a physical cause for their wetting, an underlying problem such as urinary tract infection, diabetes, bowel problems, or an upper airway obstruction can contribute to the problem.

Types of enuresis

  • Nocturnal enuresis refers to wetting that occurs during the night or during sleep such as naps.
  • Diurnal enuresis refers to wetting that occurs when the child is awake.
  • Primary enuresis is when the child has never been dry for an extended time (3-6 months).
  • Secondary enuresis refers to wetting that begins after a child has been dry for 3-6 months.

Facts about enuresis

  • Nocturnal enuresis is more common in boys than girls.
  • Most children will outgrow bedwetting even without treatment. Unfortunately, we do not know at what age this will happen for a specific child.
  • Bedwetting should not be thought of as a behavioral problem. It is not the child's fault. It does not mean the child is lazy or bad. Children do not want, or like, to wake up in a wet bed.
  • Bedwetting can cause stress in the family and poor self esteem in the child if not managed properly.
  • Punishment or making fun of a child who wets the bed will only make the situation worse.

How will my child be evaluated?

  • A parental questionnaire
  • A detailed medical and voiding history
    • Families may expedite treatment by observing the child's voiding pattern and wetting pattern before the appointment, including information about how often the child urinates and how often they move their bowels (as well as the size and character of the bowel movement)
  • Physical examination
  • Urine tests (urinalysis and urine culture)
  • Other tests may be ordered if your child has other problems such as daytime wetting, other problems with urination, a history of urinary tract infections, chronic constipation, and/or soiling. Most children do not need additional tests.

Should my child be treated?

Not all children with night-time wetting need to be treated. Children should be treated if it causes a problem for both the child and the family. Several factors need to be considered in the choice of treatment. These factors include the child's age, how often the child wets, the child's motivation, other family factors, such as sleeping arrangements, and the family's schedule.

No one treatment plan works for all children. When your child is evaluated, we work to individualize treatment to fit the needs of the child and your family. It may take patience and time before your child becomes dry.

For further information or to schedule an appointment, please contact us.

Treating bedwetting: general guidelines

  • Remember to have your child go to the bathroom right before going to bed.
  • Encourage your child to drink 6-8 oz. of fluid per year of age (example: 6 glasses for a 6-year-old) before 3:30 pm, and limit to 6-8 oz. of fluid total from 3:30 pm until bedtime.
  • Keep track of drinks. Avoid drinks with caffeine, carbonation, citru,s and chocolate. These types of drinks increase the chance of an accident.
  • If your child wakes up at night for any reason, encourage him or her to get up and try to go to the bathroom. For the younger child, you may want to turn on a night light or put a potty chair in the room.

No one treatment works for all children. One or more of the following treatments may be recommended.

  • Motivational and behavioral therapy
  • Conditioning therapy
  • Medication therapy

Motivational and behavioral therapy

Motivational therapy

This involves the use of positive reinforcement. This can be either verbal praise or simple material rewards. A progress record (stickers and calendar) is kept, and stickers are placed on the calendar for each dry night. The child is rewarded each time a goal is reached.

Behavioral therapy

Children with small bladders will not stay dry unless they get up to urinate during the night. The best ways to have this happen is for your child to learn to wake up at night. Have your child practice following this self-awakening exercise at bedtime.

Tell the child to:

  1. Lie on your bed with your eyes closed.
  2. Pretend it's the middle of the night.
  3. Pretend your bladder is full.
  4. Pretend it is starting to ache.
  5. Pretend it is trying to wake you up.
  6. Pretend it is saying, "Get up before it's too late."

The child then gets up, walks to the bathroom and urinates.

Remember: Encourage your child to get up like this if he or she needs to in the middle of the night.

Conditioning therapy

This involves the use of alarms that teach the child to wake up at night when he needs to urinate. Small, battery-operated alarms are worn against the child's body and respond to moisture. The alarm awakens the child as soon as urination begins. The child should then get up and finish urinating in the toilet. The goal is for the child to learn to wake up when the bladder is full. This may take two to three months.

There are two types of alarms available. One alarm uses sound, much like a loud alarm clock. This method has a good long-term success rate of 70 percent. The newer alarm uses a mechanical vibration rather than sound to awaken the child. This is useful for the child who does not wake up to the sound alarm or for families in which the sound alarm is disruptive for other family members.

There are several resources for these alarms, including Bedwetting Store.

Medication therapy

There are three medications used to help children with wetting. They do not cure the problem but may help control the condition until the child outgrows it. The medicines may not work for everyone.

  • DDAVP nasal spray or tablets: This works by decreasing the amount of urine your child makes when sleeping. It may be used continuously, every night for several months or for special occasions such as sleepovers or camp.
    Cost: Expensive
    Side Effects: Rare
  • Imipramine (Tofranil®): An antidepressant which also helps with enuresis. We are not certain how it works. It may require a higher dose when using it long term. There is a high relapse rate when discontinued.
    Cost: Inexpensive
    Side effects: May cause anxiety, difficulty sleeping. Overdoses can be fatal. It is being used less frequently due to concerns about its toxicity.
  • Anticholinergics (ie. Levsinex®): These work by relaxing the bladder, allowing it to hold more urine. They may be useful in some children with enuresis who have a small bladder capacity and daytime symptoms such as urgency and frequency.
    Cost: Moderate
    Side Effects: Dry mouth, heat sensitivity, flushed cheeks, irritability, blurred vision.

In a small number of children, a combination of both DDAVP and an anticholinergic medication has been used successfully. Also, a combination of an enuresis alarm and medication has been successful in some children.

Page reviewed on: Apr 29, 2009

Page reviewed by: Leslie T. McQuiston, MD

Disclaimer