Nocturnal Enuresis "Bed Wetting"
Introduction
Your child wakes up in the morning only to find that the bed is wet, again. You feel like you are continuously washing sheets and pajamas. You thought it would go away when your child got older, but it just continues to happen. Bedwetting in children, adolescents, and adults--is this abnormal? Can bedwetting be treated, or is it outgrown? Read on to learn more about bedwetting in children.
What is it?
Enuresis is involuntary voiding at an age when voluntary control of urination is expected. Nocturnal enuresis, bedwetting, is the uncontrolled discharge of urine during sleep.
Two types of nocturnal enuresis exist, primary and secondary. Primary nocturnal enuresis is bedwetting when the patient has never established urinary control. Secondary nocturnal enuresis is bedwetting after being dry for at least six months. It is not restricted to children and adolescents. Nocturnal enuresis, although uncommon, can be seen in adults.
What causes it?
The exact cause of nocturnal enuresis is unknown. It appears to be caused by multiple factors, and there are several theories available to help explain what is going on.
- Genetics: A child with both parents who experienced nocturnal enuresis as children has approximately a 77% risk of having nocturnal enuresis. There is about a 43% risk in children with one parent that had nocturnal enuresis. The children whose parents did not have nocturnal enuresis have a 15% risk of experiencing it.
- Bladder Capacity: The bladders of children with and without nocturnal enuresis have similar amounts of room to hold urine (bladder capacity). The difference is that children with nocturnal enuresis have a smaller functional bladder capacity. Functional bladder capacity is the amount of urine that is voided after prolonging urination as long as possible. Having a smaller functional bladder capacity also means that there will be an increased residual volume (the amount of urine left in the bladder after voiding). The smaller functional bladder capacity and increased residual volume can make it harder for these children to hold their urine through the night.
- Bladder Dysfunction: At one time people believed that nocturnal enuresis was caused by problems with the function of the bladder. Current research, however, shows that the bladder of children that experience nocturnal enuresis functions the same as a child that does not wet the bed.
- Sleep: Parents consistently report having more difficulty arousing their children with nocturnal enuresis from sleep compared to awakening their children without nocturnal enuresis. It is believed that this difficulty in arousal is what prevents them from awakening to go to the restroom.
- Psychologic Stressors: For a long time it was thought that nocturnal enuresis was caused by psychological problems in children. However, newer research shows that psychological problems, seen in children that wet the bed, are more likely the result of nocturnal enuresis and not the cause of it.
- Nocturnal Diuresis: There is a hormone released in the body that helps to regulate the amount of urine that is produced (antidiuretic hormone, ADH). An increase in ADH causes a decrease in the amount of urine produced. Most people release less ADH throughout the day and then have an increase at night. It is thought that children with nocturnal enuresis do not release high amounts of ADH at night and, thus, have an increased frequency and urgency to use the restroom at night.
- Other Causes: There are several other possible causes of nocturnal enuresis including: urinary tract infections, constipation, and delays in development. It can also be caused by an undiagnosed medical disorder, such as, diabetes or a seizure disorder. It is important to work with your child's physician to rule these out as the cause of the nocturnal enuresis.
Who has it?
Boys are 2-3 times more likely to wet the bed than girls are. Fifteen to twenty-five percent of five-year-old children have multiple episodes of nocturnal enuresis. For every year after the age of five, 14 out of every 100 children who had been wetting the bed stop. Although the chance is slim, nocturnal enuresis can last up to and through adolescence and adulthood.
What are the risk factors?
- Family history of nocturnal enuresis
- Impaired sleep arousal
- Nighttime bladder dysfunction
- Excessive nighttime urine production
- Constipation
- ADHD, attention deficit hyperactivity disorder
- Upper airway obstruction
- Sleep apnea
What are the symptoms?
Repeated urination into bed
- At least twice a week for at least three months
- Affects social or academic functioning
- Causes distress in parents and/or child
How is it treated?
Nocturnal enuresis is typically not treated until the patient is at least five years of age. More important than age when determining when to treat, is the child's readiness to receive treatment. If the child is not ready, the therapy is less likely to be successful. There are two basic types of treatment: behavior modification and drug therapy.
Behavioral Modification
Behavior modification therapies include bedwetting alarm, positive reinforcement, and responsibility training.
Bedwetting Alarm: These alarms are triggered to go off when the child wets the bed. The child, when awoken, will then either get up and finish voiding in the restroom or hold it until later. Most alarms that are available will emit a sound when they go off. However, there are alarms available that will vibrate instead. The vibrating alarms are useful in situations where the child is sharing a room with another sibling by preventing the awakening of others. The bedwetting alarm may need to be used for up to 16 weeks before symptoms resolve. After 14 dry nights in a row, the alarm should no longer be needed. Bedwetting alarms have proven to be the most effective treatment of nocturnal enuresis. They are also associated with the lowest percentage of patients who return to wetting the bed after stopping treatment.
Positive Reinforcement: There are a couple different methods used in positive reinforcement. One method involves the child placing stickers on a chart for every dry night. The child is working toward a preset number of stickers. The other method uses connect-the-dots. The child gets to connect two dots for every dry night, with the goal of completing the picture. For both methods, once the child reaches the preset number of stickers or completes the picture, the child is given a prize.
Responsibility Training: This method requires the child being given a responsibility that is age appropriate and a consequence of wetting the bed. It is important that the child does not feel like he or she is being punished. When the child wets the bed the assigned task is carried out. Taking the sheets off of the bed may be appropriate for younger children, while washing the sheets may be fitting for an older child.
Drug Therapy
The main drugs used to treat bedwetting are desmopressin (DDAVP), imipramine, and oxybutynin (Ditropan).
Desmopressin (dDAVP): Desmopressin is the first-line drug therapy for patients who experience nocturnal enuresis. It is a man-made form of vasopressin, an anti-diuretic hormone. It helps to decrease the amount of urine that is produced.
Imipramine: Imipramine is a tricyclic antidepressant that can be used to treat nocturnal enuresis. It works by decreasing the bladders ability to contract (or get smaller) this allows for the bladder to get fuller before needing to void. Imipramine also works by decreasing the depth of sleep that patients have during the last third of sleep. This will make it easier for the child to be awakened when he or she has the urge to go to the restroom.
Oxybutynin (Ditropan): Oxybutynin is an anticholinergic medication that works to relax the muscles of the bladder. It is most effective in patients that not only have wetting problems at night, but also during the day.
Other Measures
Other general measures that should be taken to help with the treatment of nocturnal enuresis include:
- Having children keep a voiding diary
- Improving access to the toilet
- Discontinuing fluids 1 or 2 hours before bedtime
- Encouraging voiding prior to going to bed
- Preserving the child's self-esteem.
Parents and children should be aware that it takes time for the treatments to be effective. If one treatment does not work one of the other treatments or a combination of treatments may be tried. Whichever treatment is chosen follow-up, support, and encouragement are important components of therapy.
After successful treatment and discontinuing of therapy there is still a possibility that the patient will rebound and begin wetting the bed again.
What is on the horizon?
Studies are now looking at combining indomethacin with desmopressin for treating nocturnal enuresis in those children that do not respond to treatment with desmopressin alone. Researchers are also studying a drug called temiverine, which will decrease bladder contractions and increase the amount of urine the bladder will hold. Specific sites in the bladder have been found that may cause enuresis. Researchers are looking at the possibility of new drug therapies that will target these sites. There is also research being done looking for treatments that will have an effect on the bladder, but not cause problems in other parts of the body.
References
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- Friman PC, Handwerk ML, Swearer SM, et al. Do children with primary nocturnal enuresis have clinically significant behavior problems? Archives of Pediatrics and Adolescent Medicine. 1998; 152 (6): 537-539.
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- Nocturnal Enuresis. Clinical Trials. U.S. National Institutes of Health. http://clinicaltrials.gov/. Accessed October 17, 2008.
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Nocturnal Enuresis "Bed Wetting" Health Condition Last Updated: October 2008
Note: The above information is intended to supplement, not substitute for, the expertise and judgment of your physician, pharmacist, or other healthcare professional. It is not intended to diagnose a health condition, but it can be used as a guide to help you decide if you should seek professional treatment or to help you learn more about your condition once it has been diagnosed.