Bedwetting

What is bedwetting?

Night-time bedwetting, known formally as nocturnal enuresis, is a condition in which a toilet-trained child regularly urinates (pees) while sleeping. It is a common condition among young children and is not a sign of laziness, naughtiness, or any emotional immaturity. It is important not to blame or shame the child over this behavior, which is not under the child's control.

The question of when bedwetting becomes a 'problem' depends greatly on the attitude of the child and the family. The main factor in deciding whether to treat bedwetting is the child's degree of concern with the issue and their internal motivation to resolve it.

As a broad rule of thumb, regular (at least twice weekly) bedwetting above the age of about five years can be considered worth looking into. About 50% of three-year olds, 20% of four-year olds, and about 15% of five-year olds still wet their beds regularly. ^[1]

Many boys do not stop until the age of eight. Many more children wet their beds occasionally until they're 10. In a few people, bedwetting can persist into the teen years or adulthood.

There are several treatments available for bedwetting. For the vast majority of children, bedwetting eventually goes away by itself with or without treatment.

Types of treatment

There are several approaches to treating bedwetting. In-home methods are usually the first to be tried. If these do not help, your doctor can suggest more advanced options. Treatment strategies can often be combined for greater effect.

In-home treatment methods

• Making sure the child drinks enough fluids during the day;
• Restricting sugary or caffeinated drinks (cola, etc.) before bedtime;
• Motivation therapy - keeping records of dryness and establishing a reward system for 'dry' periods and for other related positive behavior;
• Encouraging (but not forcing) the child to help you with changing the bedding;
• Keeping a record of 'wet' and 'dry' nights to help assess the extent of the condition;
• Awareness training - at bedtime, asking the child to visualize that it is the middle of the night, their bladder is full and they wake up and go to the toilet;
• Leaving a night light on to help the child find their way to the toilet, and;
• Encouraging the child to empty their bladder just before bed.

The following strategies do not help stop bedwetting:

• Blaming or punishing the child;
• Diet restrictions;
• Bladder control training, and;
• Strict restriction of drinking before bedtime.

The practice of waking the child at night to go to the toilet is recommended by some experts, but not by others. It provides more 'dry' nights, but may not help your child's body learn to react to signals from their bladder.

Managing bedwetting

Until bedwetting stops, some techniques can help the family deal with it. These include:

• Using a mattress protector under the sheets;
• Spreading a large cloth or towel over the sheets, tucked under the sides of the mattress (the towel is easier to remove, wash and replace than a bedsheet);
• Having cleaning solutions on hand for the urine stains (in this writer's household, a mixture of equal parts water and white vinegar in a standard spray bottle with 10 drops of lemongrass essential oil is used to great effect);
• Making sure the child is clean and dry before going to day care or school, and;
• Being calm and patient and not allowing siblings to tease the child about their bedwetting.

Conditioning therapy

Alarm systems have proven to be the most effective long-term solution to bedwetting. Two out of three children respond positively to the treatment and many of them remain dry afterwards.

Alarm systems consist of an alarm or bell attached to a moisture-sensitive pad. The pad might be worn on top of the child's night clothes, or placed on the child's mattress. When the pad gets wet, the alarm rings and wakes the child up.

It is important that the child be the one to turn off the alarm. After going to the toilet, the child replaces wet bedding and clothes, dries off the pad, and goes back to sleep. The child needs to be fully awake and aware of their actions, otherwise the effect of this method is lost.

Alarm training helps about two-thirds of children stop bedwetting within weeks or a few months. ^[2] Sometimes the treatment needs to be repeated more than once.

Medication for bedwetting

Medication treatment for bedwetting is less effective than alarm systems as a long-term solution. It is usually tried after alarm training has been attempted.

Medications work more quickly, but their effect stops as soon as you stop taking the medicine. They can also have side effects such as headaches and nausea, though this is not common. Of these medications, desmopressin is the one most often used to treat bedwetting. It reduces the volume of urine the body produces. Imipramine is more effective than desmopressin, but is more likely to produce side effects.

Potential complications

Underlying problems

In most cases, bedwetting happens by itself. In certain cases of bedwetting it may be caused by an underlying condition. If bedwetting is persistent, your doctor may suggest examining the child to identify or rule out these conditions, which may include:

• Diabetes;
• Urinary tract infections;
• Constipation;
• Malformed urethra or other urological disease;
• Nerve problems;
• Sleep apnea, or;
• Emotional distress, violence or sexual abuse.

Investigations may include urine tests, blood tests and an ultrasound of the kidneys and bladder.

Secondary enuresis

Some children can start to wet their beds again after a dry period of six or more months. This is known as 'secondary enuresis'. Though this can happen for no particular reason, and go away after a while, it may also be a sign of emotional distress or an underlying physical condition as mentioned above. For this reason, it may be advisable to consult your doctor.

Prognosis

Bedwetting causes no physical harm to the child, generally stopping without treatment as the child becomes older. About 15% of children naturally stop every year. ^[2] One or more of the above treatment methods will help most children.

References

1. Murtagh J. MD. (2011) John Murtagh’s General Practice (5th revised edition). North Ryde N.S.W.: McGraw-Hill Australia Pty Ltd.
2. Robson W.L.M. (2009) Evaluation and management of enuresis. New England Journal of Medicine 360:1429–1436.
3. Caldwell P.H.Y. Deshpande A.V. and Gontard A.V. (2013) Management of nocturnal enuresis. BMJ 347:f6259–f6259.
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8. Caldwell P.H.Y. Deshpande A.V. & Gontard A.V. (2013). Management of nocturnal enuresis. BMJ 347: f6259f6259.
9. Choices N.H.S. (2013 November 29). Bedwetting - NHS Choices. Accessed 4 August 2014 from link here
10. Clearinghouse T.N.N.K. and U.D.I. What I need to know about My Childs Bedwetting. text. Accessed 4 August 2014 from link here
11. Information N.C. for B. Pike U.S.N.L. of M. 8600 R. MD B. et al. (2011). Fact sheet: Bedwetting in children and teenagers. PubMed Health. Accessed from link here
12. Murtagh J. (2008). John Murtaghs Patient Education (Australian edition.). North Ryde N.S.W.: McGraw-Hill Book Company Australia.
13. Murtagh J. MD. (2011). John Murtaghs General Practice (5th Revised edition.). North Ryde N.S.W.: McGraw-Hill Medical Publishing.
14. National Clinical Guideline Centre (UK). (2010). Nocturnal Enuresis: The Management of Bedwetting in Children and Young People. London: Royal College of Physicians (UK). Accessed from link here
15. Robson W.L.M. (2009). Evaluation and Management of Enuresis. New England Journal of Medicine 360: 14291436.
16. The Cochrane Collaboration (ed.). (1996). Cochrane Database of Systematic Reviews: Reviews. Chichester UK: John Wiley & Sons Ltd. Accessed from link here

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