About children's bedwetting
Posted by Karen Radford on
Bedwetting, known technically as Primary Nocturnal Enuresis, or just plain Enuresis1, has been around for thousands of years. Indeed, the term ‘Enuresis’ is the Latin medical name for a Greek word meaning to urinate in. So, the ancient Greeks were obviously acquainted with the matter of involuntary night-time wetting.
The first references to bedwetting are found in the Ebers papyri, Egyptian medical manuscripts on herbs and cures, written around 1550 BC, over 3,500 years ago! The cure recommended for bedwetting was to boil faïence beads, made of steatite or soapstone, and make a pellet for the child to ingest...it was apparently the magnesium released on boiling the beads that provided its medicinal value!
Fast-forward several millennia and there has been good, evidenced-based, research identifying some of the underlying causes of enuresis and appropriate treatments regimes. However, even though it is one of the most common paediatric health issues affecting 15-20% of five-year-olds, 6-8% of eight-year-olds and 1-2% of over fifteen-year-olds, our reticence to talk openly about bedwetting means that affected families and many health practitioners often have limited understanding of its causes and cures.
Part of the reason may be embarrassment- uncontrolled urination does not invoke the same feelings of sympathy for the sufferer as do more pernicious diseases and conditions. Also, because enuresis is a pathologically benign condition-no-one dies from it- and there is a spontaneous cure rate in 15% of bedwetters per year, it is often the expectation that time will be the antidote.
This approach may work where the child is in a caring and supportive environment, but peer pressure can often lead to self-esteem issues and, in this case, the best approach is to treat it.
Enuresis - Gender and Genetics
Enuresis tends to favour boys until adolescence -around 2/3 of bedwetters are boys and 1/3 are girls. By adolescence the ratio is closer to 50/50. During late teens, however, around two-thirds of bedwetters are female, while one-third are male. There is no scientific explanation for bedwetting’s gender bias at certain age groups. A possible explanation is that girls mature faster than boys then boys close this gap as they get older.
Genes are an important factor in bedwetting. If one parent was bedwetter then a child has a 40% chance of being one too, and, if both parents were this increases to 70%. Some clinics report that if bedwetting also occurred in grandparents, immediate uncles and nephews, then the child has a more than 90% chance of being a bedwetter.
Unfortunately, despite genes, if a bedwetter’s parent/s outgrew bedwetting at a certain age this doesn’t mean that the child will too.
Types of Enuresis
Involuntary night-time urination in children can take several forms:
The child is dry during the day and only wets during the night. Up to 75% of bedwetters are mono-symptomatic.
The main causes of mon-symptomatic enuresis are usually developmental:
- High sleep arousal thresholds that prevent the child waking up when the bladder signals that it is full. Often the child will also sleep through loud noises e.g. loud music, the dog barking.
- Low levels of anti-diuretic hormone (ADH) which stops the kidneys producing so much urine during sleep. The child with low ADH levels will tend to go to the toilet multiple times during the night (nocturia) and wet in large volume when they don’t wake to go to the toilet.
Also, some children also have small bladder capacity in conjunction with these symptoms.
The child is dry during the day but displays symptoms of Lower Urinary Tract dysfunction (LUTD). Up to 25% of bedwetter are non-mono-symptomatic.
LUTD can include:
- daytime urgency indicative of an overactive bladder (the child must rush to the toilet when the urge strikes). During the day the child will tend to visit the toilet frequently and always in an urgent rush. They tend to have multiple wet patches during the night and can wake up after wetting the bed.
- postponement of toileting using withholding tactics such as sitting on the heels to apply pressure on the crotch and stop the let-down (very busy children!).
- atypical toileting habits e.g. having stop/start wees, or having to apply pressure to the lower abdomen to go wees.
Treating enuresisMost experts believe that Urotherapy should be an integral part of the management of enuresis, no matter what form it takes.
- optimising fluid intake to ensure the child is sufficiently hydrated during the day. A 250ml glass of water taken 6 times a day is ideal (when the child wakes, before leaving for school, at morning tea, at lunchtime, at afternoon tea and at dinner). This can help stretch the bladder, for those with small bladder capacity, so it may not need to void so many times during the night.
- programmed regular toilet visits (every 2-3 hours, or 4-7 times/day).
- teaching a child to recognise and employ conscious control over their lower urinary tract using effective voiding postures, comfortable buttock support and hip abduction, as well as foot rest (elevating a child’s legs on a small stool during toileting may help achieve these outcomes).
Alarm treatment can be very successful for children with high arousal thresholds.
In the case of nocturia, pharmacological treatments such as desmopressin2 can also produce improvements where low levels of ADH are indicated and the child is unresponsive to alarm treatment or Urotherapy. However, it is generally not prescribed for children under 6 years old because of the risk of rare but harmful side effects.
Diagnosis of the cause of LUTD in children with non-mono-symptomatic enuresis requires proper Uroflowmetry3 and Scan analysis4.
Urotherapy including programmed toilet visits can help with children with an overactive bladder. Where small bladder capacity is implicated together with an overactive bladder then anticholinergics5 may provide improvement in the child’s bedwetting when Urotherapy fails.
However, not all children with an overactive bladder and small capacity improve with anticholinergics and bladder training. In this case bladder biofeedback6 can be successful.
Treatment of atypical toileting where there is dysfunctional and incomplete voiding may require biofeedback or urologist referrals.
The benefits of curing enuresis
Treating and curing enuresis can be beneficial to a child’s self-esteem, particularly if it is undertaken before their social and school calendar involves nights away from home e.g. sleepovers and school camps.
Treating bedwetting can also be an early lesson in resilience, persistence and the ability to problem-solve, all good skills for later in life.
There are also benefits for the household budget in terms of reduced laundry costs and diapers….and, hopefully, more sleep!
If you would like to discuss this please contact me or leave a comment below.
- Update report from the Standardisation Committee of the International Children’s Continence Society (ICCS) on The Standardisation of Terminology of Lower Urinary Tract Function in Children and Adolescents (Wiley Periodicals Inc, Neurology and Urodynamics DOI 10.002/nau.22751).
- Desmopressin mimics the natural hormone that causes the kidneys to conserve body water and concentrate the urine, decreasing urine output during sleep.
- A Uroflowmeter tests the amount of urine voided during urination. It also measures the speed of urination and can help identify the causes of certain urinary difficulties.
- A scan will reveal whether the bladder empties completely during urination.
- Anticholinergics reduce the number of involuntary bladder contractions and also have a relaxant effect on the smooth muscle of the bladder so that it stays closed when the bladder fills.
- Biofeedback training for children is based on the assumption that relaxation and contraction of the urinary external sphincter is a habitual phenomenon and can be restored. With specially developed, computer-assisted biofeedback programs, sphincter contraction and relaxation can be transformed into acoustic or visual signals. Acoustic or optical feedback indicates relaxation and contraction control to the patient.