Bedwetting • Healthy Parenting
31 January 2021
Bedwetting in Children (Nocturnal Enuresis)
Bedwetting, also known as nocturnal enuresis, is an uncontrollable leakage of urine while asleep. In children aged 5 years or over, enuresis is considered abnormal.
- Bedwetting is a common childhood problem, affecting up to 15 % of children aged 5 years old and above, and 0.5% to 2% of adults over 18 years of age.
- Children aged 8 to 16 years old have named bedwetting to be the 3rd most disturbing factor in their life, ranked after parental divorce and parental argument.
- 50% of the affected affected children did not receive timely and correct medical intervention, which may then lead to impaired social development skill.
- 25-30% of the affected children are subjected to some forms of physical punishment by caretaker.
- 15% of the affected children also have troublesome fecal incontinence or constipation.
- Non-monosymptomatic enuresis may be a symptom of more severe medical problems in the affected child.
Primary Enuresis vs Secondary Enuresis
Children who have never achieved a satisfactory period of nighttime dryness have primary enuresis, which accounted to 80% of childhood enuresis.
Secondary Enuresis refers to bedwetting that took place after a child has achieved a dry period of at least six months prior to wetting the bed again. It is often ascribed to an unusually stressful event (for example parental divorce or the birth of a sibling) at a time of vulnerability in a child's life. Stool retention and suboptimal daytime voiding habits often play a role. However, the exact cause of secondary enuresis may remain unknown.
Monosymptomatic vs Non-Monosymptomatic Enuresis
Monosymptomatic enuresis is defined as enuresis in children without any other lower urinary tract symptoms and without a history of bladder dysfunction.
In contrast, Non-monosymptomatic enuresis associated with other lower urinary tract symptoms (for example, daytime incontinence, difficulty initiating urination, weak urinary stream with drippling, painful urination, and the presence of constipation).
Non-monosymptomatic enuresis may warrant a timely referral to the Paediatric Nephrologist/ Urologist for further investigations, so as to rule out any structural or functional urinary tract anomaly.
Why it happens
What are the most common causes of bedwetting?
In most cases, bedwetting is caused by over-production of urine at night or reduced capacity of the bladder.
Anti-diuretic hormone/ Vasopressin (ADH) is a hormone secreted from brain to regulate the amount of water in the blood by telling the kidney how much water to save or to let out. In children who do not wet the bed, urine output decreases during the night following surge of ADH secretion. The opposite can be noticed in children with enuresis.
Delayed bladder maturation plays a role in nocturnal enuresis, and it can be observed that children with nocturnal enuresis have a smaller bladder capacity than age-matched children who can control their bladder at night.
Both delay in bladder maturation and reduced bladder capacity appear to be functional rather than anatomic, and treatment is generally not necessary as bedwetting ceases on its own as the child grows older.
Is bedwetting genetic?
There is a genetic tendency toward nocturnal enuresis. Bedwetting in monozygotic twins is almost twice as frequent as that among dizygotic twins (68% versus 36%). When one or both parents have a history of prolonged nighttime wetting, a staggering 40% and 75% of the children are affected respectively.
Is deep sleep pattern to be blamed for?
Whether abnormally deep sleep contributes to enuresis is controversial. Parents often describe their children with enuresis as excessively deep sleepers. This may be a bias of observation, since parents rarely attempt to wake children without enuresis.
An observation study reported children with severe and refractory enuresis (more than 4 wet nights a week) slept more lightly than children in the control group, but failed to wake before voiding. Other studies showed that sleep patterns among children with and without enuresis are similar.
Does it happen because my child is psychologically disturbed?
There is no direct causal relationship between psychologic abnormalities and bedwetting.
Life adjustment problems and low self-esteem tend to improve after bedwetting has stopped, which suggests that behavioral abnormalities are a result of bedwetting rather than the cause.
Constipation has been commonly associated with bedwetting amongst schoolgoing children, as it renders bladder unable to stretch and fill adequately. So, the mainstay of management in such cases would largely focus on managing the child's bowel problem.
Neurogenic bladder, in which a child lacks bladder control due to an injury or congenital defect to the nervous system, may too affect effective bladder emptying during daytime. Other urological conditions, such as posterior urethral valves (extra flaps in the urethra of boys that prevent the urine to pass from the bladder) and ectopic ureter (the tube that is supposed to connect the kidney to the bladder does not connect to the bladder, but drains urine to another site instead) would cause persistent incontinence throughout the day.
Nocturnal enuresis may be associated with neurodevelopmental problems, including intellectual disability, autism spectrum disorder, and attention deficit hyperactivity disorder. Other systemic medical conditions – diabetes mellitus, diabetes insipidus (conditions associated with deficient ADH secretion), too can cause bedwetting due to excessive urine production.
When should a doctor come in?
Most nocturnal enuresis usually can be managed by the primary care provider. A fraction of them will need timely intervention by a Paediatric Nephrologist/ Urologist when the condition has significantly compromised his or her quality of life, which includes:
- Suspicion of structural or anatomic abnormalities
- Non-monosymptomatic enuresis.
- Developmental, attentional, or learning difficulties.
- Behavioral or emotional problems
- Known or suspected physical or neurologic problems.
- Parents who have difficulty coping with the child's bedwetting, or tend to express anger, negativity, or blame towards the child
- Refractory enuresis (more than 4 wet nights a week)
Should a child or family is noted to cope poorly with the condition with regards to behavioral, social or/and learning difficulties, they may need additional support from a Developmental-Behavioral Paediatrician, a Behavioral Psychologist, a Child Psychiatrist, or an Adult Psychiatrist.
How can I help my child cope?
Words and actions of affirmation
Encouragement, positivity, and avoiding the administration of punishments help children boost their self-esteem, confidence, and eagerness to learn to stop wetting the bed.
Reduced fluid intake at night and urinate before bed
Let the child drink plenty of water (6-8 cups) throughout the day: Not drinking enough during the day will make the problem worse at night.
Only have a small drink before going to bed if necessary, and ideally stop liquid intake an hour before bedtime. Ensure the child urinate during teeth brushing, and another one just before being tucked into bed.
Quitting caffeine (soft drinks) and sugar (fruity or chocolatey drinks)
Caffeine stimulates the bladder to produce more urine, and an overload in sugar causes the body to try to flush it out via urine. Limiting these components in the child’s daily diet reduces chances of inflammation and irritability, and may stop the body from eliminating too much water.
A bedwetting alarm is an alarm placed in the child’s pyjamas, and rings when it gets wet. It works through by training the child’s conditioned reflex to respond to the sensation of wetness by waking up and going to the bathroom.
Desmopressin is a synthetic hormone resembling ADH, that helps to reduce nighttime urine production.
The use of desmopressin is effective when short-term improvement is a priority (for example, to attend an overnight camp; to cope with parents who express anger, negativity, or blame towards the child), but comes with a higher chance of relapse after cessation.
How should I not help my child cope?
Waking the child up to pee in the middle of the night interferes with the child's sleep and does not help to stop bedwetting.
Using diapers/ pull up pants to prevent the child from sleeping in wet clothes can demotivate the child to put in actual work towards achieving dry nights.
Criticisms or comparisons with other children can make the child feel inadequate for failing to meet the parents’ expectations, and subsequently become ashamed of themselves without knowing how to solve the problem.
Bedwetting can be a harmless part of the natural progression of life, or the symptom of a serious medical condition. In no circumstances should the child be punished or shamed for not hitting a developmental milestone others consider to be normal or inevitable.
Monitor children’s bedwetting problems and invite them to share so that more light can be shed on the possible causes of their problem and how to best address them. Your Paediatrician can also help support you on the best steps to take, and to provide an achievable treatment plan.
Explain to children how the urinary system (the kidneys, ureters, bladder, urethra, and brain) works, so that they can understand their own body more, and learn how to act at their own pace to alleviate the frustration.
Sunway Medical Centre Consultant Paediatric Nephrologist
Sunway Medical Centre Children's Health Centre
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