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Nocturnal enuresis, also called Bedwetting, is involuntary urination while asleep after the age at which bladder control usually occurs. Nocturnal enuresis is considered primary (PNE) when a child has not yet had a prolonged period of being dry. Secondary nocturnal enuresis (SNE) is when a child or adult begins wetting again after having stayed dry.

Most bedwetting is a developmental delay—not an emotional problem or physical illness. Only a small percentage (5% to 10%) of bedwetting cases are caused by specific medical situations. Bedwetting is frequently associated with a family history of the condition.
Treatments range from behavioral-based options such as bedwetting alarms, to medication such as hormone replacement, and even surgery such as urethral enlargement. Since most bedwetting is simply a developmental delay, most treatment plans aim to protect or improve self-esteem. Bedwetting children and adults can suffer emotional stress or psychological injury if they feel shamed by the condition. Treatment guidelines recommend that the physician counsel the parents, warning about psychological damage caused by pressure, shaming, or punishment for a condition children cannot control.
Bedwetting is the most common childhood complaint. Most girls stay dry by age six and most boys stay dry by age seven. By ten years old, 95% of children are dry at night. Studies place adult bedwetting rates at between 0.5% and 2.3%.

What Is Bedwetting?

Bedwetting, or nocturnal enuresis, refers to the unintentional passage of urine during sleep . Enuresis is the medical term for wetting, whether in the clothing during the day or in bed at night. Another name for enuresis is urinary incontinence .

For infants and young children, urination is involuntary. Wetting is normal for them. Most children achieve some degree of bladder control by 4 years of age. Daytime control is usually achieved first, while nighttime control comes later.

The age at which bladder control is expected varies considerably.

  • Some parents expect dryness at a very early age, while others not until much later. Such a time line may reflect the culture and attitudes of the parents and caregivers.
  • Factors that affect the age at which wetting is considered a problem include the following:
    • The child’s gender: Bedwetting is more common in boys.
    • The child’s development and maturity
    • The child’s overall physical and emotional health. Chronic illness and/or emotional and physical abuse may predispose to bedwetting.

Bedwetting is a very common problem.

  • Parents must realize that enuresis is involuntary. The child who wets the bed needs parental support and reassurance.

Bedwetting is a treatable condition.

  • While children with this embarrassing problem and their parents once had few choices except waiting to “grow out of it,” there are now treatments that work for many children.
  • Several devices, treatments, and techniques have been developed to help these children stay dry at night.

What Causes  Bedwetting?

While bedwetting can be a symptom of an underlying disease, the large majority of children who wet the bed have no underlying illness. In fact, a true organic cause is identified in only a small percentage of children who wet the bed. However, this does not mean that the child who wets the bed can control it or is doing it on purpose. Children who wet the bed are not lazy, willful, or disobedient.

There are two types of bedwetting: primary and secondary. Primary bedwetting refers to bedwetting that has been ongoing since early childhood without a break. A child with primary bedwetting has never been dry at night for any significant length of time. Secondary bedwetting is bedwetting that starts again after the child has been dry at night for a significant period of time (at least six months).

In general, primary bedwetting probably indicates immaturity of the nervous system . A bedwetting child does not recognize the sensation of the full bladder during sleep  and thus does not awaken during sleep to urinate into the toilet.

The cause is likely due to one or a combination of the following:

  • The child cannot yet hold urine for the entire night.
  • The child does not waken when his or her bladder is full. Some children may have a smaller bladder volume than their peers.
  • The child produces a large amount of urine during the evening and night hours.
  • The child has poor daytime toilet habits. Many children habitually ignore the urge to urinate and put off urinating as long as they possibly can. Parents are familiar with the “potty dance” characterized by leg crossing, face straining, squirming, squatting, and groin holding that children use to hold back urine.

Secondary bedwetting can be a sign of an underlying medical or emotional problem. The child with secondary bedwetting is much more likely to have other symptoms, such as daytime wetting. Common causes of secondary bedwetting include the following:

  • Urinary tract infection : The resulting bladder irritation can cause lower abdominal pain  or irritation with urination (dysuria ), a stronger urge to urinate (urgency), and frequent urination  (frequency). Urinary tract infection  in children may in turn indicate another problem, such as an anatomical abnormality.
  • Diabetes : People with type I diabetes  have a high level of sugar (glucose) in their blood. The body increases urine output as a consequence of excessive blood glucose levels. Having to urinate frequently is a common symptom of diabetes .
  • Structural or anatomical abnormality: An abnormality in the organs, muscles, or nerves involved in urination can cause incontinence  or other urinary problems that could show up as bedwetting.
  • Neurological problems: Abnormalities in the nervous system, or injury or disease of the nervous system, can upset the delicate neurological balance that controls urination.
  • Emotional problems: A stressful home life, as in a home where the parents are in conflict, sometimes causes children to wet the bed. Major changes, such as starting school, a new baby, or moving to a new home, are other stresses that can also cause bedwetting. Children who are being physically or sexually abused sometimes begin bedwetting.
  • Sleep patterns: Obstructive sleep apnea  (characterized by excessively loud snoring  and/or choking  while asleep) can be associated with enuresis.
  • Pinworm infection : characterized by intense itching of the anal and/or genital area.
  • Excessive fluid intake.

Bedwetting tends to run in families. Many children who wet the bed have a parent who did, too. Most of these children stop bedwetting on their own at about the same age the parent did.

What Are Risk Factors for Bedwetting?

Risk factors for the development of enuresis include

  • male gender and family history;
  • medical conditions such as abnormal anatomy or function of the kidneys, bladder, or neurologic system;
  • sleep apnea ;
  • chronic constipation ;
  • sexual abuse;
  • excessive fluid intake before bedtime;
  • urinary tract infection ; and
  • some medications (for example, caffeine ).

What Symptoms May Be Associated With Bedwetting?

Most people who wet their beds, wet only at night. They tend to have no other symptoms other than wetting the bed at night.

Other symptoms could suggest psychological causes or problems with the nervous system or kidneys and should alert the family or health-care provider that this may be more than routine bedwetting.

  • Wetting during the day
  • Frequency, urgency, or burning on urination
  • Straining, dribbling, or other unusual symptoms with urination
  • Cloudy or pinkish urine, or blood stains on underpants or pajamas
  • Soiling, being unable to control bowel movements (known as fecal incontinence  or encopresis )
  • Constipation

Frequency of urination is different for children than for adults.

  • While many adults urinate only three or four times a day, children urinate much more frequently, in some cases as often as 10-12 times each day.
  • “Frequency” as a symptom should be judged in terms of what is normal for that particular child.
  • Equally important, “infrequent voiding” (less than three times urinating/day) can be a sign of other underlying problems.

Fecal impaction may present as constipation. Both fecal impaction and constipation cause straining, which can injure the nearby urinary sphincters, muscles that control flow of urine out of the body.

  • Fecal impaction occurs when feces becomes so tightly packed in the lower intestine (colon ) and rectum that passing a bowel movement becomes very difficult or even impossible. When the stool is passed, it is often a painful experience.
  • The hard, tightly packed feces in the rectum can press on the bladder and surrounding nerves and muscles, interfering with bladder control.
  • Neither fecal impaction nor constipation is unusual in children.
  • A strict bowel regimen utilizing dietary modification and/or over the counter medications can often alleviate bedwetting.

What Specialists Treat Bedwetting?

Routine evaluation and management of both primary and secondary enuresis should be in the domain of a pediatrician or family practice physician. If a complex cause for the child’s enuresis is determined or if routine therapies are not helpful, a consultation with a pediatric urologist would be in order.

When Should a Child Seek Medical Care for Bedwetting?

The decision of when to involve your health-care professional is variable and is most commonly based on how the situation is affecting the child, as well as the parents. If the child displays only nighttime wetting without any other symptoms, then the decision about when to seek medical treatment is up to the family.

  • It is probably a good time to seek medical help when the child is 5-7 years of age.
  • Referral to a specialized enuresis clinic is likely not needed for most children with no other symptoms. This is a reasonable problem for the child’s pediatrician to handle.

A child should be checked without delay for an underlying medical problem if he or she develops any other physical or behavioral symptoms.

What Exams and Tests Assess Bedwetting?

The health-care provider will ask many questions about the child’s symptoms and about many other factors that can contribute to bedwetting. These include the following:

  • The pregnancy  and birth
  • Growth and development, including toilet training (both urine and stool)
  • Medical conditions. Specific attention is focused on the following:
    • Wetness of underwear: indicates day and nighttime enuresis
    • Palpating stool in the abdomen: indicates possible constipation or other obstruction
    • Excoriation of genital or vaginal area: possible scratching due to pinworms
    • Poor growth and/or high blood pressure : possible kidney disease
    • Abnormalities of the lower spine: possible spinal cord abnormalities
    • Poor urinary stream or dribbling: possible urinary abnormalities
  • Medications, vitamins, and other supplements
  • Family history if one or both parents were enuretic, approximately one-half to three-quarters of their offspring may also wet the bed. Identical twins are twice as likely to both be enuretic when compared to fraternal siblings.
  • Home and school life: recent stress, how this problem is affecting the child and family, any attempts at therapy which have been tried
  • Behavior
  • Toilet habits: Record a voiding diary (daytime pattern and volume of urine, to determine bladder volume) and stool diary (to evaluate for constipation).
  • Nighttime routines
  • Dietexercise, and other habits: Is there caffeine  intake?

There is no medical test that can pinpoint the cause of primary enuresis. Secondary enuresis more commonly reflects underlying pathology and thus warrants laboratory and possibly radiologic evaluation.

  • A routine urine test (urinalysis ) usually is performed to rule out any urinary tract infection or kidney disease .
  • An X-ray or ultrasound  of the kidneys and bladder may be done if a physical problem is suspected. Occasionally, MRI  examination of the lower spine/pelvis is indicated.

Generally, medical professionals divide bedwetting into uncomplicated and complicated cases.

  • Uncomplicated cases consist of only bedwetting with no other symptoms, a normal urinary stream, and no daytime urination complaints or soiling. These children have a normal physical exam and urinalysis findings.
  • Complicated cases may be any of the following: wetting in relation to another disease or condition, problems urinating, soiling or daytime urinary incontinence, or urinary tract infections . These children require further evaluation.

Children who have complicated bedwetting may be referred to a specialist in urinary tract problems (urologist) for further evaluation.

What Is the Medical Treatment for Bedwetting?

After an organic cause has been ruled out, there is no medical urgency to treat the child. Bedwetting tends to go away by itself. Discuss the treatment options with your child’s health-care provider; together you can decide whether treatment is right for your child.

Several drug therapies are available.

  • These are typically reserved for children who have not stayed dry by using the alarms.
  • Adults with bedwetting often take medications. They may have to stay on the medication indefinitely.
  • The drugs do not work for everyone, and they can have significant side effects.
  • The two drugs have been approved by the U.S. Food and Drug Administration (FDA) specifically for bedwetting are desmopressin  (DDAVP ) and imipramine (Tofranil ). Others, which are not specifically approved for bedwetting, are oxybutynin  (DitropanUrotrol ) and hyoscyamine  (CystospazLevsinAnaspaz ).

Medical opinion is divided on using drugs to treat bedwetting. Many believe that, since the child will outgrow the bedwetting anyway, the risks outweigh the benefits of taking the drugs.

Surgery for Bedwetting

Certain underlying medical or physical conditions may require surgery.

What Medications Treat Bedwetting?

Desmopressin acetate (DDAVP) is a synthetic form of antidiuretic hormone (ADH), a substance that occurs naturally in the body and is responsible to limiting the formation of urine.

  • It has been in use for the treatment of bedwetting for about 10 years and is generally the first medication prescribed.
  • This drug imitates ADH in the body, which is secreted by the brain; it increases the concentration of the urine and reduces the amount of urine formed. It is recommended to be taken just before going to bed.
  • Its main use is for children who have not been helped by an alarm. It is also used as a stopgap measure to help children attend camps or sleepovers without embarrassment.
  • DDAVP comes as a pill and is taken before bedtime. Side effects are uncommon but include headache, runny nose, nasal stuffiness, and nosebleeds. A previously manufactured nasal spray form is generally not used since it is more likely to be associated with potentially severe side effects.
  • The dose is adjusted until effective. Once it is working, the dose is tapered if possible. About 25% of children with enuresis will have total dryness with desmopressin, while approximately 50% will have a significant decrease in bedwetting. When compared with alarm devices, however, approximately 60% of patients will return to bedwetting when DDAVP administration is stopped.

Imipramine is a tricyclic antidepressant that has been used to treat bedwetting for about 30 years.

  • How it works is not clear, but it is known to have a relaxing effect on the bladder and to decrease the depth of sleep in the last third of the night.
  • Initial cure rates range from 10%-60%, and it has a relapse rate of up to 80%.
  • Side effects tend to be rare with correct dosage, but nervousness, anxiety, constipation, and personality changes have been reported.
  • It can have toxic side effects if taken improperly or as an accidental overdose. Deaths have been attributed to accidental overdoses – most commonly associated with abnormal heart-rhythm patterns.
  • It may be combined with desmopressin if desmopressin alone is not effective.

Oxybutynin and hyoscyamine are medications that reduce unwanted bladder contractions. They help relieve daytime urgency and frequency in addition to uncomplicated bedwetting. Their side effects include dry mouth, drowsiness, flushing, heat sensitivity, and constipation.

One response to “Bedwetting (Nocturnal Enuresis)”

  1. firasat jhujh says:

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