Bedwetting (Enuresis)

What is bedwetting (enuresis)?

Bedwetting, also called nocturnal enuresis, means that a child accidentally passes urine at night during sleep. Because this is normal in infants and very young children, bedwetting is not considered a medical problem unless it happens in a child who is already in elementary school or who was completely dry day and night and then began to wet the bed again during the night.  

By age 5, 80% to 85% of children are consistently dry throughout the night. After age 5, the number of children who continue to wet the bed decreases by about 15% per year, even without treatment. Only 1% of children still wet the bed by the time they are 15 years old. 

To help make diagnosis and treatment easier, doctors sometimes classify bedwetting into two types, primary and secondary nocturnal enuresis. In primary nocturnal enuresis, the child has never been consistently dry at night. In secondary nocturnal enuresis, the child has been dry at night for at least three to six months (or one year, according to some experts) and has begun to wet the bed again. It is very important to remember that in both types, the child is not wetting the bed on purpose.  

Primary Nocturnal Enuresis

This is the most common type of nocturnal enuresis, pediatricians think is caused by several developmental, genetic and hormonal factors acting together. 

• Developmental factors — Children with prolonged bedwetting may not yet be able to recognize that the bladder is full, or may not have developed enough control over the bladder's urinary sphincter (the muscle that controls the bladder opening) to stop urinating during sleep. In some children, areas of the brain that control arousal also may be affected, allowing the child to sleep through a full bladder rather than waking up to urinate.  
• Genetic (hereditary) factors — If both parents wet the bed when they were younger, three out of four of their children will have bedwetting problems. If only one parent wet the bed as a child, the odds decrease to slightly less than half. If neither parent wet the bed as a child, the odds that a child will wet the bed drop to one out of seven.  Recently, researchers have pinpointed two genes that are associated with bedwetting.  One is located on chromosome 12 and one on chromosome 13. Further research continues in this area.  
• Hormonal factors — Under normal circumstances, the body's level of a hormone that decreases the production of urine by the kidneys (antidiuretic hormone, or ADH) rises during sleep, causing the bladder to fill more slowly. In some children who wet the bed, this nighttime rise in antidiuretic hormone does not happen as expected. Therefore, the amount of urine made remains the same as during waking hours, so the bladder continues to fill as much as it would during the daytime.  
• Other factors — Some children with prolonged nighttime bedwetting may simply have smaller bladders compared with their "dry" peers.  

Although the specific combination of factors varies from child to child, the result is the same — bedwetting. In a small number of cases, primary nocturnal enuresis arises from a purely medical problem, such as a physical defect in the child's urinary tract, a neurological problem related to the spinal nerves or brain, or a urinary tract infection.  

Secondary Nocturnal Enuresis 
When a child starts to wet the bed again after being dry for months or sometimes even years, there is often an identifiable cause. One of the most common is stress, when a sudden change rocks a child's world.  

Almost any change in the environment — good or bad — can be a trigger; for example, a new baby, a death in the family, parents' divorce or marriage problems, a new home or school, or even a long visit from relatives. Secondary bedwetting may be related to sexual abuse or to extreme bullying. Rarely, this form of bedwetting is related to a medical problem, such as a urinary tract infection or diabetes, and in these cases there are usually other obvious symptoms of medical illness. 

Symptoms of bedwetting

In most children with bedwetting, soaked sheets and wet pajamas are all that parents will see. In rare cases caused by a medical illness, such as urinary tract infection or diabetes, there may be other symptoms. It is especially important to watch for such symptoms in an older child who starts wetting the bed after having been dry in the past: 

• Urinary tract infection — If a child's bedwetting is being caused by a urinary tract infection, he or she may urinate more often than normal day and night. The child may complain of an uncomfortable, painful or burning feeling when urinating, and his or her urine may look cloudy or have a very strong odor. Other symptoms may include fever, chills and pain in the back or abdomen. 
• Diabetes — This illness affects one out of every 400 to 600 children younger than 16, with many cases beginning around ages 5 to 7 or at the time of puberty. 

Typical symptoms include frequent trips to the bathroom to urinate, excessive thirst, being tired all the time, inactivity and weight loss, even though the child may have a healthy appetite and eat a lot. 

Diagnosing bedwetting

The doctor will ask about any family history of bedwetting. If one or both parents were affected during childhood, the doctor will want to know the age when a parent's bedwetting stopped. In many cases, a child's bedwetting will stop around the same age. 

The doctor will ask about your child's eating and drinking habits, especially about drinking right before bedtime and eating snacks that melt into liquids, such as ice cream or gelatin desserts. In a child who has been dry in the past, your doctor will want to know about any unusual stresses, either at home or at school, that might be triggering the bedwetting. 

To rule out medical illnesses and conditions as a cause of your child's bedwetting, the doctor will ask about additional symptoms related to a urinary tract infection or diabetes. The doctor will ask whether there is anything unusual about the way your child urinates, including straining during urination or changes in his or her urine stream.  

The doctor will examine your child, paying special attention to your child's belly (abdomen), genital area and lower spine, looking for any physical changes in these areas. The doctor will order a test of your child's urine (urinalysis) to look for signs of a urinary tract infection or diabetes. In most cases, your doctor can make a correct diagnosis based on your child's age, the history of bedwetting, any additional symptoms, and the results of the physical examination and urine test. 

If your child has symptoms that suggest a urinary tract infection, diabetes or other problems, additional tests may be needed. Children with primary nocturnal enuresis do not routinely need X-rays or other tests that measure bladder size, shape or function.  

Expected duration of bedwetting

Almost all children stop wetting the bed by the time they reach their mid-teens, even without treatment. By age 15, only one out of 100 children is not completely dry at night.

Preventing bedwetting

To help your child achieve his or her first dry night, try these suggestions: 

• Provide encouragement and praise for dry nights. Never punish, shame or blame. 
• Remind your child to urinate before going to bed. If he or she doesn't feel the need to urinate, tell your child to try anyway. 
• Limit liquids in the last two hours before bedtime. Also, limit foods that melt into liquids, such as ice cream and flavored gelatin (Jell-O).  
• Use cloth underwear rather than diapers or plastic pants. "Grown-up" pants help remind your child to stay dry.  
• Try waking your child once each night for a bathroom trip. Set an alarm near your child's bed or your own. 
• To make cleanup easier, place a rubber liner or large plastic bag under cloth sheets.  
• Even after your child has become completely toilet trained, occasional accidents will happen. It is important that you remain calm and casual as you change the bed sheets and underpants. You can do this with your child's help. Do not show disgust or disappointment. 

Treating bedwetting

When bedwetting is caused by a medical problem, treatment depends on the specific diagnosis. 

If your child has no specific medical problem causing him or her to wet the bed, but has never been dry at night, there are several treatment options: 

• Motivational therapy — Your doctor may suggest that you begin by trying a "token and reward system" to motivate your child to stop bedwetting. This typically involves using a colorful chart to keep track of your child's progress, with a gold star for every dry night. When the chart is filled, you can let your child select a treat. Many doctors encourage the use of three to six months of motivational therapy before trying other treatments. 
• Behavioral therapy — After age 8, your doctor may recommend behavioral therapy with an enuresis alarm. An enuresis alarm uses sounds or vibrations to wake a child who wets the bed or his or her underwear. In some cases, behavioral therapy is combined with motivational therapy to reinforce successful behavior by rewarding the child for dry nights. 
• Bladder training exercises — A few children with bedwetting respond to bladder-retention training. In this approach, the child is encouraged to hold his or her urine for longer and longer periods during the daytime. 
• Medications — Several medications are available to treat primary nocturnal enuresis, though these rarely are used first. 
  • One of the safest and most commonly used medications for treating bedwetting is desmopressin acetate (Concentraid, DDAVP, Stimate), a synthetic drug that is similar to the body's natural antidiuretic hormone. The initial treatment usually lasts for three to six months.  
  • If desmopressin is successful in keeping the child dry during this treatment period, the drug is tapered gradually and eventually stopped. Often the problem returns after the child has stopped taking the medication. Some children can use this medication to stay dry only when needed, such as when the child is away at summer camp or at a friend's sleepover party.  
• Combination therapy — In some children, a combination of medications and behavioral therapy will stop bedwetting when other treatments have failed.  
• Other options — Studies show that hypnosis, diet therapy (especially cutting out caffeine) and psychotherapy work in some cases. 

When to call a professional

Call your doctor immediately if your child starts wetting the bed after being dry for several months or if your child has symptoms of a urinary tract infection or diabetes.  

Call your doctor to discuss whether treatment would be recommended for your child who has never been dry at night and has started elementary school.  

Prognosis

Because almost all children eventually outgrow bedwetting, the outlook is excellent, even without treatment. 

With treatment, the success rate depends on the type of therapy. Motivational therapy succeeds in about 25% of children, behavioral therapy in about 70%, and bladder training in about 66%. The success rate of the drug, desmopressin acetate, may be as high as 70%, but varies widely in research studies.  

Additional info

National Institute of Diabetes & Digestive & Kidney Disorders
https://www.niddk.nih.gov/

American Academy of Family Physicians (AAFP)
https://www.familydoctor.org/

American Academy of Pediatrics (AAP)
https://www.aap.org/