BED WETTING – (NOCTURNAL ENURESIS)
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What is bed wetting?
Bed wetting is normal in small children. Over the age of 5 years it is called nocturnal enuresis. Nocturnal = night. Enuresis = incontinence of urine. Most of the time bed wetting is the only symptom, but some children also have problems with toileting during the day.
How common is bed wetting?
| Age | 5 year olds | 10 year olds | 15 year olds |
| How many | 1 in 7 | 1 in 20 | 1 in 100 |
| % | 15% | 5% | 1% |
In childhood, more boys than girls are affected.
70% of affected children have a parent who had enuresis.
What is the prognosis?
Every year, 1 in 7 (15%) cases of bed wetting resolve spontaneously.
What causes bed wetting?
Genetic
Bed wetting tends to run in families. The chance of a child having enuresis is just under 50% if one parent had it and about 75% if both parents had bed wetting in the past. No specific gene has been isolated; certainly multiple genes will be involved.
Stress
Events stressful for the child such as bullying, moving house or family problems can be associated with bed wetting.
Diet
Cola, chocalate, tea, coffee and alcohol can cause more urine to be made and can exacebate enuresis.
Constipation
Bowel problems are often associated with bladder problems, including enuresis.
Breathing problems
Problems breathing at night, from enlarged tonsils and adenoids for example, can cause enuresis.
Medical problems
Rarely, disorders that increase urine output, decrease bladder capacity or impair arousal from sleep can result in bed wetting. Generally other symptoms will also be present.
How does bed wetting happen?
Normally, the body reduces the amount of urine it makes at night, the bladder can hold enough urine to last the night and, if the bladder does fill up, one awakes from sleep to go to the toilet.
The 3 factors that can lead to bed wetting are:
1. Too much urine production at night
2. Small functional bladder capacity
3. Poor arousal from sleep (“deep sleep”).
How is bed wetting evaluated?
Your doctor will take a history and perform an examination. Considerations include:
- Has there ever been a period (>6 months) of being dry at night?
- Are there any symptoms during the day eg urgency, day wetting?
- Is constipation present?
- Is there snoring or other breathing problems?
- Is the bed wetting causing problems / distress?
- Are there other stresses / problems in the home or at school?
Children should have a urine test looking for any glucose or any signs of infection. When daytime symptoms are also present, an ultrasound examination of the kidneys and bladder may be needed.
A voiding diary can be helpful if there is a question of urinary symptoms during the day. Parents should note down in the diary:
- Time of urination
- Volume of urine
- Relationship to urination and common events
- Any urgency or incontinence
A bowel calendar kept for 2-4 weeks is helpful if constipation is suspected to be a contributory factor.
TREATMENT
When should bed wetting be treated?
Treatment is usually delayed until at least 7 years of age. Treatment is more likely to be successful if there is motivation on behalf of the child. Treatment should certainly be instituted if the child is suffering any embarrassment, problems at school, loss of self esteem or any other form of psychological distress.
Simple measures
1. Drink plenty of fluid during the day (eg one 750ml bottle full)
2. Avoid drinking too much in the evening
3. Empty bladder before going to bed
4. Ensure easy access to the toilet (eg leave a light on, sleep on bottom bunk, have a torch handy)
5. Let child be involved in cleaning up but do not use any punishments – punishment is counterproductive
6. Keep a diary
7. Use positive reinforcement, encouragement, a star chart, rewards for dry nights.
Scheduled wakening
The child is woken during the night to get up and urinate. After a period of dry nights, wakening can become progressively earlier in the night.
Alarm Therapy
- After instituting simple measures, and trying scheduled wakening, alarm therapy can be instituted if necessary.
- Alarm therapy will have the highest chance of success in children who are motivated and over 7 years of age.
- Alarm therapy is successful in about three quarters of children.
- Successfully treated children usually begin to have a response in the first month.
- Regular dryness typically takes a total of 3-6 months of continuous therapy.
- Alarms can be borrowed from a local Public Health Nurse or Incontinence Nurse or
purchased (many pharmacy stock or can order in alarms) or hired privately – see www.KEEA.org.nz
- Different types of alarm are available, with no evidence that one is better than another:
- Pad and bell
- Body-worn
- Vibrating
- Therapy is considered successful after 14 consecutive dry nights.
- It is useful to give extra fluids to drink in the evening for another 7-14 days after the initial success before discontinuing the alarm (‘overlearning’).
Relapse
- Relapse occurrs in about 20% of cases (although some report up to 50%).
- Relapse should be treated promptly.
- With another course of alarm therapy relapse is usually successfully treated.
Medication
Treatment with a drug called desmopressin works more quickly than alarm therapy but relapse if about 10 times more common after treatment has stopped. Desmopressin can be useful for:
- Short term use
- Nights away from home
- Camps
- Sleep overs
- Temporary help at the start of alarm therapy
- Second line treatment where alarm therapy has failed For short term use, desmopressin treatment may need to start a few days before it is needed because it may not work on the first night.
- When used long-term, desmopressin should be stopped every 3 months for 1-3 weeks to see if the enuresis has resolved. Withdrawal of therapy can be made gradually with rewards for dry nights without medication.
Side effects of Desmopressin
- Water intoxication
- Cerebral oedema
- Convulsions
- Rare
- Prevented by avoiding fluid intake in the evening (no drinks after dinner)
- Nasal problems (from desmopressin spray)
- Nose bleeds
- Nasal congestion
- Rhinitis
Precautions with desmopressin
- Children should not drink for 2 hours before bedtime nor during the night.
- The medication should not be administered on nights when there has been excessive fluid intake (eg evening sports or socials)
- Discontinue desmopressin if headache, nausea or vomiting develop.
Other medication
For children with an overactive bladder and symptoms during the day, oxybutinin treatment may be prescribed. Side effects of oxybutinin include:
- Dry mouth
- Blurred vision
Other treatments
Several other forms of treatment of enuresis have been trialled, some effective, some not. Most are not widely available. Apart from the medications outlined above, drug treatment is not recommended.
Resources
Waitemata Health Child and Youth Service, Jill Bolland, ph 09 4868996 ext 2575
www.bedwet.net.nz (hire alarms)
http://www.i-c-c-s.org/
Bed alarms can be purchased from some pharmacies (eg North Harbour Pharmacy, 326 Sunset Rd, currently sell Dry Sleep alarms (Dec 09)).
References
1. Paediatric Society of New Zealand, Best Practice Evidence Based Guideline: Nocturnal Enuresis “Bedwetting”. 2005. www.paediatrics.org.nz
2. Glazener CMA, Evans JHC, Peto RE (last update 2003) Simple behavioural and physical interventions for nocturnal enuresis in children (Cochrane Review). The Cochrane Database of Systematic Reviews. The Cochrane Library volume (1) 2004.
3. Glazener CMA, Evans JHC, Peto RE (last update 2003) Complex behavioural and educational interventions for nocturnal enuresis in children (Cochrane Review). The Cochrane Database of Systematic Reviews. The Cochrane Library volume (1) 2004.
4. Glazener CMA, Evans JHC, Peto RE (last update 2003) Alarm interventions for nocturnal enuresis in children (Cochrane Review). The Cochrane Database of Systematic Reviews. The Cochrane Library volume (1) 2004.
5. Glazener CMA, Evans JHC, Peto RE (last update 2003) Desmopressin for nocturnal enuresis in children (Cochrane Review). The Cochrane Database of Systematic Reviews. The Cochrane Library volume (1) 2004.
6. Robson WLM. Evaluation and management of enuresis. NEJM 2009;360(14):1429
