Enuresis

Commonly called bed-wetting, enuresis can also occur during the day. Not a concern before children are 6, the disorder can restrict activity and cause humiliation. Most children outgrow the condition on their own or with bladder training techniques.

Definition

Enuresis is the involuntary discharge of urine by a child age 5 and over. It can be psychologically distressful and a source of embarrassment for a child, but not physically harmful. Enuresis places a child at risk of being a target for name-calling and teasing from peers, behavior that can damage a child's self esteem and place him or her at risk of rejection. The presence of enuresis can place a limit on participation in highly desirable social experiences such as sleepovers and summer camp. The child may also have to face anger and humiliation from parents who do not understand the nature of this disorder.

Enuresis can be nocturnal-only or diurnal-only. Nocturnal enuresis is the most common form and is defined as passage of urine only during nighttime sleep. Diurnal enuresis, the voiding of urine only during waking hours, is more common in females than in males and is uncommon after age 9. Children being so preoccupied with a particular event that they are reluctant to use the toilet may cause it. A combination of nocturnal and diurnal enuresis can occur but it is extremely rare.

Primary enuresis refers to a condition whereby the child has not established at least 6 months of continuous nighttime control after reaching age 5. Secondary enuresis, whereby children establish urinary continence and relapse after age 5 or 6 is less common, and is associated with more stressful life events.

Roughly 20% of children still wet their beds at age 5, only 5% do so by age 10, and 2% by age 15. Only 1 out of 100 children who wet their bed continues to have a problem in adulthood.

Symptoms

Essential feature of enuresis is repeated voiding of urine during the day or at night in bed or clothes. Most often this is involuntary but occasionally this may be intentional. To receive a diagnosis of enuresis, the voiding of urine must occur at least twice per week for at least three consecutive months or else cause clinically significant distress or impairment in social, academic (occupational), or other important areas of functioning. The individual must have reached an age at which continence is expected (that is, the chronological age of the child must be at least five years, or, for children with developmental delays, a mental age of at least 5 years). The urinary incontinence is not due exclusively to the direct physiological effects of a substance (for example, diuretics) or a general medical condition (for example, diabetes, spina bifida, a seizure disorder).

The amount of impairment associated with enuresis is a function of the limitation on the child's social activities (for example, ineligibility for sleep-away camp) or its effect on the child's self-esteem, the degree of the social ostracism by peers, and the anger, punishment, and rejection by caregivers. Although most children with enuresis do not have a coexisting mental disorder, the prevalence of coexisting behavioral symptoms is higher in children with enuresis than in children without enuresis. Developmental delays such as speech and learning delays, encopresis, sleepwalking disorder, and sleep terror disorder may be present. Urinary tract infections are more common in children with enuresis, especially the diurnal type.

Causes

Primary bed wetting is usually due to a delay in the maturation of the part of the nervous system that controls bladder function. Another cause for children who to urinate during the night may have be a deficiency of the antidiuretic hormone ADH. The presence of this hormone concentrates urine and prevents the bladder from filling up during sleep; enuresis may be the result of an insufficient amount of this hormone. Young children do not have a sufficiently mature signaling mechanism between the bladder and the brain to become aware of a full bladder. Consequently, they fail to wake up and consequently wet the bed.

Secondary bed wetting may be due to either psychological problems or medical disorders, such as a urinary tract infection, urinary tract abnormalities, or diabetes.

Daytime incontinence that is not associated with urinary infection or anatomic abnormalities is less common than nighttime incontinence and tends to disappear much earlier than the nighttime versions. One possible cause of daytime incontinence is an overactive bladder. Many children with daytime incontinence have abnormal elimination habits, the most common being infrequent voiding and constipation.

Approximately 75 percent of all children with enuresis have a direct biological relative (parent or sibling) who has the disorder. Furthermore, the co-occurrence rate for identical twins is 68 percent and 36 percent for fraternal twins.

Treatments

Treatment techniques can include moisture alarm systems, dry bed training which includes bladder training and medications.

The alarm system attaches a moisture sensor attached to the child's pajamas, and a small speaker to the shoulder of the child. A single drop of urine is sufficient to activate a piercing alarm that causes the child to tense so that he or she stops urinating. This alarm may not waken a child. If the child sleeps through the alarm, the parent then awakens and escorts him or her to the toilet.

Dry bed training entails bladder and contingency training. The first part of dry bed training involves strengthening bladder retention control. To achieve this, the child is given more and more fluids during the day and is instructed to delay urination for progressively longer periods. At night the child is wakened hourly for trips to the toilet and has a clean-up routine to perform in the event of an accident. Rewards are offered for dry nights only. This routine is practiced each night for one or two weeks. Frequently, the alarm system is often used in conjunction with this method so that continence is established quickly.

Techniques that may help diurnal enuresis include:

  • urinating on a schedule, such as every two hours
  • avoiding caffeine or other foods or drinks that you suspect may contribute to your child's incontinence
  • following suggestions for healthy urination, such as relaxing muscles and taking your time

Nocturnal enuresis may be treated by increasing ADH levels through medications. The hormone can be boosted by a synthetic version known as desmopressin, or DDAVP, which recently became available in pill form. Patients can also spray a mist containing desmopressin into their nostrils. Desmopressin is approved for use by children. Desmopressin stops bed wetting in 60 - 75% of children while taking the drug, but is not a permanent cure. Once the medication is stopped, the bed wetting tends to come back. As a result, children need a behavioral intervention before they can be taken off medication.

If a young person experiences incontinence resulting from an overactive bladder, a doctor might prescribe a medicine that helps to calm the bladder muscle. This medication controls muscle spasms and belongs to a class of drugs called anticholinergics.

Here are some suggestions that can be helpful for a child with enuresis:

  • Do not worry about bed wetting in children before the age of 6, unless they were previously well toilet trained and the bed wetting is now a new problem.
  • Do not punish a child who wets. Bed wetting is NOT caused by laziness or rebelliousness. Shaming a child for wetting the bed can lead to poor self-esteem and feelings of low self-worth.
  • Reassure, encourage, and express confidence in the child. You can also have your child take an active part in cleaning up from the bed wetting (such as helping to strip the bed and put the sheets in the laundry).
  • Reward your child for dry nights. Some families use a chart of diary that the child can mark each morning. While this is unlikely to solve the problem completely, it can help and should be tried before medicines are used. It is most useful in younger children, about 5 to 8 years old.

Sources

  • National Institutes of Health, 2008
  • American Psychiatric Association
Last reviewed 11/24/2014