Bedwetting (also known as nocturnal enuresis) is a condition in which there is an uncontrollable and involuntary leakage of urine from the bladder while asleep. Bedwetting affects millions of children worldwide, as well as some adults and elderly individuals.
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What is bedwetting?
Although frequent urination whilst asleep is common for children younger than five years, bedwetting is a cause for concern in children older than five years. It is estimated that 5-10% of 7-year-olds regularly wet their beds. Bedwetting is more common amongst boys than girls, however, the cause of this gender difference is not known. There is also a genetic component, with children more likely to wet the bed if the mother had a history of bedwetting.
Bedwetting may be associated with:
- Uncontrollable leakage of urine whilst asleep
- Needing to visit the toilet frequently during daytime hours
- Pain on urination or fever due to possible urinary tract infection
- Straining to pass urine
- Excessive thirst
- Accidental passing of stools due to nerve abnormality
Bedwetting can have a serious effect on the quality of life of children and their families.
Bedwetting can be very distressing for children, however, the impact is often underestimated and trivialized by parents and doctors.
Children may suffer from feelings of low self-esteem at an age when personal appearance and self image is extremely important for optimal personal development. Bedwetting is also associated with reduced daytime functioning, including school and social performance.
More than half of parents whose children have nocturnal enuresis do not allow their children to spend time away from home, so they often miss out on social activities such as sleepovers at friends’ houses and school trips. A lack of understanding can also cause parents to be frustrated and this contributes to the child’s sense of failure and shame; reinforcing the social stigma surrounding bedwetting.
Aside from social and emotional stress, there is also a recognized economic burden on families. Bedwetting creates additional work for families in the form of increased household duties and so results in often substantial financial costs.
What causes bedwetting?
A frequent misconception of bedwetting is that the cause is psychological - extensive research suggests that this is not the case. For most children who wet their beds, there is no underlying disease or pathology causing the condition. Bedwetting may resolve over time as the child develops and grows up.
In general, childhood bedwetting does not have a known underlying cause and is not the child's fault. Bedwetting is often caused by over-production of urine at night or reduced capacity of the bladder. There are also likely to be genetic factors, with nearly two thirds of children who wet the bed having one or both parents with a history of the condition.
Common causes of bedwetting include:
Failure to wake up and use the toilet – Normally, when the bladder is full, a signal is sent to the brain that causes a person to wake up and go to the toilet. However, children under five years of age may sleep so deeply that they fail to wake up. This is due to underdevelopment of the nerves that carry signals along the spine from the brain to the bladder. Furthermore, even when children do wake up they may be too afraid of the dark to get up and go to the toilet.
Excessive fluid intake before bedtime – Compared with adults, children have a smaller bladder with less filling capacity and they are therefore more likely to wet the bed if they have had too much fluid during the evening or before bedtime.
Caffeine intake before bedtime – Drinking caffeine-containing drinks before bedtime can lead to increased bedwetting as caffeine is a diuretic and therefore increases urine output. Caffeine is found in drinks such as tea, coffee, Coca-Cola and hot chocolate, all of which need to be avoided if bedwetting is to be prevented.
Vasopressin deficiency – Excess urine production may be caused by a deficiency of vasopressin, a hormone that regulates urine production.
Overactive bladder syndrome – Some children may suffer from overactive bladder syndrome, a condition which causes the bladder muscles to contract more frequently, leading to excessive voiding of the bladder.
Associated medical conditions
- Type 1 Diabetes
- Chronic constipation – full bowels can press on the bladder
- Sleep apnoea
- Certain infections – largely urinary tract infections that can also cause excessive daytime wetting
- Bladder cancer in older individuals
- Moving to a new school or house
- Introduction of a new sibling
- Parental discord
- Clinical depression
Often, when bedwetting is acquired through the emotional stress of infection, it is known as secondary nocturnal enuresis. Emotional distress (e.g. through punishing) can also enhance the condition.
What to do if bedwetting occurs?
There are many things that can be done to manage bedwetting at home, without having to consult a doctor or a specialist. These include:
- Making sure that your child has easy access to a toilet at night (e.g., bottom bunk and lighting to help the child get to the toilet without difficulty or fear)
- Waterproof covers over the mattress and duvet
- Not waking your child purposefully in the middle of the night to go to the toilet
- Having a bedwetting alarm which has a moisture sensory attached to an alarm to wake your child up automatically if moisture is detected – these need to be used nightly to provide an additional signal to help the child associate the feeling of needing to urinate with the need to go to the toilet
- Petroleum jelly can be applied to the child's buttocks and inner thighs can help prevent rashes associated with frequent bedwetting
If bedwetting occurs frequently after seven years of age, or comes about suddenly after prolonged dryness during the night, it may be important to see your GP. Diagnosis of the condition involves obtaining a detailed history of the child's symptoms and the frequency of their bedwetting.
Parents are asked to keep a diary recording the number of times per week the child has wet their bed as well as daily recordings of their fluid intake, toilet visits, and voiding volume. The child is then examined and tests are run to rule out other underlying conditions.
Some of these diagnostic tests include:
- Blood sugar assessment to check for type 1 diabetes
- Urine analysis if urinary tract infection is suspected
- An abdominal ultrasound to test for urinary tract disorder and the presence of stones
Rewarding your child for following bedtime routines and management techniques can greatly encourage morale and self-esteem, and may improve the condition. It is recognized that punishing children for bedwetting or shaming a child can actually make the physical aspect of bedwetting worse. Parents, therefore, need to refrain from scolding, berating or frightening a child who bed wets, as this will only worsen the condition.
How to overcome bedwetting
Successfully treating bedwetting removes the burden placed on both the child and family.
Bedwetting can and should be treated, but despite this, nearly half of parents do not seek help, as many believe that their child will eventually outgrow the problem. In fact, if left untreated bedwetting will not necessarily go away by itself and can persist for life, with approximately 1 in 100 people continuing to wet the bed into adulthood.
In the majority of cases, childhood bedwetting does not require any specific treatment and usually resolves with parental support and lifestyle modifications (including management techniques mentioned earlier). Such lifestyle alterations include:
Specific therapies may be used to treat children with underlying causes of bedwetting and these include:
- Antibiotic treatment for urinary tract infections
- Glucose lowering treatment for type 1 diabetes
- The prescription of desmopressin, a synthetic form of the hormone vasopressin which regulates urine production
- The use of oxybutynin to relax the bladder muscles and increase its capacity to hold urine
- The use of imipramine to treat mood disorders that may be exacerbating bedwetting, such as panic disorders or depression
With careful management at home, in addition to minimizing emotional disturbances caused by scolding, bedwetting may naturally improve. If it does not resolve by the age of seven, there may be underlying causes that can be treated effectively by medication.