Enuresis (Bed-Wetting)

What is enuresis?

Enuresis (say "en-yur-ee-sis") is the medical term for bed-wetting during sleep. Bed-wetting is fairly common. About 5 million to 7 million children wet the bed. It's more common among boys than girls.

What causes bed-wetting?

Some of the causes of bed-wetting include the following:

• Genetic factors (it tends to run in families)
• Difficulties waking up from sleep
• Slower than normal development of the central nervous system--this reduces the child's ability to stop the bladder from emptying at night
• Hormonal factors (not enough antidiuretic hormone--this hormone reduces the amount of urine made by the kidneys)
• Urinary tract infections
• Abnormalities in the urethral valves in boys or in the ureter in girls or boys
• Abnormalities in the spinal cord
• Inability to hold urine for a long time because of small bladder

Bed-wetting isn't caused by drinking too much before bedtime. It's not a mental or behavior problem. It doesn't happen because the child is too lazy to get out of bed to go to the bathroom. And children do not wet the bed on purpose or to irritate their parents.

When do most children achieve bladder control?

Children achieve bladder control at different ages. By the age of 5 years, most children no longer urinate in their sleep. Bed-wetting up to the age of 5 is not unusual, even though it may be frustrating to parents. Treating a child for bed-wetting before the age of 5 is not necessary and may even be harmful to the child.

How can my family doctor help?

First, your doctor will ask questions about your child's daytime and nighttime bathroom habits. Then your doctor will do a physical exam and probably a urine test (called a urinalysis). Although most children who wet the bed are healthy, your doctor will also check for problems in the urinary tract and the bladder.

The doctor may also ask about how things are going at home and at school for your child. Although you may be worried about your child's bed-wetting, studies have shown that children who wet the bed are not more likely to be emotionally upset than other children. Your doctor will ask about your family life, because treatment may depend on changes at home.

What are the treatments for bed-wetting?

Most children outgrow bed-wetting without treatment. However, you and your doctor may decide your child needs treatment. There are 2 kinds of treatment: behavior therapy and medicine. Behavior therapy helps teach your child not to wet the bed. Some behavioral treatments include the following:

• An alarm system that rings when the bed gets wet and teaches the child to respond to bladder sensations at night.
• A reward system for dry nights.
• Asking your child to change the bed sheets when he or she wets.
• Bladder training: having your child practice holding his or her urine for longer and longer times.

What kinds of medicines are used to treat bed-wetting?

Your doctor may give your child medicine if your child is 7 years of age or older and if behavior therapy hasn't worked. But medicines aren't a cure for bed-wetting. One kind of medicine helps the bladder hold more urine, and the other kind helps the kidneys make less urine. These medicines may have side effects.

How can I help my child not feel so bad about wetting the bed?

Bed-wetting can lead to behavior problems because of the guilt and embarrassment a child feels. It's true that your child should take responsibility for bed-wetting (this could mean having your child help with the laundry). But your child shouldn't be made to feel guilty about something he or she can't control. It's important for your child to know that bed-wetting isn't his or her "fault." Punishing your child for wetting the bed will not solve the problem.

It may help your child to know that no one knows the exact cause of bed-wetting. Explain that it tends to run in families (for example, if you wet the bed as a child, you should share that information with your child).

Help For Bedwetters

Most doctors consider a bed-wetting child to be any girl older than age four and any boy over age five who wet the bed.  Bedwetting generally declines with age.  About 10% of all six year olds and about 3% of all 14 year olds wet the bed.  In a very small number of cases, bedwetting can continue into adulthood.   Bedwetting (enuresis) is considered to be PRIMARY if the child has never been dry at night or only is occasionally dry at night.  SECONDARY enuresis refers to bedwetting episodes that occur after a child has been dry at night for a considerable length of time.

Primary Enuresis:   This is the main topic for this page and will be considered in depth.  When the problem continues into the school years, appropriate intervention can usually correct the problem.  This page will review the causes and treatments for Primary Enuresis.

Secondary Enuresis:  Children who have been dry at night for a considerable period of time may have occasional episodes of bedwetting.  These are usually related to stresses in a child's life and clear up on their own.  Three of the more common events likely to cause bedwetting in young children are: hospitalization, entering school and the birth of a sibling.  Children can also experience stress from such family problems as divorce, parental alcoholism, financial pressure as well as abuse and neglect.  If the symptoms persist, you should consult your child's doctor because the cause may be a physical problem which may require diagnosis and treatment.

Primary Functional Enuresis
(Chronic Bed-wetting) 

Cause:   Chronic bed-wetting is thought to be related to (1) a physically and/or neurologically immature bladder and/or (2) a deep sleeping pattern.  Apparently these children often sleep so deeply that they are not aware of the message the bladder sends to the brain saying it is full.  It is presumed that bed-wetting is an inherited condition.  Usually a parent, aunt, uncle, grandparent or other family member(s) will have had the condition.  Also, children with attention deficit disorder, learning disabilities or allergies seem to be more likely to be bed-wetters than children in the general population.

Effect of Bed-wetting on the Child and Family:   By the first grade, most children are embarrassed by their bed-wetting condition.  They ten to withdraw from social activities that require sleeping outside their home.  They also often suffer from low self-image.  These children's feelings can be greatly affected by the attitudes of their parents, who may feel that their efforts to end the bed-wetting have failed.  Parents may also feel frustrated, angry and embarrassed about their children's bed-wetting condition.  Parents can help their children reduce negative feelings about their bed-wetting condition and speed up the process of overcoming it, by offering positive support, understanding and encouragement.

Treatment:

Behavioral treatment is often more effective and certainly is safer than medical treatment.  While behavioral treatment may take somewhat longer to show results, the improvement usually continues indefinitely.  There are several methods that may be helpful:

Retention Control Training:   The child is asked to control urinating during the day by postponing it, first by a few minutes and then by gradually increased amounts of time.  This exercise can extent the capacity of the bladder and strengthen the muscle that holds back urination.  Parents should always check with a doctor before asking their child to practice retention control:

Night-lifting:   This procedure involves waking your child periodically throughout the night, walking your child to the bathroom to urinate, and then returning your child to bed.  By teaching your child to awaken and to empty his or her bladder many times during the night, it is hoped that he or she will eventually stay dry.

Moisture alarm:   Moisture alarms are considered a useful and successful way to treat bed-wetting.  Medical research has shown that moisture alarms have helped many children stay dry.  This treatment require a supportive and helpful family and may take many weeks or even several months to work.  Moisture alarms have good long-term success and fewer relapses than medications.

An alarm consists of a clip-on sensor probe that attaches to the outside of bed-clothing.  An alarm is set off when the child begins to wet the bed.  The alarm wakes the child, who will then go to the bathroom to finish back to sleep.  This slowly conditions the brain to respond appropriately during sleep to messages from the bladder.