Nocturnal Enuresis (Bedwetting)

Nocturnal enuresis (betwetting) affects 5-7 million children in the United States. Incidence decreases with age. About 15% of 5 year olds wet the bed; the incidence decreases by 15% per year after that. By age 10, about 6% of children wet the bed; by age 15, about 1% of adolescents still wet the bed.  Treatment is generally suggested only for children over 6 years old.

Patients can be seen by Texas Children's experts in Urology.

Causes & Risk Factors

  • Family history. If there is a family history of parents, siblings, or other close relatives with bedwetting, it is more likely that your child will inherit the condition.
  • Inadequate production of vasopressin during sleep. This hormone, also called antidiuretic hormone (ADH), reduces urine production.   If your child’s body is not producing enough vasopressin overnight, he/she may make more urine than the bladder can hold.
  • Delayed bladder maturity.  Just like some children learn to walk and talk at different ages, bladder control also varies.
  • Increased arousal threshold. Children fail to wake when bladder reaches capacity.

Symptoms & Types

  • Monosymptomatic nocturnal enuresis: bedwetting is the only symptom.
  • Polysymptomatic nocturnal enuresis: bedwetting is associated with daytime symptoms (urgency, frequency, wetting, etc.).
  • Primary nocturnal enuresis: child has never been dry at night since toilet training.
  • Secondary nocturnal enuresis: child has been dry for 6+ months, then resumed bedwetting.

Diagnosis & Tests

During the initial visit, a careful history will be taken, including:

  • history of urinary tract infections
  • daytime symptoms such as urgency, frequency, wetting, constipation, developmental milestones such as age at toilet training
  • family history of bedwetting

The physical exam includes examination of the abdomen and external genitalia, as well as inspection of the lower back for abnormalities that would suggest underlying neurologic problems.  We will also collect a urine sample and perform a urine test in the office. If all of the above are normal, no further testing is needed.

Treatment & Care

Treatment for bedwetting is usually not started until after 6 years of age, because it is so common before that age. Treatment options can begin with behavior modification to optimize daytime habits. These include:

  • Limiting fluids 2-3 hours before bedtime
  • Double voiding (urinating) before bed (1 hour prior and immediately before bed)
  • Voiding every 2-3 hours during the day on a schedule
  • Drinking most of the day’s fluids earlier in the day, not in the afternoon or evening hours
  • Treating any constipation if present, often with the use of fiber supplements
  • Avoiding drinks which irritate the bladder, such as caffeinated drinks, carbonated drinks, and citrus drinks

After behavior modification, if the bedwetting continues, there are 2 other treatment options to try:

Bedwetting Alarm: The bedwetting alarm is conditioning therapy which helps children learn to recognize the need to wake up to go to the bathroom. Bedwetting alarms consist of a sensor that is clipped onto the underwear and an alarm that is attached to the shirt to awaken the child at the first sign of wetness.

It works for 60-80% of children when used appropriately, but requires a high level of commitment from the child and family. The parents must help the child wake up to the alarm for the conditioning therapy to work. It may take 3 to 4 months to accomplish mostly dry nights. Eventually the alarm teaches your child to wake up when his bladder is full, rather than to the sound of the alarm.

Desmopressin (DDAVP): This medication mimics the natural hormone our bodies produce to decrease urine production at night. It causes children to produce less urine, leading to a less full bladder overnight. This does not cure bedwetting; it just treats the symptoms on the night taken. It is 40-75% effective. There are not many side effects, but children must limit fluid intake 1 hour before and 8 hours after taking this medicine. Children should take a “drug holiday” every 3-6 months to assess bedwetting symptoms and determine whether they have obtained nighttime control.

Living & Managing

There is a 15% spontaneous cure rate yearly, even without treatment. It is acceptable to choose no therapy (in absence of concerning symptoms). Bedwetting is neither the child’s nor parent’s fault. It is not due to “laziness”; there should not be punitive actions.

 

Evaluation and treatment for monosymptomatic enuresis: A standardization document from the international children’s continence society. Vol. 183, 441-447, February 2010. The Journal of Urology.

Pediatric Urology for the Primary Care Provider. Zderic, S. and Kirk, J. Slack Incorporated, 2009.