Stop Bedwetting

Many people want to stop bedwetting. Bedwetting is uncontrolled urination during sleep beyond the age when bladder control is normally expected. The medical term for this condition is "nocturnal enuresis". Primary nocturnal enuresis (PNE), is if a child has not stayed dry overnight on a regular basis. Secondary enuresis (SNE), is if a child or adult begins wetting again after becoming dry.

Nocturnal enuresis is the most common child health problem. Studies show that parents worry because children are expected to stay dry too early. Most girls can stay dry by six years and most boys stay dry by seven years. By age ten, 95% of children are dry at night. Adult bedwetting rates are between 0.5% and 2.3%.

Most bedwetting is due to a developmental delay, rather than an emotional or physical problem. Only a small percentage (5% to 10%) of cases are due to medical conditions. Enuresis often has a family history.

Normal bladder control

Two physical processes normally stop bedwetting. The first is a hormone that diminishes urine production at night. The second is the ability to waken if the bladder is full. Children, usually become dry at night by the development of one or two of these capacities. There seem to be hereditary factors in the timing of this.

The first characteristic is a hormone that signals the body to produce less urine at night. At sunset each day, the body releases antidiuretic hormone (known as arginine vasopressin or AVP). This hormone decreases the breakdown of urine from the kidneys during the night, so that the bladder does not get completely full until the morning. This hormone cycle does not exist birth. Many children develop it between two and six years while others take a little longer - between six and late puberty. Some do not develop it at all.

The second characteristic thal allows humans to stay dry is waking up when the bladder is full. This capacity is developed at the same age as the the hormone cycle, but separately.

Bedwetting frequency

Most girls stop bedwetting by six years and most children stay dry by seven years. Males represent 60% of total bedwetters.

Doctors usually regard bedwetting as a temporary problem, because most children outgrow it. A very small percentage of children do not overcome the problem. More information about bedwetting teenagers.

Adult bedwetting does not show the same rates of spontaneous recovery. People who still bedwet at age 18 years are likely to deal with it throughout life.

Primary nocturnal enuresis (PNE)

Primary nocturnal enuresis (PNE) is the most common type of enuresis. Bedwetting is considered a problem when a child is old enough to stay dry but still wets the bed at least two nights a week on average, without dry spells, and without being taken to the bathroom.

Medical guidelines differ regarding when a child is old enough to stay dry. Common medical practice is to diagnose PNE at between 4 and 5 years.

Some researchers, however, recommend a different starting age group, saying that bedwetting should only be considered a problem if the child regularly bedwets after turning seven.

Secondary enuresis

Secondary enuresis occurs after a person expriences a long period of dryness at night (around 6 months or more) and returns to bedwetting. Enuresis may be secondary to stress or illness such as a bladder infection.

Possible Causes

See Adult Bedwetting for causes and solutions to bedwetting in later life.

* Diseases/Infections - most commonly, urinary tract infections. Clear the infection to stop bedwetting.

* Physical Disorders - Fewer than 10% of bedwetters have urinary tract malformations, such as a bladder smaller than normal. This can affect the functional capacity of the bladder.

* Lack of anti-diuretic hormone (ADH) production - Some children do not produce enough of the urinary cycle hormone. As explained above, the body usually increases the hormone ADH at night, signaling the kidneys to produce less urine. In some cases, the night-time change does not happen until 10 years of age, making it unrealistic to expect the child to stop bedwetting earlier.

* Constipation - Long-term constipation can cause bedwetting. If the bowel is full, this may put pressure on the bladder.

* Attention Deficit-Hyperactivity Disorder (ADHD) - Children with ADHD are nearly three times more likely to have bedwetting problems than children without ADHD.

* Developmental disabilities - people with intellectual and developmental disabilities such as Down Syndrome have a higher rate of problems with bedwetting.

Other less common causes:

* Heavy sleeping - parents often report that their bedwetting children are heavy sleepers. Researchers have shown mixed study results. Although bedwetting children may be harder to wake up, the hormone ADH may play a role in waking the body.

* Stress does not cause primary nocturnal enuresis (PNE), but may cause a return to bedwetting. Researchers believe that the transition to a new city, parental conflict or divorce, arrival of a new child or the loss of a loved one or an animal can do that job insecurity, the cause a return to bedwetting. See pain and stress reduction section for suggestions.

Psychological and social effects

Children with enuresis are not responsible for their situation. Many medical studies show that the psychological impact of parental efforts to stop bedwetting is most important. The way the family and the child react to the bedwetting determines whether it becomes a problem or not.

Parents become concerned to stop bedwetting much earlier than doctors. Researchers found that the average parent believes children should be dry at night by 2.75 years old, whereas the average doctor believes children should be dry at night by 5.13 years old. Parents seem to have unrealistic ideas about when children are capable to stop bedwetting.

Impact on self-esteem

Bedwetting can cause low self-esteem if not handled well. Children report that bedwetting is almost as stressful as parental divorce and fighting.

Children who bedwet are often teased by siblings and may also be unfairly punished by parents. They are often scared friends will find out and think less of them.

Psychologists have shown that the degree of harm depends on whether bedwetting affects self-esteem or the development of social skills. Important factors to consider:

• Does the enuresis limit social activity, such as sleepovers and camps
• The degree of social exclusion by peers
• The anger and disapproval of parents and caregivers
• The number of failed attempts at treatment
• How long the child has been bedwetting

Studies show that punishing or humiliating a child for bedwetting usually makes the situation even worse. Doctors describe a cycle of decline if a child is punished resulting in shame and loss of confidence. This can lead to an increase in bedwetting incidents and more embarrassment.

Treatment options

Current treatments options to stop bedwetting include alarms and drugs involving hormone replacement. As most bedwetting is a developmental matter, treatment aims to protect or enhance self-esteem. Children and adults who bedwet often suffer from emotional or psychological damage, when they feel ashamed of their bedwetting. A treating practitioner may advise parents to avoid psychological damage caused by pressure, shame or punishment, when the the condition is one that children can not control.

There are a number of treatments and management options for enuresis. The following options may be helpful when bedwetting is not specifically due to a deformity of the bladder or diabetes.

Punishment is not effective and may hinder treatment.

* Waiting - Nearly all children outgrow bedwetting. For this reason, urologists and pediatricians often recommend waiting to treat the child until at they are least six or seven years old. If doctors begin treatment sooner, it may be harmful to the child's self-esteem and relationships with family and friends.

* Bedwetting alarms - these sound an alarm if moisture is detected. This can help teach a child to detect a full bladder. These alarms are effective, with wearers becoming more than 13 times more dry at night. There is a 29% to 69% reversion rate, so the treatment may need to be repeated.

* Desmopressin tablets are a synthetic substitute for antidiuretic hormone, the hormone that reduces urine production during sleep. Desmopressin patients are 4.5 times more likely to stay dry. Serious concerns exist about desmopressin in the form of a nasal spray, and this form of the drug has been banned in the U.S.

* Tricyclic antidepressants have been successful in the treatment of nocturnal enuresis, but also carry an increased risk of adverse effects, including death by overdose. These drugs were amitriptyline, imipramine and nortriptyline. Studies show that patients taking these drugs are 4.2 times more likely to stay dry. The rate of recurrence after stopping medication are nearly 50%.

Management options

* Diapers or absorbent underwear - stores sell a wide range of absorbent underwear, in children's and adult sizes. They can lower embarrassment and make cleaning up easier. The bedwetting diapers pages gives contact details for some manufacturers specialising in the needs of older children and adults.

* Waterproof mattress covers can help to make cleaning easier. Be aware that they only protect the mattress, not the sheets, bedding or sleepwear.

Unproven and ineffective treatments

* Dry bed training involves keeping a strict timetable of waking the child at night, in the hope that this will develop an independent habit. Studies show that this training does not work.

* Star/reward charts - there is no evidence to show that charts tracking and rewarding dry nights have any effect on bedwetting or self-esteem. They assume the child is in control of their bedwetting, when this is not the case.

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