Bedwetting (nocturnal enuresis)

What is bedwetting?

Bedwetting (nocturnal enuresis) is when a child over 5 cannot hold urine during sleep at least once a month. It is one of the most common problems of childhood: it happens in 5–10% of 7-year-olds and in 1–2% of teenagers. It is about twice as common in boys as in girls.

Each year the wetting resolves on its own in about 15% of these children, but out of every 100 seven-year-olds who wet the bed, about 7 still do so as adults. It affects the child’s self-esteem, friendships and family life, so waiting for years and saying “it will pass on its own” is not always the right choice.

Types

• Primary: the child has never had a dry period at night lasting at least 6 consecutive months. This is the most common type.
• Secondary: it has started again after the child was dry for at least 6 months. It is sometimes linked to stress, infection, constipation or another cause.
• Monosymptomatic: only bedwetting, with no daytime symptoms.
• Non-monosymptomatic: there are also daytime symptoms (urgency, frequent peeing, daytime wetting), repeated urinary tract infections or bowel problems. In this case the daytime problems are treated first.

Why does it happen?

Bedwetting is explained by a combination of several mechanisms:

1. Difficulty waking up. The child does not wake up to the signal of a full bladder. This is considered the key mechanism.
2. Making too much urine at night. The body releases the hormone vasopressin to make less urine at night. In some children this hormone does not rise enough at night.
3. Bladder overactivity at night (nocturnal overactive bladder) or a small bladder capacity at night.

Disturbances of the body’s internal clock (circadian rhythm) may also play a part.

Heredity plays a strong role: with no family history the chance is about 15%; if one parent or a close relative wet the bed as a child, it is about 44%; if both parents did, about 77%.

Constipation (often hidden), snoring and sleep apnea, being overweight, attention deficit hyperactivity disorder (ADHD) and allergic conditions are often found together with bedwetting. In children with ADHD, bedwetting tends to be more severe, treatment takes longer to work and relapse is more common. A child who snores may benefit from seeing an ENT doctor, but removing the adenoids and tonsils is not recommended as a treatment for bedwetting.

How to prepare for the visit

A bladder diary helps with the assessment: for 2 days, you record when and how much the child drinks and when and how much the child pees. To find out how much urine is made at night, for one week you write down the weight of the used diaper and the volume of the first pee every morning. If the night urine is more than 130% of the expected bladder capacity for the child’s age, the body is making too much urine at night (nocturnal polyuria). You can print the diary here and fill it in.

Treatment

When to start

Bedwetting is not treated in children under 5. The family is told that it is not under the child’s control, often goes away on its own, and that punishment does not help. Explanation and treatment usually start from age 6–7, taking the child’s and family’s situation into account.

Basic advice

• Regular meals and drinks. A normal amount of fluid during the day, mainly in the morning and at midday. Cut down in the hours before bed.
• Regular toilet visits 5–7 times during the day, and always before bed.
• Less caffeine (tea, cola, energy drinks). Avoid sweet and fizzy drinks and salty foods in the evening.
• Limit phones, tablets and computers before bed.
• Treat constipation, if present, at the same time as the bedwetting.
• Do not punish the child. Praise the child for following the agreed habits (toilet before bed, the diary, taking part in treatment), and involve the child in the process.

These habits are useful, but a wet/dry chart and this general advice on their own have not been shown to work as a first treatment. Parents often feel frustrated; psychological support for the child and family is offered when needed.

Bedwetting alarm

A sensor placed in the underwear or on the mattress makes a sound at the first drop and wakes the child. Over time the child learns to wake up on their own with a full bladder. It is the most effective long-term treatment, but it requires motivation, patience and nighttime support from the family. It is usually used every night for 8–12 weeks, and up to 16–20 weeks if needed. Regular contact with the doctor increases the chance of success. Compared with desmopressin, more children become completely dry and fewer relapse. If wetting comes back after successful treatment, the doctor looks for an overactive bladder.

Desmopressin

This is a medication that reduces urine production at night and is taken before bed. It is used in children who are shown to make a lot of urine at night, and it helps about 70% of them. It works better in older children, in those with fewer wet nights and in those with a high night urine volume. It comes as standard tablets (200–400 µg) or as tablets that melt under the tongue (120–240 µg). The nasal spray is no longer recommended because of the risk of overdose.

Starting 1 hour before the dose and for 8 hours after it, limit fluids as your doctor instructs. Do not give the medication during vomiting or diarrhea; contact your doctor. If the medication does not seem to work, the first step is to check that it is being taken correctly every night. Wetting often comes back after the medication is stopped; it has not been shown that reducing the dose gradually prevents this.

Combined and other treatments

In children who do not respond to a single treatment, the alarm and desmopressin can be used together. In children who do not respond to desmopressin, or when a nighttime overactive bladder is suspected, a medication that relaxes the bladder (an anticholinergic) is added to desmopressin. Recent evidence suggests that starting both medications together from the beginning may also give better results. A bladder-relaxing medication is not used on its own to treat bedwetting. With treatment that combines several methods, about 80% of children have a full or partial response.

Waiting

If the child and family are not ready for treatment, it is fine to wait for now. During this time the child wears night diapers so that sleep is normal.

Online program

A 12-week online program has been developed for bedwetting, to be followed step by step at home: the diary, advice and explanations for parents are all in one place. You can learn about the program at bedwettingdoctor.com.