Enuresis: Problems with Bedwetting

Enuresis is the name given to bedwetting which occurs in children who have reached the age when most are able to pass the night without urinating in the bed.

Enuresis What Does It Mean?

Enuresis means that your child repeatedly wets the bed during the night. This is perfectly normal in children up to the age of five, and many children continue to involuntarily pass urine in the bed up until the age of seven years. If your child is over seven years of age and continues to wet the bed two or three nights a week you should talk to your doctor. This is known as Primary Enuresis. You should also consult with him if your child suddenly starts bedwetting again after a period when he did not, which is called Secondary Enuresis. There are other types of Enuresis but here we will be considering nocturnal enuresis, also known as nighttime incontinence, or bedwetting.

Stats: How Many Suffer from this Disorder?

Enuresis is more common in boys than girls. At 5 years of age, it is estimated that 7-percent of boys and 3-percent of girls suffer from Enuresis or 5-10-percent of all children. By the time they are ten, just three-percent of boys and two-percent of girls continue with bedwetting issues, and by the age of 15, one percent still have problems. However, some studies suggest that the numbers could be much higher, with as many as ten percent of children of 10 years old still suffering from the condition. That translates to about 9-million children across the US.

What Causes Enuresis?

Enuresis in children has many different possible causes, most of which resolve themselves naturally as the child grows.

Bladder size. Your child’s bladder simply may not be large enough, as yet, to contain all of the urine produced during the night.
Not registering the need to get up and go to the bathroom. In some children, the nerves which advise that the bladder is full, develop more slowly. That means, that particularly if your child sleeps deeply, he does not realize that he needs to visit the bathroom.
Our bodies produce an anti-diuretic hormone (ADH) which slows down the production of urine during the night. Sometimes children do not produce enough of this hormone.

Occasionally, bedwetting can indicate some other health problem. If your child has any of the symptoms below you should consult with your doctor, as Enuresis can also be caused by the following conditions-

If your child experiences pain while urinating, must urinate frequently, or the urine is dark in color, he could be suffering from a urinary tract infection.
Sleep apnea. If your child snores or is sleepy during the day, he could be suffering from sleep apnea which causes the interruption of regular breathing during sleep. This can be due to inflammation or enlargement of the adenoids or tonsils.
If your child urinates large quantities at a time, is always thirsty, is tired during the day, or starts bedwetting after having achieved bladder control he could be developing Diabetes.
If your child has trouble opening his bowels every day, this can cause bedwetting as the same muscles control both urine and stool evacuation.
Structural problem. Very rarely the cause of Enuresis is due to a physical problem in the urinary tract or in the nervous system.
Sometimes a stressful situation, such as a death in the family, or a change of house, can precipitate the condition.

Signs and Symptoms of Enuresis

The most obvious sign is a wet bed and pajamas and an embarrassed child.

What are the Common Behaviors/Characteristics?

Bedwetting is quite common until the age of five. Even if your child is “potty-trained” during the day, often at night they do not make it to the bathroom. This is often because their small bladder gets overfull and they pass urine before they can get to the bathroom. Or, that they sleep so soundly they do not wake up until it is too late.

Patience and understanding are very important. The child does not deliberately wet the bed, and so, even though it makes a lot of extra work don’t blame the child or tell them off. Put a plastic cover over the mattress to prevent the urine passing through or put a piece of plastic over the center of the bed with a small draw sheet over it. Always have clean sheets and nightclothes ready nearby. Always wash your child’s buttocks and genitals before putting on the clean dry pajamas and apply a little soothing cream if there is any redness or irritation.

Testing: What are the Diagnostic Criteria Per the DSM 5?

Repeated voiding of urine into bed or clothes, whether involuntary or intentional.
The behavior is clinically significant as manifested by either a frequency of at least twice a week for at least 3 consecutive months or the presence of clinically significant distress or impairment in social, academic (occupational), or other important areas of functioning.
Chronological age is at least 5 years (or equivalent developmental level).
The behavior is not attributable to the physiological effects of a substance (e.g., a diuretic, an antipsychotic medication) or another medical condition (e.g., diabetes, spinabifida, a seizure disorder).

Enuresis and Other Conditions

Enuresis can be related to other conditions and you should visit your doctor if your child exhibits any of the following conditions.

Enuresis vs Encopresis

Encopresis is the term given for an uncontrolled bowel movement. Most children learn to control their anal sphincter by the age of four years old. If your child continues to soil the bed or his clothes after this age you should see your doctor. Enuresis and Encopresis can occur together.

Enuresis vs Neurogenic Bladder and Other Medical Conditions

Neurogenic Bladder is the term given to a lack of control over the bladder due to a problem in the nervous system. This, and other medical conditions can be the cause of Enuresis, and the diagnosis and treatment of the underlying condition can solve the bedwetting.

Related Conditions

Other related conditions can be, chronic constipation, sleep apnea, diabetes, or a urinary tract infection.

Enuresis in Adults/Children

Enuresis is much more common in children who normally grow out of the condition. Approximately one percent of the population suffer Enuresis throughout their lives. In old age, it is common for people to develop enuresis as the bladder muscles weaken or as nerve functioning deteriorates, often due to a stroke.

Example Case of Enuresis

“Douglas” went through “potty training” without any trouble and by the age of 4½, he was in complete control of both his urine and his stools. From this age on, he very rarely wet the bed. At the age of seven, his family moved to another city and “Douglas” had to change schools and make new friends. Shortly after moving he started wetting the bed. His parents tried their best not to make a big thing of it, but they were obviously concerned about the situation. “Douglas” was extremely distressed about his nighttime accidents particularly as he had not experienced many in his earlier childhood. He became withdrawn and found it hard to make new friends at his new school.

After about four months with regular bedwetting, they went to see the doctor. He asked them when the problem began, and they explained that it coincided with the move. The doctor felt that the stress caused by the change in his life was the cause of the Secondary Enuresis and recommended visiting a therapist.

The therapist worked with “Douglas” on his poor self-esteem and on showing him how to relate to new people and to make new friends. She also recommended to his parents that they reduce the amount of liquids he drank in the evening and cut out Cola drinks, of which he was quite fond. She also encouraged them to be patient and understanding and to have a quick and simple clean-up routine. She also suggested that “Douglas” should be encouraged to help by putting his wet pajamas and sheets straight into the washing machine ready for washing. In this way, he would feel more responsibility and more able to control the situation.

After just a few months of therapy, “Douglas” had stopped wetting the bed and was happily attending sleepovers with his new mates.

How to Deal/Coping with Enuresis

Patience and understanding are the key factors in dealing with Enuresis. Also,

Have a simple efficient clean-up routine
Encourage communication and offer support
Praise liberally when the child has a dry night
Do not tell the child off or complain about a wet night
Don’t allow siblings to tease
Make simple life changes to reduce urine production at night

Some parents find that a bedwetting alarm can help. This is a small alarm which sounds when it senses moisture. The idea is that it wakes the child so that he can stop the flow of urine and go to the bathroom to evacuate his bladder. It can take several weeks before they have a noticeable effect.

Look out for These Complications/Risk Factors

Notice-

If your child goes to the bathroom a lot.
If they pass a lot of urine at one time
If the urine is dark or cloudy
If there is any pain while passing urine
If the child is stressed or worried about something
If they are lacking in self-confidence

Enuresis Treatment

Normally Enuresis sorts itself out as the child grows or by making simple routine changes. Sometimes, your doctor may prescribe a medicine to help, but often the problem can return when the medication is stopped.

Possible Medications for Enuresis

Desmopressin (DDVAP) is sometimes prescribed to decrease the amount of urine which is produced at night.

Oxybutynin may help to decrease bladder contractions and to increase bladder capacity.

Imipramine has been shown to achieve dryness in 10-50-percent of children, but how it does this is not certain.

Home Remedies to Help Enuresis

Make sure that it is easy for your child to get from his bed to the bathroom. Leave nightlights on to mark the way, and maybe leave the doors to both rooms open. Sometimes bedwetting can be aggravated by the incapacity to get to the bathroom quickly and without fear. Nights, when your child remains dry, congratulate them in the morning. If you have other children don’t allow them to tease or ridicule the bedwetter. Some children can become very distressed about their condition and it can prevent them from wanting to join in normal childhood activities like sleepovers or camp. Be understanding and encourage your child to talk about the problem, as stress and shame can make the condition worse.

Try to make sure that your child avoids all caffeine-based drinks which can stimulate the bladder. Also, reduce the amount of liquid that your child drinks in the evening. Get your child into the habit of visiting the bathroom at regular intervals throughout the day. At bedtime, encourage your child to use the bathroom when you are starting your bedtime routine and then again just before going into bed.

If the problem continues, go to the doctor. He will ask you if there is a history of bedwetting in the family. It is more common for a child to wet the bed if someone else in the family did. The doctor will also want to know if there have been any stressful situations recently in your child’s life. He might ask you to keep a record of when your child drinks, when they use the bathroom and when they have a wet bed. He might want to do some examinations to rule out physical causes such as an infection. Depending on what he discovers the doctor may want to do more tests, or he may prescribe a drug that can help, or he may refer you to a therapist.

Some parents may want to try alternative therapies such as acupuncture, hypnosis, herbs, or visiting a chiropractor. These may be of help but always check with your doctor before starting any alternative treatments.

Living with Enuresis

Fortunately, most of the cases of Enuresis in children end of their own accord with the passing of the years. During the time while the child is bedwetting, it is essential to maintain a positive attitude and to provide the support and security that the child needs to get through this time. You may find help by joining a bedwetting group or forum on the internet.

Insurance Coverage for Enuresis

Enuresis is not normally covered by medical health insurance policies. However, a bed-wetting alarm may be covered by some policies of it is prescribed by your doctor.

How to find a Therapist

Your doctor will be able to recommend a therapist to help you with your child’s Enuresis is he feels that it is necessary.

What Should I be Looking for in an LMHP?

For any therapy to be effective it is important that both you and your child feel comfortable with the therapist and are willing to follow the suggestions and recommendations made by them. Before deciding on a particular therapist see if they have a web page where you can learn more about them and see if they have had success treating other people with this condition.

Questions to Ask a Potential Therapist

How can therapy help my child with this problem?

How long will it take to see the results?

Would therapy be with just the child or with the family?

How often will therapy take place?

Enuresis is normally a passing phase which most children will eventually grow out of without further intervention. However, if the bedwetting persists, or, if it starts after your child has been able to control his nighttime urine, it is important to try to find the cause so that it can be treated. Stress can often be the reason for bedwetting to start, and this can be well managed with therapy. If there is no evident psychological reason, a physical reason should be looked for. If your child is more than seven years old and regularly wets the bed at least twice a week go and talk to your doctor. Not investigating the cause can result in negative effects on both you and your child, so make an appointment to see your doctor today.

Enuresis Resources and Support Helpline

-National Kidney Foundation, 30 East 33rd Street, New York, NY 10016

NKF Cares Patient Information Help Line (855) NKF-CARES (1-855-653-2273) nkfcares@kidney.org

-National Institute of Mental Health: https://www.nimh.nih.gov/index.shtml

-National Alliance on Mental Health: https://www.nami.org/Find-Support/NAMI-HelpLine 1-800-950-NAMI (6264) or info@nami.org