What is bed wetting

Bed wetting also known as nighttime incontinence or nocturnal enuresis, is very common in childhood. Bed wetting happens when children do not wake up when their bladder is full at night, and the bladder automatically releases the urine (pee). Bed-wetting is involuntary urination while asleep after the age at which staying dry at night can be reasonably expected. Bed wetting is more common for boys to have poor bladder control while asleep than girls and it often runs in the family.

Soggy sheets and pajamas — and an embarrassed child — are a familiar scene in many homes. But don’t despair. Bed-wetting isn’t a sign of toilet training gone bad. It’s often just a normal part of a child’s development. Bed wetting is not your child’s fault. Bed wetting is not caused by laziness or a desire to get attention. Bed wetting is something that a child has no control over.

Night time dryness usually occurs by the time children reach 5 to 7 but happens at different ages for different children. Night time dryness is a natural development that occurs when the mechanism controlling that part of the body matures.

Most kids are fully toilet trained by age 5 to 5 and a half, but there’s really no target date for developing complete bladder control. Between the ages of 5 and 7, bed-wetting remains a problem for some children. After 7 years of age, a small number of children still wet the bed. At this age, your child may still be developing nighttime bladder control. Seek medical advice to be sure there is no physical cause.

Up to the age of 5, wetting the bed is normal. It usually stops happening as your child gets older without the need for any treatment.

• up to 1 in 5 5-year-olds wet the bed
• 1 in 20 10-year-olds wet the bed
• about 1 in 50 teenagers wet the bed
• about 1 in 100 teenagers continue to wet the bed into adulthood

The exact mechanism behind bed wetting is not clearly understood, but is thought to result from a combination of three key factors:

• Difficulty rousing from deep sleep (arousal difficulties);
• Producing too much urine at night (nocturnal polyuria); and
• Overactivity of the detrusor muscle, which makes up part of the bladder wall.

For most children who wet the bed, there is a family history of bedwetting. This means the child has at least one sibling, parent or extended family member, such as an aunt, uncle or grandparent who also wet the bed after the age of 5.

Children who wet their beds are usually normal and happy in all other ways.

If bed-wetting continues, treat the problem with patience and understanding. Lifestyle changes, bladder training, moisture alarms and sometimes medication may help reduce bed-wetting.

If the child is usually dry by day and passes urine normally, bed wetting is very unlikely to be the result of any bladder or kidney disease. However, if the child is ill or feverish, dribbles urine day and night or has pain, you should consult your doctor.

A child’s self-esteem can be damaged by punishing or embarrassing the child. It also hurts when siblings or friends make fun of them so:

• praise your child for dry nights and be understanding after wet nights
• do not punish your child for wetting the bed
• be patient and supportive, and remember that it is not the child’s fault
• do not get angry – it does not help and may make your child more anxious
• do not shame your child – it does not help the child gain bladder control.

What happens in primary nocturnal enuresis?

Children with primary nocturnal enuresis lack night-time bladder control at an age when this would be expected.

• True bed wetters do not waken after wetting. They are not necessarily heavy sleepers nor are they being lazy and it has nothing to do with dreaming. Wetting the bed is quite unconscious; from the child’s point of view it is a matter of going to bed dry and waking up wet, with no recollection of it happening.
• Some children who wet the bed produce more urine at night than others, due to a low level of a hormone which controls how much urine is made while the child is asleep.
• Some children who wet the bed have bladders that cannot hold a large amount of urine.
• Sometimes bedwetting can be due to a medical problem, so it is wise to check with your doctor
• Sometimes children who wet the bed at home are dry when sleeping in a strange place. They may be a bit worried when sleeping away from home, and sleep more lightly for the first few nights.
• Stressful events in a child’s life may interfere with the normal development of night time dryness. These events could include a new baby in the family, being unwell, family separation or break-up.

Key point to remember

• Reassure your child that bed wetting is a common part of growing up and you should encourage them to not feel embarrassed or ashamed.
• Don’t punish, criticize, tease or offer rewards for something your child cannot control.
• In some children, the nervous system can take a little longer to develop, so the brain and bladder may not fully communicate with each other until the child is older.
• Bed wetting is rarely caused by a medical problem such as a urinary tract infection, diabetes or a nerve or muscle problem. Although if a child has not wet the bed for a long time and starts to do it again, you should take your child to a doctor for a check-up.
• Consider using a bladder training or alarm program if your child is over 5 and 7.
• Help your child to feel as comfortable as possible about going to school camps and sleepovers.

Bed wetting at night complications

Although frustrating, bed-wetting without a physical cause doesn’t pose any health risks. However, bed-wetting can create some issues for your child, including:

• Guilt and embarrassment, which can lead to low self-esteem
• Loss of opportunities for social activities, such as sleepovers and camp
• Rashes on the child’s bottom and genital area — especially if your child sleeps in wet underwear

What causes bed wetting

No one knows for sure what causes bed-wetting, but various factors may play a role:

• A small bladder. Your child’s bladder may not be developed enough to hold urine produced during the night.
  Inability to recognize a full bladder. If the nerves that control the bladder are slow to mature, a full bladder may not wake your child — especially if your child is a deep sleeper.
• A hormone imbalance. During childhood, some kids don’t produce enough anti-diuretic hormone (ADH) to slow nighttime urine production.
• Urinary tract infection. This infection can make it difficult for your child to control urination. Signs and symptoms may include bed-wetting, daytime accidents, frequent urination, red or pink urine, and pain during urination.
• Sleep apnea. Sometimes bed-wetting is a sign of obstructive sleep apnea, a condition in which the child’s breathing is interrupted during sleep — often due to inflamed or enlarged tonsils or adenoids. Other signs and symptoms may include snoring and daytime drowsiness.
• Type 1 Diabetes. For a child who’s usually dry at night, bed-wetting may be the first sign of type 1 diabetes. Other signs and symptoms may include passing large amounts of urine at once, increased thirst, fatigue and weight loss in spite of a good appetite.
• Chronic constipation. The same muscles are used to control urine and stool elimination. When constipation is long term, these muscles can become dysfunctional and contribute to bed-wetting at night.
• A structural problem in the urinary tract or nervous system. Rarely, bed-wetting is related to a defect in the child’s neurological system or urinary system.
• Emotional problems. In some cases, bed wetting can be a sign your child is upset or worried. Starting a new school, being bullied, or the arrival of a new baby in the family can be very stressful for a young child. If your child has started wetting the bed after being dry at night for a while, there may be an emotional issue behind it.

Risk factors for bed wetting at night

Bed-wetting can affect anyone, but it’s twice as common in boys as in girls. Several factors have been associated with an increased risk of bed-wetting, including:

• Stress and anxiety. Stressful events — such as becoming a big brother or sister, starting a new school, or sleeping away from home — may trigger bed-wetting.
• Family history. If one or both of a child’s parents wet the bed as children, their child has a significant chance of wetting the bed, too.
• Attention-deficit/hyperactivity disorder (ADHD). Bed-wetting is more common in children who have ADHD.

Bed wetting at night diagnosis

Depending on the circumstances, your doctor may recommend the following to identify any underlying cause of bed-wetting and help determine treatment:

• Physical exam
• Discussion of symptoms, fluid intake, family history, bowel and bladder habits, and problems associated with bed-wetting
• Urine tests to check for signs of an infection or diabetes
• X-rays or other imaging tests of the kidneys or bladder to look at the structure of the urinary tract
• Other types of urinary tract tests or assessments, as needed

Bed wetting treatment

Most children outgrow bed-wetting on their own. If treatment is needed, it can be based on a discussion of options with your doctor and identifying what will work best for your situation.

If your child isn’t especially bothered or embarrassed by an occasional wet night, lifestyle changes — such as avoiding caffeine entirely and limiting fluid intake in the evening — may work well. However, if lifestyle changes aren’t successful or if your grade schooler is terrified about wetting the bed, he or she may be helped by additional treatments.

If found, underlying causes of bed-wetting, such as constipation or sleep apnea, should be addressed before other treatment.

Options for treating bed-wetting may include moisture alarms and medication.

What you can do

Children need to know that bedwetting is a common childhood problem.

If a preschooler still wets the bed:

• Make sure the mattress has an adequate waterproof cover – a length of plastic, covered by a bath towel, over the bottom sheet
• Ensure the bed is warm and comfortable
• Try using ‘pull ups’ (a type of nappy) on your child.
• Establish a morning routine to deal with wet pyjamas and bedding. Have your child help with the clean-up, but do not make the child feel ashamed for a wet bed.
• Encourage double voiding before bed. Double voiding is urinating at the beginning of the bedtime routine and then again just before falling asleep. Remind your child that it’s OK to use the toilet during the night if needed. Use small night lights, so your child can easily find the way between the bedroom and bathroom.
• Make sure the bed is low enough to get in and out easily
• Keep a low-powered globe or night light on
• Consider a potty close to or in the bedroom.
• Encourage an adequate and regular fluid intake throughout the day. This may help produce more urine and help enlarge the bladder.
• Encourage your child try to wait an extra 15 minutes before using the toilet during the day. Try to slowly make the waiting times longer and longer. This can help stretch an unusually small bladder to hold more urine.
• Avoid soft drinks containing caffeine – these can cause more urine to be produced, meaning your child may need to go to the toilet more often.
• Avoid beverages and foods with caffeine. Beverages with caffeine are discouraged for children at any time of day. Because caffeine may stimulate the bladder, it’s especially discouraged in the evening.
• Limiting drinks or ‘lifting’ during the night does not help to achieve bladder control.
• Encourage regular toilet use throughout the day. During the day and evening, suggest that your child urinate every two hours or so, or at least often enough to avoid a feeling of urgency.
• Prevent rashes. To prevent a rash caused by wet underwear, help your child rinse his or her bottom and genital area every morning. It also may help to cover the affected area with a protective moisture barrier ointment or cream at bedtime. Ask your pediatrician for product recommendations.

Small children are unlikely to be worried by wetting the bed unless Mum or Dad (or other extended family) makes a big issue of it.

It is not helpful to punish children who wet the bed, no matter how desperate you feel about the extra washing. There is no instant cure for wet beds when the child concerned just hasn’t reached that stage of development yet.

Coping and support

Children don’t wet the bed to irritate their parents. Try to be patient as you and your child work through the problem together. Effective treatment may include several strategies and may take time to be successful.

• Be sensitive to your child’s feelings. If your child is stressed or anxious, encourage him or her to express those feelings. Offer support and encouragement. When your child feels calm and secure, bed-wetting may become less problematic. If needed, talk to your pediatrician about additional strategies for dealing with stress.
• Plan for easy cleanup. Cover your child’s mattress with a plastic cover. Use thick, absorbent underwear at night to help contain the urine. Keep extra bedding and pajamas handy. However, avoid the long-term use of diapers or disposable pull-up underwear.
• Enlist your child’s help. If age-appropriate, consider asking your child to rinse his or her wet underwear and pajamas or place these items in a specific container for washing. Taking responsibility for bed-wetting may help your child feel more control over the situation.
• Celebrate effort. Bed-wetting is involuntary, so it doesn’t make sense to punish or tease your child for wetting the bed. Also, discourage siblings from teasing the child who wets the bed. Instead, praise your child for following the bedtime routine and helping clean up after accidents. Use a sticker reward system if you think this might help motivate your child.

With reassurance, support and understanding, your child can look forward to the dry nights ahead.

Bedwetting alarms

Bedwetting or moisture alarms are widely used and are considered the most effective and safe method of treatment. These small, battery-operated devices — available without a prescription at most pharmacies — connect to a moisture-sensitive pad on your child’s pajamas or bedding. When the pad senses wetness, the alarm goes off.

Success depends on the bedwetting treatment being part of a supervised self-management program using high quality and reliable equipment.

Bedwetting alarms work by conditioning the child to wake when they want to pass urine.

Ideally, the moisture alarm sounds just as your child begins to urinate — in time to help your child wake, stop the urine stream and get to the toilet. If your child is a heavy sleeper, another person may need to listen for the alarm and wake the child.

When the child begins to wet, a bell rings and the child wakes. Because the feeling of a full bladder and the sound of the bell happen at the same time, the child’s brain associates one with the other. Eventually the child wakes when they feel the need to pass urine. The treatment programme takes approximately 6 to 16 weeks.

If you try a moisture alarm, give it plenty of time. It often takes one to three months to see any type of response and up to 16 weeks to achieve dry nights. Moisture alarms are effective for many children, carry a low risk of relapse or side effects, and may provide a better long-term solution than medication does. These devices are not typically covered by insurance.

Other interim treatment methods that may suit your child include positive reinforcement and star charts (for under school age) or your doctor may suggest short term medication therapy (for school camps and sleepovers).

Bed wetting medication

As a last resort, your child’s doctor may prescribe medication for a short period of time to stop bed-wetting. Certain types of medication can:

• Slow nighttime urine production. The drug desmopressin (a synthetic form of the natural substance vasopressin) reduces urine production at night. But drinking too much liquid with the medication can cause problems, and desmopressin should be avoided if your child has symptoms such as a fever, diarrhea or nausea. Be sure to carefully follow instructions for using this drug. Desmopressin is given orally as a tablet and is only for children over 5 years old. 30% of children treated with desmopressin remain completely dry and 40% wet the bed less, but still have some wet nights. The average child treated with desmopressin wets the bed 1.34 nights fewer per week, when compared to placebo. Desmopressin needs to be taken 1 hour before going to sleep to optimise its effect. The main side effects associated with desmopressin are that of low sodium levels in the blood which can result in seizures. To prevent this it is advised that your child doesn’t drink in the 2 hours before going to bed or overnight. According to the Food and Drug Administration, nasal spray formulations of desmopressin (Noctiva, others) are no longer recommended for treatment of bed-wetting due to the risk of serious side effects.
• Calm the bladder. If your child has a small bladder, an anticholinergic drug such as oxybutynin (Ditropan XL) works to stop the bladder wall from contracting which results in the bladder being able to store a larger volume of urine, especially if daytime wetting also occurs. Anticholinergic medication should be considered in combination with other medications in children who do not become dry with either a bed wetting alarm or desmopressin. This medication is usually used along with other medications and is generally recommended when other treatments have failed. The current evidence suggests that anticholinergic medication should be used in combination with either desmopressin or tricyclic antidepressants in children who wet the bed. The combination of desmopressin and anticholinergic medication can reduce the risk of bed wetting by 66% when compared to placebo. Similarly, the combination of desmopressin and the tricyclic antidepressant, imipramine, was found to reduce the number of wet nights from 6.1 to 1.7 per week. Anticholinergic medication can take up to 2 months to achieve its optimal effect. Side effects are common, affecting up to 76% of patients. The most serious side effects are those that affect the brain and this can occur in up to 33% of children. These side effects include agitation, drowsiness, confusion, memory loss, nightmares and hallucinations.
• Tricyclic antidepressants. Tricyclic antidepressants (TCAs) are used when other medications have not been successful. Imipramine (for example, sold as Tofranil and Tolerade) is the name of the most commonly used agent. Imipramine can have serious effects on the heart and if taken in an overdose can cause death. Other common side effects include mood changes, nausea and difficulty sleeping. For this reason your child will be started on the lowest effective dose and should be reassessed at regular intervals.

Sometimes a combination of medications is most effective. There are no guarantees, however, and medication doesn’t cure the problem. Bed-wetting typically resumes when medication is stopped, until it resolves on its own at an age that varies from child to child.

Alternative medicine

Some people may choose to try complementary or alternative medicine approaches to treat bed-wetting. For approaches such as hypnosis, acupuncture, chiropractic therapy and herbal therapy, evidence of effectiveness for bed-wetting is weak and inconclusive or such efforts have proved to be ineffective. In some cases, the studies were too small or not rigorous enough, or both.

Be sure to talk to your child’s doctor before starting any complementary or alternative therapy. If you choose a nonconventional approach, ask the doctor if it’s safe for your child and make sure it won’t interact with any medications your child may take.

Nocturnal enuresis summary

Despite bed wetting being a very common condition, it is still poorly understood making strategies to prevent the disease difficult. There are, however, several treatment options available to either cure or minimise bed wetting episodes. Before embarking on a treatment regime simple measures should be addressed including ensuring adequate fluid intake, regular toileting and the option of using a reward system. Once you and your child are willing and motivated to commence treatment, either a bed wetting alarm or desmopressin therapy should be considered as the initial treatment of choice. Where these measures are not successful, your doctor will consider trialling other medications including anticholinergic and tricyclic antidepressants.

Adult bed wetting

Bed-wetting that starts in adulthood also known as secondary enuresis, is uncommon and requires medical evaluation.

Causes of adult bed-wetting may include:

• A blockage (obstruction) in part of the urinary tract, such as from a bladder stone or kidney stone
• Bladder problems, such as small capacity or overactive nerves
• Diabetes
• Enlarged prostate
• Medication side effect
• Neurological disorders
• Obstructive sleep apnea
• Urinary tract infection

Tests and procedures used to determine the cause of adult bed-wetting include:

• Physical exam
• Urine tests
• Urologic tests
• Neurological evaluation

Treatment of adult bed-wetting is directed at the underlying cause, when possible.