Bed Wetting (Nighttime Incontinence)

bed wetting

Nighttime incontinence or bed wetting (Nocturnal Enuresis) is a common condition that causes substantial distress in children. Bed wetting is defined as night time bed wetting in children five years of age or older. There is strong genetic association in this condition. Boys are found to have more severe bed wetting than girls. Bed-wetting isn’t a issue with toilet training. It’s often just a normal part of a child’s development. Generally, bed-wetting up to the age of 7 isn’t a concern. At this age, child may still be developing nighttime bladder control

Bed wetting could be due to excessive nocturnal urine production, over activity of urinary bladder and failure to awaken in response to bladder sensation.  

Most children recover from bed-wetting on their own. Few children need medical help to overcome this problem. Bed-wetting may be a sign of an underlying condition that needs medical attention. Usually doctor’s consultation is required when bed wetting continues after 7 years of age, bed wetting starts after few months of normal urinary control or child has associated symptoms like painful urination, unusual thirst, pink or red urine, hard stools or snoring.

Causes:

There is no definite known cause of bed wetting. However, there are certain factors that could lead to this problem.

  1. Heredity: There is strong association between family history and bed wetting.  If one or both of a child’s parents wet the bed as children, their child has a significant chance of wetting the bed.
  2. Small urinary bladder: Urinary bladder of the child may not be fully developed.    
  3. Inability to recognize the sensation of full bladder:  The child does not wake up due to lack of sensation of full bladder or deep sleeper.
  4. Urinary infection: Urinary tract infection in child may cause bed wetting. This may be associated with frequent urination, painful urination or pink/red urine.
  5. Hormones: There could be inadequate formation of anti-diuretic hormone (ADH) that helps reduce formation of urine during night.
  6. Diabetes: Bed wetting could be the first sign of diabetes in a child particularly if associated with excessive thirst, fatigue and weight loss.           
  7. Constipation: Prolonged constipation in child may lead to bed wetting at night as same muscles are involved in control of stool and urine.        
  8. Sleep apnea:   Sometimes bed-wetting is a sign of obstructive sleep apnea, a condition in which the child’s breathing is interrupted during sleep due to enlarged tonsils. Other symptoms could be snoring and daytime drowsiness.      
  9. Attention-deficit/hyperactivity disorder (ADHD). Bed-wetting is more common in children who have ADHD.
  10. Structural defect in urinary tract or nervous system: Rarely bed wetting could be due to structural anomaly in the urinary tract or neurological system of the child.

In rural areas in India, the prevalence is higher among children from poor socioeconomic class compared to those from the upper middle class. More enuretic children have a history of birth asphyxia, cesarean birth, low birth weight, and absence of breastfeeding.

Complications:

There is no direct health risk associated with bed wetting. However, there certain issues that could be seen in child like feeling of guilt, embarrassment, and low self esteem. Child may not participate in social activities like sleepovers and camps. Sometimes there could be rashes on child’s bottom or genital areas due to irritation caused by bed underwear.

Diagnosis:

Diagnosis of nocturnal enuresis is mainly by taking detailed medical history including family history, bowel and bladder habits, and other associated problem like anxiety, stress (new baby in

the home, recent move, loss of a loved one, living with a single parent, living with stepparents, parents with health problems, conflicts at home, stress due to enuresis, scolding, and poor scholastic performance),etc. Child may undergo local and systemic physical examination to identify any physical anomaly. Doctor may recommend few investigations to identify the cause of this problem:  

  • Urine tests to exclude urinary infection or diabetes
  • X-rays or other imaging tests of the kidneys, ureter & bladder or spine to look at any structural anomaly or functional impairment.

Treatment:

Commonly accepted treatments include the bed alarm (Moisture alarm), desmopressin and tricyclic antidepressants. The bed alarm is believed to address the difficulty children may have in waking in response to bladder sensations; however, many children who are successful using the alarm may remain dry without waking. It is the only treatment that has been shown to treat bedwetting with long-lasting effect. Alarm therapy with an enuresis alarm is the most effective strategy for curing nocturnal enuresis. Success rates of 66%–70% are reported despite being a difficult treatment modality Alarm therapy is advantageous since it provides a real cure with no adverse effects. However, it requires significant parental involvement and sleep disturbance, which could be stressful for child and family. Currently, the availability of alarm devices in India is limited. A simple body worn alarm is available and other types of alarms can be imported. However, patient acceptability of these devices is a major limitation.

Desmopressin is used when there is excessive formation of urine which is seen only in a subset of children. Tricyclic antidepressants act at the level of brain but the results of these drugs usually are not sustained once the medication is stopped. Parents must be warned of cardiotoxic and hepatototoxic potential of tricyclic overdose.  If the child has a small bladder, an anticholinergic drug such as oxybutynin may help reduce bladder contractions and increase bladder capacity, especially if daytime wetting also occurs. This drug is usually used along with other medications and is generally recommended when other treatments have failed.

Alternative therapies for bed wetting have been tried like hypnotherapy, psychotherapy, and acupuncture and chiropractic treatment. The evidence of efficacy of any of these treatments is very weak.             

Support

Effective treatment may include several strategies and may take time to be successful.

  • Encourage the child to express his or her feelings. Motivation and support should be offered. When child feels calm and secure, bed-wetting may become less problematic.
  • Cover 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.
  • Consider asking 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 child feel more control over the situation.
  • Do not punish or tease the child for wetting the bed. It is involuntary act without the fault of the child. Instead, praise the child for following the bedtime routine and helping clean up after accidents.
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