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Bedwetting

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What is it?

Bedwetting is also called sleep enuresis. It is a parasomnia. A parasomnia involves undesired events that come along with sleep. Bedwetting occurs when a person urinates by accident in his or her sleep.

It results from a failure to wake up from sleep when the bladder is full. It may also result from a failure to prevent a bladder contraction. These are skills that you acquire as you grow and develop.

There is a wide range in the age at which these skills are gained. Urinating is a reflex for infants when they are asleep and awake. This occurs up to about 18 months of age.

From 18 months to about three years of age, a child begins learning to delay urination when the bladder is full. First the child learns to do this while awake.

At a later age, he learns to do this while asleep. The developmental maturity of the child will help determine the age at which this skill is gained.

Most children should be able to control their bladders during sleep by the time they are about five years of age. Thus, bedwetting is not considered a sleep disorder unless it occurs at least twice a week in a person at least five years of age.

Bedwetting can be primary or secondary. A child with primary bedwetting has never regularly stayed dry during sleep for six straight months.

A child or adult with secondary bedwetting had earlier stayed dry for at least six straight months. Then he or she began bedwetting at least twice a week for a period of at least three months.

The amount of vasopressin in your body normally increases during sleep. This is a hormone that is produced by the pituitary gland. It reduces the amount of urine that is produced by the kidneys.

The increase in vasopressin keeps you from having to go the bathroom so often at night. A small number of children with primary bedwetting lack this normal increase of vasopressin during sleep. As a result, they have more urine than their bladders can hold. If they do not wake up, then they will wet their beds.

A child’s self-esteem can be hurt when he or she wets the bed. This is the main risk involved with primary bedwetting. How well the child’s family deals with the symptom is very important. Their reaction will determine to a great extent how severe the problem becomes.

Who gets it?

Primary bedwetting is present at the following rates in children and teens:

  • 10% of six-year-olds
  • 7% of seven-year-olds
  • 5% of 10-year-olds
  • 3% of 12-year-olds
  • 1% to 2% of 18-year-olds

Primary bedwetting is more common in boys than in girls. The rate of children with primary bedwetting who get better on their own is about 15% each year.

There appears to be a genetic link to primary bedwetting. Children are more likely to have it if their parents and/or siblings had it as children. Bedwetting is reported by 2.1% of older adults in assisted-living homes. It is more common among women than men.

Some people may also urinate by accident when they are awake. This tends to be related to a physical problem. Social or mental stress is rarely the cause of primary bedwetting. But it does occur more often in the following children:

  • Children with attention-deficit/hyperactivity disorder
  • Children living in disorganized families

Secondary bedwetting occurs more often in children who have recently faced a strong social or mental stress. This includes the following:

  • Parental divorce
  • Physical or sexual abuse
  • Neglect

Children with secondary bedwetting are also more likely to have constipation and to soil their pants.

A disorder such as confusional arousals (waking during a very deep stage of sleep) may involve a child urinating in a strange place during sleep. Otherwise, this child tends to keep a dry bed at night.

Secondary bedwetting can occur at any age. It can be related to or caused by any of the following:

  • An inability to concentrate urine, as in sickle cell disease or some forms of diabetes
  • An increase in urine production caused by the use of caffeine, diuretics, or other substances
  • A urinary tract problem, such as urinary tract infections or an irritable bladder
  • Chronic constipation and involuntary soiling of the pants
  • A neurologic problem, such as seizures and epilepsy
  • Obstructive sleep apnea (OSA)
  • Social or psychological stress

Among older adults, it may be related to symptoms of the following:

  • Congestive heart failure
  • Obstructive sleep apnea (OSA)
  • Depression
  • Dementia

How do I know if I have it?

  1. Is your child older than five years of age?
  2. Does your child urinate by accident during sleep at least twice a week?
  3. Has your child never been regularly dry during sleep for at least six straight months?

If you answered yes to these questions, then your child might have primary bedwetting.

  1. Are you/your child older than five years of age?
  2. Do you/your child urinate by accident during sleep at least twice a week?
  3. Have you/your child regularly stayed dry during sleep for a period of at least six straight months in the past?

If you answered yes to these questions, then you or your child might have secondary bedwetting.

It is also important to know if there is something else that is causing the bedwetting. It may be a result of one of the following:

  • Another sleep disorder
  • A medical condition
  • Medication use
  • A mental health disorder
  • Substance abuse

Do I need to see a sleep specialist?

Talk to your child’s doctor about bedwetting concerns. You should consult a therapist if social or mental stress seems to be at the root of the problem.

You should see a sleep specialist if you/your child isn’t sleeping well or is very sleepy during the day. Another sleep disorder could be involved in this case.

What will the doctor need to know?

The doctor will need to know when the bedwetting started. He or she will also want to know how often it occurs. Tell your doctor about what has been going on in your life. Share with him or her any sources of stress that you are dealing with. The doctor will need to know your complete medical history. Be sure to inform him or her of any past or present drug and medication use.

Also tell your doctor if you have ever had any other sleep disorder. Find out if you have any family members with sleep problems. It will also be helpful if you fill out a sleep diary for two weeks. The sleep diary will help the doctor see your sleeping patterns. This data gives the doctor clues about what is causing your problem and how to correct it.

Will I need to take any tests?

You or your child should have a complete physical exam. This should include a routine lab analysis of your urine.

The doctor may have you do an overnight sleep study. This study is called a polysomnogram. It charts your brain waves, heart rate, and breathing as you sleep. It also records how your arms and legs move. This study will help reveal if the bedwetting is related to any other sleep disorder.

How is it treated?

Treatment for bedwetting begins with a thorough examination. This will rule out any underlying physical causes of the problem. Then other possible underlying causes should be examined.

The goals of treatment are to reduce the social and psychological impact of bedwetting. Treatments often include one or more of the following methods:

Behavior Modification
These methods have been shown to be very effective. They often improve nighttime dryness within the first month. During treatment, it is important to minimize the person’s embarrassment and anxiety as much as possible. Parents need to be very patient while waiting for children to outgrow bedwetting.

Behavioral methods include the following:

  • Positive reinforcement
    This is a useful way to reward a child for keeping a dry bed. An example is to make a chart that shows the nights when the child remains dry.

  • Periodic waking
    This is when you wake the child at certain times of night to use the bathroom. It can also be very useful. Initially, a parent may wish to wake the child. Over time, the parent can allow the child to wake up alone. An alarm clock can be used to wake the child a few hours after going to bed.

  • Fluid Restriction
    This is when you reduce the amount a child drinks in the late afternoon and early evening. It also helps to ask the child to use the bathroom just before going to bed. Regular use of the bathroom during the day is also important. This helps the child to maintain a good routine.

    Fluid restriction should not be made to seem like punishment. It should be done in a thoughtful manner. Use a much smaller glass than normal for liquids during the evening. Use caution during very hot weather to prevent dehydration.

  • Alarm therapy
    This is commonly called the “bell and pad” method. It has been shown to be highly effective. Its success rate is about 70%. This method works best with children who are slightly older and motivated.

    It uses a moisture-sensitive pad that is placed under the child. An alarm sounds when the pad becomes wet. All family members should be committed to this process. The sound of the alarm may wake them during the night.

    Most children sleep through the alarm. But they tend to stop urinating when it sounds. A parent then should help the child to the bathroom to finish. Wet sheets and pajamas should be changed. The alarm should also be reset. Then the child can go back to bed.

    This therapy will help some children sleep through the night without urinating. Others may continue to get up during the night to use the bathroom, which is called nocturia.

    The length of treatment varies widely among children. It may take from two weeks to several months. You should not use this method for more than three months. If the child does not improve after this length of time, then stop the treatment. You can try it again when the child is older.

Surgery
Surgery may be used to correct the underlying cause of bedwetting. This often eliminates nocturnal enuresis. Examples of these root causes include the following:

  • Ectopic ureter and other structural abnormalities in the urinary system
  • Obstructive sleep apnea
  • Heart block

Medication
Drug therapy usually is reserved for children who have had no success with behavioral treatments. Medications used to treat nocturnal enuresis include the following:

  • Desmopressin acetate (DDAVP®)
  • Oxybutynin chloride (Ditropan®)
  • Hyoscyamine sulphate (Levsin®)
  • Imipramine (Tofranil®)

Desmopressin (DDAVP®) is an antidiuretic. It is used to treat primary nocturnal enuresis. DDAVP® is available in a nasal spray (10-40 mcg, at bedtime) or oral form (0.2-0.6mg, at bedtime). It is up to 55% effective. It may also be combined with alarm therapy. Side effects of the nasal spray include the following:

  • Nasal discomfort
  • Nosebleed
  • Abdominal pain
  • Headache

It is important to reduce fluid intake when taking DDAVP®. If fluids are not restricted, water intoxication may occur. This condition requires immediate medical attention. Symptoms of water intoxication include the following:

  • Headache
  • Nausea
  • Vomiting
  • Seizure

Ditropan® and Levsin® are anticholinergic medications. They reduce muscle contractions in the bladder. The usual dose is 2.5 mg to 5 mg taken at bedtime. Side effects include the following:

  • Blurred vision
  • Constipation
  • Dizziness
  • Dry mouth
  • Facial flushing
  • Fluctuations in mood

Oral antibiotics
These are used to treat urinary tract infections (UTIs) that might be the cause of bedwetting. Examples include the following:

  • Bactrim®
  • Amoxicillan
  • Macrobid®
  • Levaquin®

Reviewed by Donald R. Townsend, PhD
Updated October 24, 2005

Tips for Parents
Some children may continue wetting the bed even after they reach five years of age. Follow these tips to help your child overcome a bedwetting problem:

  • Remain positive and encourage your child.
  • Reduce the amount of fluids your child drinks in the evening.
  • Have your child use the bathroom just before going to bed.
  • Wake your child to have him or her use the bathroom once or twice during the night.
  • Reward your child after nights when he or she stays dry.
  • Discuss an ongoing bedwetting problem with your child’s doctor.

Ask a Specialist
Will my child outgrow bedwetting without treatment?


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