Bed wetting (nocturnal enuresis)

• What is bed wetting?
• Statistics
• Risk factors
• Progression
• Symptoms
• Clinical examination
• How is it diagnosed?
• Prognosis
• Treatment
• Bed wetting prevention
• References

What is bed wetting?

Bed wetting or nocturnal enuresis is defined as intermittent episodes of wetting the bed while asleep in children who are over 5 years of age. Two types of bed wetting are described, although there is often overlap between the two types. Monosymptomatic nocturnal enuresis (MNE) refers to bed wetting the bed that occurs in children who have no other bladder problems and who do not wet themselves during the day. Non-monosymptomatic nocturnal enuresis (NMNE) refers to children who wet the bed at night and have additional daytime symptoms. These symptoms may include needing to pass urine frequently, wetting during the day, urgent desire to pass urine, straining to pass urine, difficulty passing urine or incomplete emptying of the bladder, leakage of urine after using the toilet, and pain arising from the genitals or lower urinary tract.
Bed wetting can be further classified into primary or secondary bed wetting. The primary form occurs in a child who has never achieved night-time dryness. The secondary form refers to wetting in children who have previously established dryness for a period of 6 months.

Anatomy of the urinary tract

The urinary system is divided into upper and lower sections. The upper urinary system is made up of the kidneys and a tube called the ureter which transports urine from the kidney to the bladder. The lower urinary system consists of the bladder and another tube called the urethra which transports urine from the bladder out of the body. The function of the urinary system is to remove waste products from the body, regulate water and salt balance, and store and transport urine.

For more information on the upper urinary tract, see Anatomy of the Renal System.

For more information on the lower urinary tract in males, see Anatomy of the Male Urogenital System.

For more information on the lower urinary tract in females, see Anatomy of the Female Urogenital System.

How does the urinary system work?

The process of urination is controlled by a complex circuit of nerves which relay messages between the bladder, the spinal cord and the brain.
Until approximately 2–5 years of age, a simple circuit is involved in the process of urination. At this age, the central nervous system is immature and urination is therefore an involuntary process over which the individual has no control. As the brain develops with age, we develop the ability to control this process and choose an appropriate time and place to urinate.
Micturition, also referred to as urination or voiding, refers to the act of emptying the bladder of urine. It has two phases, known as the filling and voiding phases. Urine collecting in the bladder during the filling phase causes the bladder wall to stretch and sends a signal to the spinal cord. Nerve pathways from the brain to the spinal cord have the ability to block the process of passing urine until it is necessary to void. When voiding is appropriate, the spinal cord sends a message back to the bladder, causing its muscular wall to contract and the external sphincter to relax, forcing urine out of the body via the urethra.

For more information on how urine is produced, stored and voided, see Urinary Tract.

Impact of bed wetting

Bed wetting is a distressing disorder that carries a significant burden for the affected child and their family. Half of children who wet their bed are teased by their peers, and feelings of bewilderment and humiliation are common. Low self-esteem results from tension in families, social marginalisation and treatment failure. There is often a social impact in that the child is reluctant to participate in sleepovers, school trips and family holidays. Research shows that children with NMNE experience greater distress and have lower self-esteem than children with MNE.
A Swedish study compared self-esteem between children who wet their beds and those who didn’t, and found that bed wetting had a significant impact on self-esteem. Another study examining the psychological impact of bed wetting found that primary school aged children ranked it as the third most distressing out of a series of 11 critical life events.  Divorce and strident parental fighting were the only two events that ranked as more distressing to this group of children. Bed wetting was more distressing than being teased frequently, which ranked fourth.
Where a person wets the bed as an adult, the impact is much greater and can affect one’s career, personal relationship and social life. A Hong Kong study looked at bed wetting in a large group of adults, and found that rates of depression, low self-esteem and sleep disturbance were much higher in the bed wetting group. Furthermore, those with MNE were less likely to reach university education level.
The impact of bed wetting on the parents of the child is also significant. Research has shown that the greatest concern of parents of children who wet their beds is the impact on their child’s emotional and social development. Parents of younger children understood that the child could not control the wetting episodes. However, parents of older children thought that the child had control over the episodes and this impacted negatively on their relationship with the child. In some circumstances, parents resorted to punishing the child, particularly in migrant populations.
Bed wetting also creates an additional workload for parents in the form of washing and drying bed linen, and this is associated with significant financial costs. One study estimated the financial burden associated with a child who wets their bed to be $1,000 USD per year.
 

For more information about how bed wetting can impact on the psychological wellbeing of an individual, and how these impacts can be minimised, see Impact of Bed Wetting.

Statistics

Bed wetting is extremely common, affecting 20% of 5-year-olds, 10% of 10-year-olds and 3% of 15-year-olds.The proportion of children who wet their beds reduces with age. Research has shown that without any treatment, 14% of bed wetters will overcome this condition each year.
An Australian study looked at bed wetting in children aged 5–12 years and found that 18.9% of these children wet their beds. Of this group, 15% wet at night with no daytime symptoms, and 4% wet at night and during the day. Bed wetting was more common in males, who made up 60% of the bed wetters in this study. Most of these children wet their bed less than once a month.
A study conducted in Hong Kong showed that bed wetting persisting into adulthood affected 1.9% of adults. Of these adults, 53% wet the bed more than 3 nights per week and 26% wet the bed every night.
A British study found that the percentage of children who wet their bed declined from 30% at 54 months to 9.5% at 115 months. Bed wetting was most pronounced between 54 and 65 months of age. In this large study, 68.5% of bed wetters had MNE versus 31.5% who had NMNE.

Risk factors

Bed wetting is likely to result from many different factors, including both genetic predisposition and environmental factors. Where daytime wetting is concerned, predisposing factors include a family history of daytime symptoms, infections of the urinary tract, neuropathic bladder, disorders of the urinary system, and psychiatric disorders.

Family history

Research has shown that children with parents who wet the bed are more likely to be bed wetters themselves. In families where both parents were bed wetters as children, their own child has a 77% risk of wetting the bed. Where only one parent wet the bed, the risk is 43%, and where no parents wet the bed, the risk is 15%.
A family history of bed wetting is also strongly associated with the age at which the child will become dry. Children who have two first-degree relatives who wet the bed became dry 1.5 years later than those children with no family history of bed wetting.

Genes

Bed wetting has been linked to several genetic defects, although the relationship between these defects and bed wetting is poorly understood. Recently a gene known as ENUR1 has been identified as having a possible link to bed wetting, although more research is required for the link between the gene and bed wetting to be better understood.

Obstructive sleep apnoea

A close relationship exists between bed wetting and obstructive sleep apnoea (OSA). It is thought that OSA results in altered pressures within the ribcage while sleeping, and that this affects the production of a hormone known as atrial natriuretic peptide. This hormone plays a role in increasing the amount of water and salt that the kidneys excrete through urine. Studies examining the relationship between OSA and bed wetting have yielded inconsistent results to date.

Progression

Research has shown that the rate of bed wetting reduces with time. One Chinese study found that the rate reduced from 16.1% in 5-year-olds to 10.1% in 7-year-olds and 2.2% in 19-year-olds. Those with severe bed wetting are less likely to become dry, with only 60% of severe bed wetters achieving dryness before adulthood. This same study suggested that bed wetting that persists into adulthood is usually severe, with 43.9% of 19-year-old bed wetters wetting the bed 7 nights per week.
Children who wet their bed are more likely to develop bladder problems, including incontinence, as adults.

Symptoms

What causes bed wetting?

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 more information about the causes of bed wetting view the video: Causes of Bedwetting.

Impaired arousal

Difficulty waking from deep sleep is thought to be one of the key factors involved in bed wetting. Children who wet their beds are often described by their parents as being very deep sleepers who are difficult to rouse. New research has identified an area of the brain, known as the locus ceruleus, which is responsible for arousal from sleep. It is closely related to the part of the brain that controls bladder function, and may be disturbed in children who wet their beds.

For more information about how the bladder and the brain communicate and what goes wrong when children have difficulty rousing view the video: Causes of bedwetting- difficulty rousing from sleep.

Nocturnal polyuria (overproduction of urine at night)

Over-production of urine at night is thought to be the result of reduced levels of a hormone known as anti-diuretic hormone (ADH), which is released from the pituitary gland in the brain. ADH works to reduce the amount of urine produced by the kidneys. Under normal circumstances, the level of this hormone produced is significantly greater at night, thus limiting the production of urine overnight. Children who wet their bed do not demonstrate this increase in ADH levels, resulting in large quantities of urine being produced over night. These children typically have bladders which fill in the first third of the night, and as a result tend to flood the bed during the early parts of the night and don’t usually wet the bed again that night. Children with this pattern of bed wetting are more likely to respond to desmopressin, which is a form of ADH found in certain medications used to treat bed wetting.

For more information about overproduction of urine view the video: Causes of bedwetting- overproduction of urine.

Detrusor muscle overactivity (overactive or twitchy bladder)

The third factor thought to contribute to bed wetting is that of an overactive detrusor muscle. Children with this disorder usually pass small amounts of urine and void more frequently. This is often associated with an urgent desire to pass urine, and incontinence associated with not reaching the toilet in time. Bed wetting occurs when an abnormally small bladder fills up or contracts suddenly at night, resulting in a very variable wetting pattern and often several bed wetting episodes per night.

Learn how an overactive bladder can cause children to wet the bed by viewing the video: Causes of Bedwetting: Overactive or Twitchy Bladder.

Seeing your health practitioner for the first time

The first point of contact with your health practitioner will focus on obtaining some information about your child’s medical history and their pattern of bed wetting. This is important for ruling out any underlying medical problems that may be contributing to your child’s bed wetting and establishing the best way to manage the bed wetting.
Some topics that your health practitioner may wish to discuss include:

• How long the bed wetting has been a problem for;
• The pattern of bed wetting (i.e. how many nights a week, how many times a night, whether or not your child has daytime wetting or other bladder symptoms);
• Factors that may contribute to bed wetting, including constipation, diabetes, learning difficulties or behavioural problems; and
• The impact that bed wetting is having on your child and family.

Clinical examination

Most children who wet their bed have a normal physical examination. Your health practitioner may wish to examine your child’s spine to exclude nervous system abnormalities, and their tummy to exclude constipation. Examination of the child’s rectum and genitals are not usually necessary and should only be performed if the child and family feel comfortable with this being done.

How is it diagnosed?

Urine sample

Bed wetting is a diagnosis that is made principally from information given by the parents and child. Any tests that are conducted are usually done to exclude other problems that may be causing your child to wet their bed. A sample of your child’s urine may be collected to check for diabetes, kidney disease and urinary tract infection.

Urinary tract ultrasound

As a general rule, an ultrasound of the urinary system is not required in children with straightforward bed wetting. Children thought to have NMNE or an underlying abnormality of the urinary system may require an ultrasound. This can detect if there is any obstruction to the flow of urine, reflux of urine from the bladder back up to the kidneys, or thickening of the bladder wall.

Bed wetting diary

Another useful tool that your health practitioner might discuss is a diary to record how much your child drinks, how often your child uses the toilet, how often they wet and how much urine they pass each time they use the toilet. Ideally the diary should be kept for a period of 1 week.

Other investigations

Other tests that may be requested by your health practitioner include an x-ray of the tummy or the spine, and special tests that measure urine flow and volume before and after using the toilet. These tests are usually only required in complicated cases of bed wetting or where your health practitioner suspects that there may be an underlying medical problem contributing to your child’s bed wetting.

Prognosis

Studies of children who wet their bed over time have shown that the rate of bed wetting reduces with age. Even in children who receive no treatment, 14% will overcome their bed wetting each year. Research shows that treatment in the form of a bed wetting alarm or medication is often successful. When used properly, a bed wetting alarm results in dryness in about two-thirds of children. Treatment with desmopressin results in complete dryness in 30% of children and partial dryness in 40% of children, with the average child wetting the bed 1.34 less nights per week. Relapse rates are higher with desmopressin therapy than alarm therapy, with 54% versus 35% of children wetting the bed after a period of dryness.
A Chinese study looking at 16,512 children and adolescents found that severe enuresis in childhood was associated with a poor prognosis and often persisted into adulthood. At 19 years of age, 48.3% of bed wetters had severe enuresis, which was described as wetting the bed 7 nights per week. Adolescent boys over the age of 10 years were more likely to have associated daytime wetting than younger boys. Bed wetting continuing into adulthood has a much greater impact and can affect career choice, personal relationships and social life.

Treatment

The treatment of MNE is divided into general advice, the use of a bed wetting alarm, and/or the use of a drug called desmopressin. Children are generally expected to have achieved night time dryness by the age of 5 and, therefore, treatment for bed wetting is normally only considered once the child has reached 7 years of age. Your treating doctor will decide on the best form of treatment for your child’s condition. If these techniques are not successful, your treating doctor may consider other drugs, such as anticholinergics or tricyclic antidepressants (TCAs).
It is important to note that children who wet during the day in addition to wetting at night are less likely to respond to treatment. Treatment should first focus on addressing the daytime symptoms and excluding underlying medical problems. If your child wets during the day or has other medical problems that may be contributing to their bed wetting, your treating doctor may consider referring you to a specialist.

View a video of Paediatrician Dr Mark Gibbeson discussing options for treating bedwetting in children.

General advice

Your treating practitioner should discuss bed wetting with you and your child and the different treatment options that are available. It is important that the child is involved in this discussion and that both parties are motivated to make treatment work.
Your treating practitioner should also talk to you and your child about the importance of maintaining fluid intake, avoiding caffeinated drinks and eating a balanced diet to avoid constipation. Ensuring that the child is using a toilet at regular intervals throughout the day is important, and parents need to encourage this. Inadequate fluid intake or abnormal toileting patterns should be addressed before starting treatment and enuretic children should be encouraged to limit how much they drink bedtime and should use the toilet immediatly before they go to bed. Practical issues that should be considered before starting any treatment for bed wetting include making changes to sleeping arrangements if your child shares a bedroom or bed with another child, ensuring your child has easy access to the toilet during the night and also making sure your bedroom is close enough to your child’s to provide support during the night.
Waking or lifting your child out of bed at night to use the toilet can help overcome bed wetting in the short term, but won’t fix it in the long term.
If you wish to use a reward system, this shouldn’t be to reward dry nights as it places unnecessary pressure on the child. Rewards should instead be for drinking recommended levels of fluid during the day or using the toilet at regular intervals and before going to bed.
Children can be very sensitive to family problems and a stressful home enviroment may be a trigger for bed wetting. It is important that you address any family issues while you help your child manage their bed wetting.

Alarm therapy

The use of a bed wetting alarm should be considered in all children who wet their bed. Although poorly understood, the alarm is thought to work through heightening arousal and increasing the volume of urine that the bladder can hold at night. There are two types of alarm systems available in Australia which can be hired through local hospitals or community bed wetting services. The first system comprises a large pad which is placed in the bed and triggers a loud alarm when liquid comes into contact with it. The second system involves a personal alarm which is either clipped onto the child’s underpants or a pad placed inside the child’s underpants, with any liquid triggering the alarm.
Alarm therapy requires motivation on the part of the child and their parents and can take several weeks to be effective. When the alarm goes off, a parent needs to ensure that the child wakes, goes to the toilet to pass urine and then returns to bed and reattaches the alarm. This sequence needs to be followed every night for a period of 2–3 months. Consistency is the key. Once dryness is achieved, the alarm should be continued until 14 consecutive dry nights have been reached.
When used successfully, the alarm system results in dryness in about two-thirds of children. Two additional components, known as overlearning and dry night training, can help to reduce relapse rates. Overlearning requires that the child drinks a modest amount of extra water an hour before bed and repeats the same sequence as above. Dry bed training involves getting the child to go to the toilet repeatedly and changing their own sheets if they wet.Once the child has been dry for a month with overlearning, alarm therapy can be ceased.
If the child relapses after a successful course of alarm therapy, another course should be trialled. Alarm therapy requires time and motivation and is therefore not ideal where rapid success is required (for a school camp or family holiday) or in chaotic households.
 

For more information about he use of a bed wetting alarm, how effective they are and when they should be used, see Alarm Therapy.

Desmopressin

Desmopressin is a drug that acts in the same way as the hormone ADH. It acts on the kidneys to retain water, thereby inhibiting the production of urine. Desmopressin may be considered to be the next step for children who have not responded to alarm therapy or who are not likely to comply with alarm therapy. Your healthcare professional will be able to advise you about whether desmopressin is appropriate for you or your child. It is most successful in children who produce large amounts of urine at night and have normal sized bladders. Of those children treated with desmopressin therapy, 30% achieve complete dryness and 40% achieve partial dryness, meaning that the children wet their beds less frequently. A study comparing desmopressin to a placebo found that children taking desmopressin wet the bed on average 1.34 times fewer per week when compared to the placebo group. In comparison to alarm therapy, the relapse rate with desmopressin is higher than with alarm therapy, with 54% and 35% of children remaining dry respectively. Additional research has shown that when desmopressin is used in combination with a bed wetting alarm, the success rates were higher in both the short and long term.
Desmopressin is available as a tablet, a melt that dissolves on the tongue, and a nasal spray. Desmopressin should ideally be taken 1 hour before sleep as this allows time for it to reach the kidneys. If successful, your doctor will discuss continuing desmopressin on a daily basis versus using it only for nights when it is important that your child remains dry, such as at school camps, sleepovers or family holidays. If your child continues desmopressin on a daily basis, it is important to discuss treatment duration with your doctor.
The main side effects associated with desmopressin are low salt levels in the blood, known as hyponatraemia. When the salt levels are very low, it can have adverse effects on the brain and result in seizures. To prevent salt levels becoming too low, you need to make sure that your child does not drink any liquid in the 2 hours before going to bed or during the night. If your child develops any signs of low salt levels, which can include headache, nausea or vomiting, you should seek medical attention promptly.

My dryness tracker app

A free app for individuals being treated for bedwetting (nocturnal enuresis), or who plan to see a doctor about the condition. Features a bedwetting checklist, day-time and night-time voiding diaries, alarm therapy progress tracker, desmopressin progress tracker (restricted access), WetAlert® enuresis alarm ordering facility and treatment progress reports. Available from the App Store and Google play for use on smartphone and tablet.

Anticholinergics

Anticholinergics are a group of drugs that work to relax the detrusor muscle of the bladder. This class of drugs is generally reserved for children who have not had success with either alarm or desmopressin therapy.  The most commonly used agents in this class include oxybutynin (e.g. Ditropan), tolterodine (e.g. Detrusitol) and propiverine.
Expert opinion suggests that anticholinergics should be used in combination with desmopressin or TCAs in children who wet their bed. Research shows that when used alone, these drugs are not very successful. One study looked at 41 children who wet the bed, and found that the group who took anticholinergics in addition to desmopressin wet the bed 66% less. When anticholinergic medications were combined with a TCA, the number of wet nights was reduced from 6.1 to 1.7 per week.
Oxybutynin has been well researched in the setting of NMNE. An Italian study found that 50% of children were successfully treated with oxybutynin alone. In this same study, when oxybutynin was combined with desmopressin, the success rate was 71%.
Anticholinergic medication reaches its maximal effect after 2 months of use and is best taken at bed time. A study looking at side effects of this medication found that 76% of patients experienced side effects, which can include dry mouth, difficulty swallowing, dry eyes, blurred vision, diarrhoea, constipation and bloating. 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 are a group of antidepressant medications that can be used to treat bed wetting. Due to their side effects, these drugs are usually reserved for children who have not had success with a bed wetting alarm, desmopressin or anticholinergics. Within this class of drugs, imipramine (e.g. Tofranil, Melipramine) is the one most commonly used for bed wetting.
Imipramine can have serious effects on the heart and, if taken in an overdose, can cause death. For this reason, your doctor will carefully examine your child for any heart problems and may ask whether or not there are any heart conditions that run in your family. Other common side effects include mood changes, nausea and difficulty sleeping.
If your doctor recommends this drug, it will generally be trialled for a period of 1 month. After this time, the dose may be adjusted depending on your child’s response. It is important that you see your doctor regularly to assess whether or not the drug is still required.

Other treatments

There is weak evidence from individual small studies to support the use of complementary interventions, including hypnosis, psychotherapy, acupuncture and chiropractic therapy. To date, there are no reliable studies that compare these treatments to the well-researched treatment methods mentioned above, which include alarm and desmopressin therapy.
Other simple measures, including reward systems and waking your child at night to use the toilet, have demonstrated some effect and can be trialled before using alarm or desmopressin therapy.

Bed wetting prevention

Limited knowledge about what causes bed wetting makes preventing the condition difficult. Bed wetting is a complex phenomenon resulting from the interaction of several factors, including underlying medical conditions, inherited genetic defects, and developmental and psychosocial factors. We also know that children who wet the bed are more likely to have impaired arousal from sleep, over-production of urine at night and an overactive bladder.
It is important that you and your child are aware that bed wetting is not a conscious act and that the child is not at fault. Punishing your child for wetting their bed is not appropriate and can make the problem worse.

For more information about if and how bed wetting can be prevented, see Preventing Bed Wetting.

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