Preventing Bed Wetting

• Introduction
• Is bed wetting preventable?
  • What can be done to minimise bed wetting episodes?
  • Simple measures
• Alarm therapy
• Medications
  • Desmopressin 
  • Anticholinergics 
  • Tricyclic antidepressants
• Tools
  • My dryness tracker app
• Summary

 

Introduction

Bed wetting is defined as intermittent episodes of wetting the bed at night in children over 5 years of age. Two types of bedwetting are described although there is often overlap between the two types. Monosymptomatic nocturnal enuresis (MNE) refers to bed wetting 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.
Statistics show that bed wetting is a common disorder affecting 20% of 5 year olds, 10% of 10 year olds and 3% of 15 year olds. Although each year 14% of children will overcome their wetting without any treatment, in a small percentage of cases bed wetting persists into adulthood where its consequences are even greater.
The burden associated with bed wetting is significant and has psychological, social and financial implications for both you and your child. Early identification and initiation of treatment aims to minimise the impact of this condition.

For more information about what causes bed wetting and how it can be treated, see Nocturnal Enuresis (Bed Wetting).

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

 

Is bed wetting  preventable?

The exact mechanism behind bed wetting is poorly understood making prevention of this disorder difficult to study. Bed wetting is a complex phenomenon that results from the interaction of several factors which may include underlying medical conditions, genetics, developmental and psychosocial factors. In addition to these, three factors are thought to influence ones susceptibility to enuresis: disturbed arousal from sleep, an overactive bladder and increased production of urine at night.

What can be done to minimise bed wetting episodes?

Bed wetting is a very treatable condition with several effective options available. It is important to first exclude underlying causes which may exacerbate the problem including diabetes mellitus and urinary tract infections. Your first appointment with a medical practitioner will focus on excluding these secondary causes and developing a management plan tailored to you and your child.

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

Simple measures
Ensuring adequate fluid intake, regular toileting and using reward systems are simple measures which can be put in place before more invasive treatment is considered. It is important that you encourage your child to drink regularly during the day and that fluids are not restricted to minimise bed wetting.  You should encourage your child to drink at least 1.5 litres of water during the day and to avoid drinks containing caffeine. This amount will need to be adjusted based on the temperature, your child’s activity levels and dietary intake.
Your child should be encouraged to use the toilet at regular intervals throughout the day, aiming for 5–6 visits to pass urine per day. Most importantly, you need to encourage your child to use the toilet before going to sleep at night.
Reward systems should focus on rewarding agreed behaviours rather than dry nights. Drinking adequate fluids, going to the toilet before bed and participating in the treatment plan are examples of behaviours that can be rewarded. Reward systems alone can be successful as the initial treatment of bed wetting in young children who have some dry nights.

Alarm therapy

A bed wetting alarm is considered as the initial step for families who are likely to be tolerant of the alarm. When used successfully the bed wetting alarm achieves dryness in about two-thirds of children.
A typical alarm has a sensor which triggers an acoustic, vibrating or visual alarm when urine comes into contact with it. The concept behind the alarm is to condition your child to wake from sleep and prompt them to use the toilet to empty their bladder.
Alarm therapy requires a great deal of motivation and patience from you and your child. Initially you will need to ensure that your child wakes to the alarm, uses the toilet to empty their bladder and reconnects the alarm before going to sleep again. The alarm needs to be used every night for a period of 2–3 months and treatment should continue until 14 consecutive dry nights are attained.
 

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

 

Medications

Three types of medications are available for the treatment of enuresis including desmopressin, anticholinergics and tricyclic antidepressants.

Desmopressin
Desmopressin is a synthetic form of the natural substance vasopressin. Desmopressin is used for children who have unsuccessfully tried a bed wetting alarm (or for whom an alarm is not appropriate) or when rapid resolution of the bed wetting is required, such as for an upcoming school camp or sleepover.  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.

Anticholinergics
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 works to stop the bladder wall from contracting which results in the bladder being able to store a larger volume of urine.
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.

Tools

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.

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.

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