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Bed-wetting

(Enuresis; Primary Nocturnal Enuresis; PNE)

Definition

Bed-wetting is involuntary urination during sleep in children. Typically children become able to sleep through the night without wetting around ages 3 to 5 years. Talk to your doctor if your child has bed-wetting after age 5 years. There are two types bed-wetting (also called enuresis):
  • Primary nocturnal enuresis (PNE)—no periods of nighttime dryness
  • Secondary nocturnal enuresis (SNE)—periods of nighttime dryness longer than 6 months followed by bed-wetting
Bed-wetting is common and not related to a medical condition. Most will stop by the time the child reaches puberty. However, bed-wetting remains a problem for up to 1% of adults.
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Causes

Some bed-wetting may be caused by infections or abnormalities of the urinary system. Most bed-wetting has no explanation.
Some factors that may contribute to bed-wetting include:
  • Bladder control that develops more slowly than normal
  • Greater than average urine production at night
  • A sleep disorder, sometimes related to enlarged tonsils or adenoids
  • A tendency for deep sleep
In rare cases, bed-wetting may be a symptom of a health condition. These conditions may cause excess urine or prevent the bladder from completely emptying. They include :

Risk Factors

Factors that increase the chance of bed-wetting include:
  • Family members with a history of bed-wetting
  • Significant psychosocial stressors, such as:
    • Moving to a new home
    • Loss of a loved one
    • A new baby in the home
    • Initial toilet training that was too stressful
    • Physical or sexual abuse
  • Chronic constipation

Symptoms

The child wakes up and finds the bed wet from urine.

When Should I Call My Doctor?

Most children will have bladder control at night by about 5 years of age. Talk to your doctor if your child is about 5 years old and is still wetting the bed. Your doctor can help determine if the bed-wetting is just a normal part of your child's development or is caused by a condition that may need treatment.
Also call your doctor if you child:
  • Wets their pants in the daytime
  • Has pain during urination
  • Has to go to the bathroom often
  • Has blood in the urine
  • Has fever or chills

Diagnosis

The doctor will ask about symptoms and medical history. A physical exam will be done. Your doctor will ask about:
  • Family history of bed-wetting
  • Daytime urinary patterns
  • Problems urinating, such as pain or weak stream
  • Usual intake of fluids
  • Type of fluids consumed
  • Presence of blood in the urine
  • Strained family dynamics around the issue of bed-wetting
  • Child's emotional response to the behavior
  • Recent psychological trauma
Your doctor may order tests to look for infections or structural problems:
  • Urine sample—to check for infections and other problems with the urinary tract
  • X-rays or ultrasound —if a physical abnormalities is suspected
If an underlying problem in the urinary tract is suspected, your child may be referred to a specialist.

Treatment

Most treatment aims to gradually reduce the number of bed-wettings until the child grows out of it. Treatment is rarely appropriate before age six. Bed-wetting does not interfere with social development until after age 6 years.
If your child's bed-wetting is caused by an infection or physical abnormality, your doctor will create a treatment plan for that issue.

Motivation and Family Support

Bed-wetting is rarely an intentional act. Children are usually upset and ashamed when it happens. Do not punish the child. It is very important that parents offer encouragement. The bed-wetting will stop with time. Do not let siblings tease the child who wets the bed.
Keep careful records of the child's progress. Offer consistent support. A very simple motivational method is the use of positive feedback, such as a star chart.
Avoid giving the child anything to drink after 6:00-7:00 in the evening. Have your child void before going to bed. Sugar and caffeine should also be avoided after late afternoon.

Behavioral Conditioning

The doctor may recommend a conditioning device. One example is a pad with buzzer that sounds when wet. The child wears the pad in his underwear. The alarm will wake the child up so he/she can use the toilet. Parents may need to help the child get to the bathroom and reset the alarm.
Dry bed training is another type of therapy. With this training you follow a schedule where you wake your child up during the night so he/she can use the bathroom.

Bladder Training

Some doctors suggest bladder-stretching exercises. While awake, the child gradually increases the amount of time between urinations. Do not try this method without talking to the doctor. Holding in urine can lead to urinary tract infections.

Medication

Medicine is rarely given. It may be used for short term situations like a sleepover or vacation. Medication that may be considered include:
  • Desmopressin (DDAVP)—a hormone that decreases the amount of urine that is made
  • Imipramine (Tofranil-PM, Tofranil)—an antidepressant that lightens the level of sleep and may also decreases how often your child urinates
  • Oxybutynin (Ditropan XL, Ditropan, Oxytrol)

Prevention

Excess intake of fluid is rarely the cause of bed-wetting. Restricting fluids prior to bed does not help all the time. Still, it is reasonable to have all children empty their bladders prior to bed. Some parents wake their children every few hours to urinate, but most report that they rarely get much cooperation.

RESOURCES

American Academy of Child and Adolescent Psychiatry http://www.aacap.org/

American Academy of Pediatrics http://www.healthychildren.org/

CANADIAN RESOURCES

About Kids Health http://www.aboutkidshealth.ca/

Alberta Health and Wellness http://www.health.gov.ab.ca/

References

Bed wetting (enuresis). American Academy of Pediatrics website. Available at: http://www.healthychildren.org/English/health-issues/conditions/emotional-problems/Pages/Bed-Wetting-Enuresis.aspx . Updated May 26, 2011. Accessed August 7, 2012.

Enuresis. EBSCO DynaMed website. Available at: http://www.ebscohost.com/dynamed/ . Updated July 19, 2012. Accessed August 7, 2012.

Facts for families: bed wetting. American Academy of Child and Adolescent Psychiatry website. Available at: http://www.aacap.org/cs/root/facts%5Ffor%5Ffamilies/bedwetting . Updated December 2011. Accessed August 7, 2012.

Lee T, Suh HJ, Lee HJ, Lee JE. Comparison of effects of treatment of primary nocturnal enuresis with oxybutynin plus desmopressin, desmopressin alone, or imipramine alone: a randomized controlled clinical trial. J Urol . 2005;174:1084-1087.

Robson WL. Clinical practice. Evaluation and management of enuresis. N Engl J Med . 2009 Apr 2;360(14):1429-1436.

Robson WL, Leung AK, Van Howe R. Primary and secondary nocturnal enuresis: similarities in presentation. Pediatrics . 2005 Apr;115(4):956-959.

12/13/2007 DynaMed's Systematic Literature Surveillance DynaMed's Systematic Literature Surveillance : 2007 Safety Alerts for Drugs, Biologics, Medical Devices, and Dietary Supplements: Desmopressin acetate (marketed as DDAVP Nasal Spray, DDAVP Rhinal Tube, DDAVP, DDVP, Minirin, and Stimate Nasal Spray). US Food and Drug Administration website. Available at: http://www.fda.gov/medwatch/safety/2007/safety07.htm#Desmopressin . 2007 Dec 4.

9/23/2008 DynaMed's Systematic Literature Surveillance DynaMed's Systematic Literature Surveillance : Glazener C, Evans J, Peto RE. Complex behavioural and educational interventions for nocturnal enuresis in children. Cochrane Database of Systematic Reviews. 2004(1). CD004668. DOI: 10.1002/14651858.CD004668.

Revision Information

  • Reviewer: Michael Woods
  • Review Date: 09/2012 -
  • Update Date: 00/91/2012 -

This content is reviewed regularly and is updated when new and relevant evidence is made available. This information is neither intended nor implied to be a substitute for professional medical advice. Always seek the advice of your physician or other qualified health provider prior to starting any new treatment or with questions regarding a medical condition.

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