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How to deal with childhood bedwetting

Charles Broomhead
MB ChB FRCGP DA DRCOG
GP Principal
Honorary Clinical Lecturer Birmingham Medical School

It is difficult to know the exact prevalence of bedwetting (or nocturnal enuresis), but it is extremely common and affects many children and their families. It can have a considerable impact on the child's self-esteem, their relationship with adults and peers, and their performance at school.
Between the ages of two and five years, most children become dry at night. However, it has been estimated that approximately 15% of five-year-olds have a problem with bedwetting. Nocturnal enuresis often runs in the family and occurs twice as frequently in boys than girls. There is also an association with attention-deficit hyperactivity disorder (ADHD).(1)
Parents may be concerned that their child is still wetting their bed later than siblings or other children, and they should be reassured that is likely to resolve as the child gets older. Some children simply achieve continence later than others - something that is not related to intelligence or to any other aspect of the child's development. About one in six five-year-olds, one in seven seven-year-olds and one in eleven nine-year-olds still suffer from enuresis. Unfortunately, in a small number the condition persists, and between one in 50 and one in 100 teenagers and young adults continue to have a problem.(2)

Causes of nocturnal enuresis
Primary enuresis describes the situation where a child has never been dry at night, whereas secondary enuresis arises when bedwetting recurs after an extended period of dryness. Each of these situations is likely to have a different aetiology and demands a different approach to management.
In most cases of primary enuresis no specific cause can be found. Small bladder size and immaturity of the nervous system are commonly cited as causing the problem, while in some children other factors such as constipation may be significant.
Secondary enuresis, where bedwetting recurs after a period of  six months or more, may be associated with episodes of emotional stress, such as the arrival of a new sibling, the death of a loved one or problems at school.

Investigations
Most children with primary enuresis do not have an underlying illness but should undergo at least a brief physical examination, if only to reassure that there is no obvious physical abnormality. Urinalysis to check for the presence of glucose or protein and culture of the urine to exclude infection are, however, mandatory. Investigating secondary enuresis is a little more complex, looking at possible sources of stress, psychological issues or even sexual abuse.

Treatment
It is probably sensible to avoid giving extra drinks to children before bedtime, but fluid restriction will not solve the problem. The child's brain has to learn to appreciate the sensation of a full bladder and to understand that this signals a need to pass urine.
Management may be either behavioural or pharmacological, but a combined approach is often required, taking into account the wishes and views of both the child and the family.
Fundamental to successful treatment is to avoid blaming or ridiculing the child. Bedwetting is not something that they are doing deliberately, and criticising or punishing them will only exacerbate the situation. Fostering an approach where all signs of improvement, however small, are encouraged and praised will pay dividends in terms of success. Reward systems such as a "star chart", where the child is given a sticker whenever they have a dry night and an additional reward when a predetermined number have been earned, can be effective in some children.

Alarms
Enuresis alarms work by waking the child as soon as urine is passed. They reinforce the association between the sensation of bladder fullness and the need to wake up and pass urine. Eventually the child becomes conditioned to recognise this before enuresis occurs. It is generally advised that an alarm be used until 14 consecutive dry nights have been achieved. Studies have shown that alarms are effective in over 60% of cases, although relapse requiring retreatment is common.
Enuresis alarms can be purchased from the Enuresis Research and Information Centre (ERIC; see Resources) or borrowed from a local enuresis clinic.

Imipramine
Imipramine, a tricyclic antidepressant, is sometimes used to treat enuresis. How it works is not entirely clear, but it is thought to act by improving the child's sleep pattern or by a direct effect on bladder muscle. Unfortunately, it is often associated with significant and sometimes dangerous side-effects such as dry mouth, upset stomach, drowsiness and headache. A particular concern is that even a small overdose can be fatal, and great care must be taken to store and administer it safely.

Desmopressin
Children with enuresis may lack the normal diurnal cycle of ADH (antidiuretic hormone) production. This hormone increases during the night, reducing the amount of urine produced and allowing longer periods of uninterrupted sleep. Desmopressin is available as both a nasal spray and in "melt" formulations. A common regimen is to use it for a period of three months and then to stop to see whether the problem has resolved. It is effective in about 60% of cases, but bedwetting often recurs when the medication is stopped.(3) A particular feature of desmopressin is that it works very quickly, making it particularly useful for holidays or when a child is away from home, for example when staying overnight with a friend.

Who is able to help?
Evidence suggests that as few as one-third of families with children with a bedwetting problem seek professional help. There may be many reasons for this, including a sense of shame and a belief that their family doctor is too busy to deal with such a "trivial" issue. Practice nurses are in a good position to help in these circumstances, as they are often viewed as being more approachable and accessible than their GP colleagues.
Health visitors are likely to have an established relationship with the child and parents and may be somebody from whom they can seek advice. Because of their close involvement with the family, they may be aware of any difficulties that are causing or contributing to the problem. Their role places them in an ideal position to liaise with and to feedback information to their primary care colleagues. School nurses are also able to provide help and support, and some may actually run enuresis clinics within the community.
Many nurses and health visitors may have experienced similar problems with their own children and are a useful source for practical advice. They may know, from firsthand experience, the importance of mattress protectors and  simple measures such as ensuring that access to a toilet at night is easy and well lit.
For those who have prescribing rights, there is a clear rationale that lends itself well to a nurse-led service.

Conclusion
Bedwetting can have a profound adverse effect on both the child and the family. While in most cases it is a self-limiting problem, there are several ways of facilitating a more rapid improvement. No single method offers the best way of dealing with the problem. An individual approach involving the child and their family offers the best chance of success.

References

  1. Baeyens D, et al. Attention deficit/hyperactivity disorder in children with nocturnal enuresis. J Urol 2004;171(6 Pt 2):2576-9.
  2. Butler RJ. Night wetting in children; psychological aspects. J Child Psychol Psychiatry 1998;39;453-63.
  3. Patrina HJ, et al. Bedwetting and toileting problems in children. Med J Aust 2005;182(4):190-5.

Resources
Enuresis Resource and Information Centre (ERIC)
T:0117 960 3060
W:www.enuresis.org.uk
Alarm interventions for nocturnal enuresis in children
Cochrane Review
www.cochrane.org/reviews/en/ab002911.html
Best Treatments
Clinical evidence for patients from the BMJ
Bedwetting
W:www.besttreatments.co.uk/btuk/conditions/1000297385.html