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Definition

Enuresis (bedwetting) is the involuntary discharge of urine during sleep. It is called bedwetting after the age by which bladder control should have been established. In children, voluntary control of urination is usually present by the age of five. Nevertheless, nocturnal enuresis is present in about 15 to 20 percent of otherwise healthy 5-year-old children, 7 percent of healthy 7-year-olds, 5 percent of healthy 10-year-olds, 2 to 3 percent of 12 to 14-year-olds and 1 to 2 percent of normal children at age 15. Enuresis is slightly more common in boys than in girls and occurs more frequently in the first born child.

Description

Enuresis is the involuntary voiding of urine at least twice a month in a child age five or older. Children vary markedly in the age at which they are physiologically ready to awaken from sleep aware of the need to urinate. This hinders their ability to hold their urine throughout the night. If the child has never been totally dry for a year, the condition is known as primary enuresis. Eighty-percent of children who wet their bed suffer from primary enuresis. Secondary enuresis is when a child has had a dry period of at least a year before the appearance of the problem. The child invariably urinates during the first third of the night and remembers nothing of the occurrence. Although in 1 percent of cases, enuresis continues into adulthood, most children are continent by adolescence. Aside from wet pajamas, enuresis itself causes no direct impairment of the child's life, but social ostracism by peers (at sleepovers and camp, for example), and anger and rejection by parents can damage self-esteem.

Causes

For most children, there is no disease that causes bedwetting, and a true organic cause is identified in only about 2 to 3 percent of children with the condition. A number of factors may contribute to enuresis:

Genetic factors
A family history of enuresis
Delayed maturation
A stressful life event, such as the birth of a sibling, the first week of school or a parent's going away
Delayed arousal from sleep
Small functional bladder capacity
Chronic constipation can irritate the bladder, which results in frequent urination.
Sleep apnea (periods of non-breathing during sleep) decreases oxygen levels. This may make a child less responsive to the sensation of a full bladder and less likely to wakeup when they need to urinate.
Urinary tract infection
High urine production during the night

Treatment

Every year, about 15 percent of bedwetters become dry without treatment. If an organic cause has been ruled out, it should be made clear that there is no medical need to treat the child. If medical treatment is indicated, there are usually three types of medication prescribed.

DDAVP (desmopressin acetate) is a medication approved by the Food and Drug Administration for use with enuresis. Research shows that one cause of bedwetting is a deficiency in the secretion of antidiuretic hormone (ADH) during sleep. (ADH causes the body to produce less urine.) DDAVP, a synthetic version of the hormone, raises nighttime ADH levels and thereby decreases urine production. It is effective regardless of whether or not the child is ADH-deficient. Because DDAVP comes in a nasal spray, the drug is absorbed into the bloodstream much faster than broken down in the stomach, like a pill. DDAVP is odorless, tasteless and considered safe. Except for an occasional headache or irritation of the nasal passages, children do not seem to suffer side effects. The medicine can work after the first dosage of a single spray in each nostril. The drug is expensive and it does not always work.
Imipramine (Tofranil) is a relatively inexpensive inexpensive trycyclic antidepressant that has been used for bedwetting for about 30 years. It is not known exactly how it works, but it may relax the bladder, decrease the depth of sleep in the last third of the night, and increase bladder capacity (taken one hour before bedtime). Mild reactions can include nervousness, insomnia, gastrointestinal disturbances, fatigue and sensitivity to sunlight. Parents must be very careful to keep imipramine out of the reach of children, as it can be toxic in large doses and an overdose can be fatal.
Anti-spasmodic drugs, such as oxybutynin chloride (Ditropan), can be useful for daytime wetting. They reduce the frequency of bladder contractions, delaying the urge to urinate. Side effects include drowsiness, dry mouth and constipation.

Self Care

Several steps can be taken to handle enuresis without medical intervention:

Limiting the child's intake of liquids before bedtime is one way to make it easier for him or her to stay dry.
Getting the child up to go to the bathroom at night may help.
Behavior modification techniques are effective in eliminating enuresis. For example, parents use wall charts with gold stars awarded for dry nights to inspire the child to work toward token rewards and favorite treats.
Behavior modification, such as the "Bell and Pad" method (enurisis alarm). This method helps the child's brain recognize the sensation of a full bladder while they are asleep and teaches them to wake themselves up from a deep sleep. The bell and pad consists of a sensor that detects wetness and an alarm that wakes the child. The sensor is placed under the child's sheets and when the child begins to wet his bed, the alarm is triggered and wakes the child, so that they can finish urinating in the toilet.
In the case of children with secondary enuresis, the child should be examined to rule out any organic problems for example: infection, seizure disorder or diabetes.
Should the problem appear to be a reaction to stress, psychotherapy or family therapy may be helpful.

Questions

Are there any tests that need to be done? Is the child's enuresis primary or secondary? If it is stress related, should a specialist or therapist be consulted? What type of treatment or modification do you recommend? How effective is this treatment? Are there any alternative treatments?