Bedwetting, also called nocturnal enuresis, is the involuntary passage of urine (urinary incontinence) while asleep. Inherent in the definition of bedwetting is satisfactory bladder control while the person is awake. Therefore, urination while awake is a different condition and has a variety of difference causes than bedwetting.
There are two types of bedwetting:
- Primary enuresis: bedwetting since infancy.
- Secondary enuresis: wetting developed after being continually dry for a minimum of six months.
Primary bedwetting is viewed as a delay in maturation of the nervous system. At 5 years of age, approximately 20% of children wet the bed at least once a month, with about 5% of males and 1% of females wetting nightly.
By 6 years of age, only about 10% of children are bedwetters – the large majority being boys. The percentage of all children who are bedwetters continues to diminish by 50% each year after 5 years of age. Family history plays a big role in predicting primary bedwetting. If one parent was a bedwetter, the offspring have a 45% chance of a developing primary enuresis as well.
The fundamental problem for children with primary bedwetting is the inability to recognize messages of the nervous system sent by the full bladder to thesleep arousal centers of the brain while asleep. In addition, bladder capacity is often smaller in bedwetting children than in their peers.
Most people (80%) who wet their beds, wet only at night. They tend to have no other symptoms other than wetting the bed at night.
Other symptoms could suggest psychological causes or problems with the nervous system or kidneys and should alert the family or health-care provider that this may be more than routine bedwetting.
- Wetting during the day.
- Frequency, urgency, or burning on urination.
- Straining, dribbling, or other unusual symptoms with urination.
- Cloudy or pinkish urine, or blood stains on underpants or pajamas.
- Soiling, being unable to control bowelmovements (known as fecal incontinence orencopresis).
Most cases of bedwetting are PNE-type, which has two related most common causes.
This is the most common cause of bedwetting. Most bedwetting children are simply delayed in developing the ability to stay dry and have no other developmental issues. Studies suggest that bedwetting may be due to a nervous system that is slow to process the feeling of a full bladder.
Bedwetting has a strong genetic component. Children whose parents were not enuretic have only a 15% incidence of bedwetting. When one or both parents were bedwetters, the rates jump to 44% and 77% respectively. Genetic research shows that bedwetting is associated with the genes on chromosomes 13q and 12q (possibly 5 and 22 also).
These first two items are the most common factors in bedwetting, but current medical technology offers no easy testing for either cause. There is no test to prove that bedwetting is only a developmental delay, and genetic testing offers little or no benefit.
As a result, doctors work to rule out other causes.
The following causes are less common, but are easier to prove and more clearly treated:
Drinking alcohol increases urine production.
Children with ADHD are 2.7 times more likely to have bedwetting issues.
Caffeine increases urine production.
Chronic constipation can cause bedwetting. When the bowels are full, it can put pressure on the bladder.
Infections and disease are more strongly connected with secondary nocturnal enuresis and with daytime wetting. Less than 5% of all bedwetting cases are caused by infection or disease, the most common of which is a urinary tract infection.
Insufficient anti-diuretic hormone (ADH) production
A portion of bedwetting children do not produce enough of the anti-diuretic hormone. As explained above, the body normally increases ADH hormone levels at night, signalling the kidneys to produce less urine. The diurnal change may not be seen until about age 10.
More severe neurological-developmental issues
Patients with mental handicaps have a higher rate of bedwetting problems. One study of seven-year-olds showed that "handicapped and mentally retarded children," had a bedwetting rate almost three times higher than non-handicapped children (26.6% vs. 9.5%, respectively).
Less than 10% of enuretics have urinary tract abnormalities, such as a smaller than normal bladder. Current data does support increased bladder tone in some enuretics, which functionally would decrease bladder capacity.
Psychological issues (e.g., death in the family, sexual abuse, extreme bullying) are established as a cause of secondary nocturnal enuresis (a return to bedwetting), but are very rarely a cause of PNE-type bedwetting. Bedwetting can also be a symptom of a pediatric neuropsychological disorder called PANDAS.
When enuresis is caused by a psychological or neuropsychological disorder, the bedwetting is considered a symptom of the disorder. Enuresis has a psychological diagnosis code (see previous section), but it is not considered a psychological condition itself.
Sleep apnea stemming from an upper airway obstruction has been associated with bedwetting. Snoring and enlarged tonsils or adenoids are a sign of potential sleep apnea problems.
Sleepwalking can lead to bedwetting. During sleepwalking, the sleepwalker may think he/she is in another room. When the sleepwalker urinates during a sleepwalking episode, he/she usually thinks they are in the bathroom, and therefore urinate where they think the toilet should be. Cases of this have included opening a closet and urinating in it; urinating on the sofa and simply urinating in the middle of the room.
Stress is not a cause of primary nocturnal enuresis (PNE), but is well established as a cause of returning to bedwetting (secondary nocturnal enuresis). Researchers studying children who have yet to stay dry find "no relationship to social background, life stresses, family constellation, or number of residencies.
On the other hand, stress is a cause of people who return to wetting the bed. Researchers find that moving to a new town, parent conflict or divorce, arrival of a new baby, or loss of a loved one or pet can cause insecurity, contributing to returning bedwetting.
There are a number of treatment and condition management options for bedwetting. The following options apply when the bedwetting is not caused by a specifically identifiable medical condition such as a bladder abnormality or diabetes.
When treatment is recommended
Doctors consider treatment when there is a specific medical condition such as bladder abnormalities, infection, or diabetes.
Physicians also treat bedwetting when it may harm the child's self-esteemor relationships with family/friends. Only a small percentage of bedwetting is caused by a specific medical condition, so most treatment is prompted by concern for the child's emotional welfare. Behavioral treatment of bedwetting overall tends to show increased self esteem for children
Parents become concerned much earlier than doctors. A study in 1980 asked parents and physicians the age that children should stay dry at night. The average parent response was 2.75 years old, while the average physician response was 5.13 years old.
Punishment is not effective and can interfere with treatment.
Treatment options with high success rates
Almost all children will outgrow bedwetting. For this reason, urologists and pediatricians frequently recommend delaying treatment until the child is at least six or seven years old. Physicians may begin treatment earlier if they perceive the condition is damaging the child's self-esteem and/or relationships with family/friends.
Physicians also frequently suggest bedwetting alarms which sound a loud tone when they sense moisture. This can help condition the child to wake at the sensation of a full bladder. These alarms are considered effective, with study participants being 13 times more likely to become dry at night. There is a 29% to 69% relapse rate, however, so the treatment may need to be repeated.
Desmopressin tablets are a synthetic replacement for antidiuretic hormone, the hormone that reduces urine production during sleep. Desmopressin is usually used in the form of desmopressin acetate, DDAVP. Patients taking DDAVP are 4.5 times more likely to stay dry than those taking a placebo. The drug replaces the hormone for that night with no cumulative effect.
US drug regulators have banned using desmopressin nasal sprays for treating bedwetting, but say that desmopressin pills are still considered a safe bedwetting treatment for otherwise healthy patients. The regulators reviewed the drug after two adult nasal spray users died from hyponatremia, an imbalance of sodium levels in the body.
Tricyclic antidepressant prescription drugs with anti-muscarinic properties have been proven successful in treating bedwetting, but also have an increased risk of side effects, including death from overdose. These drugs include amitriptyline, imipramine and nortriptyline. Studies find that patients using these drugs are 4.2 times as likely to stay dry as those taking a placebo. The relapse rates after stopping the medicines are close to 50%.