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Understanding nocturnal enuresis


01 May 2009

can go a long way to managing this common childhood phase and reducing the stress it may cause, as Kimberly Clark explains

Bedwetting, or nocturnal enuresis, is more common than most people might think; about 20 per cent of four-year-olds and 10 per cent of eight-year-olds wet the bed at least twice a week. The condition is almost as prevalent as asthma in children[1].

But the stigma attached to bedwetting means that parents sometimes avoid seeking professional guidance. Often embarrassed, or because they feel nothing can be done, they wait for their child to ‘grow out of it’.

While time and patience are often the best cures, effective intervention can reduce the duration of the problem and improve the lives of children and their families.

Types of enuresis

Enuresis is the involuntary discharge of urine after the age at which bladder control should have been established. In nocturnal enuresis these accidents happen at night, when the child is asleep.

There are two types of enuresis, the most common being primary enuresis, when a child has never experienced being dry at night. Approximately 90 per cent of bedwetting children will experience primary enuresis. The remaining 10 per cent experience secondary enuresis – when a child begins to wet the bed after a lengthy period of being dry.

In total, 7 per cent of children aged 4-15 years wet the bed more than twice a week. So in a class of around 30 children, two are likely to be affected. Bedwetting is also more common in boys than in girls with 60 per cent of cases attributed to boys.

Causes

Bladder development

Much like learning to walk and talk, learning to recognise when the bladder is full is a skill that children achieve at different times and different speeds. A medical examination may rule out other causes such as a weak sphincter muscle, urinary tract infection or diabetes.

Anti-diuretic hormone (ADH)

During sleep, secretion of the anti-diuretic hormone vasopressin stimulates the re-absorption of water through the kidneys, resulting in small amounts of concentrated urine each morning. Some children with nocturnal enuresis do not yet produce enough of this hormone and continue to produce large amounts of urine during the night[2].

In the genes

Bedwetting can be hereditary. If one parent wet the bed as a child, there is about a 40 per cent chance that their child will too. If both parents wet the bed, the odds can rise to around 70 per cent[3].

Deep sleep

Children who wet the bed may be deep sleepers, too heavily asleep for the urge to urinate to wake them up.

Stressful life events

Emotional events like the birth of a sibling, a family upset, starting or changing school, bullying and moving house may all trigger an episode of bedwetting. Secondary enuresis is more often associated in this case.

Advising parents

Parents are likely to be feeling worried, confused and embarrassed so empathy is important. Research shows that parents do not like to be told that bedwetting is normal so gently reassure parents that it is not the child’s fault – nor their own – and that their child will almost certainly grow out of it in time.

You may wish to consider recommending the following hints and tips:

  • Do not restrict fluids. A child should have about eight drinks over the course of the day, which should include three drinks at school. Suggest that they avoid lots of fizzy drinks, tea, coffee and artificial sweeteners as these may irritate the bladder.
  • Give the child their last drink one hour or two before bedtime, but never deny a thirsty child a drink.
  • The child should go to the toilet at bedtime and again just before sleep if they stay awake to read or watch television.
  • Check that the child can get to the toilet easily during the night and that they do not have fears associated with the toilet.
  • Avoid lifting the child and placing them on the toilet if they are asleep. If they have no memory of the activity the following morning, lifting may reinforce the action of urinating during sleep, which can make the problem worse because the child is not responding to their brain waking them to a full bladder. If parents do wish to lift the child, they should wake the child properly, ensuring that they walk to the toilet and urinate with full awareness of what they are doing and why. However, some children may find this disrupts their sleep pattern and leaves them tired the next day.

Treatment

Individual assessment is the key to successful treatment, as well as practical advice to help families manage the situation and, therefore, reduce the stress it may cause. Although there is no one cure, there are a number of options available that help parents and children cope and manage bedwetting.

Motivational therapy

It is important not to ignore or overlook the emotional wellbeing of the child. A calendar system that keeps a note of a child’s progress on dry nights can be a great motivational tool.

A reward scheme can work well once the child begins to experience successful dry nights. You can also use reward charts to reward associated good behaviour such as going to the toilet before bed.

Drug treatments

Drug treatments such as vasopressin analogues may be suitable for children with low levels of vasopressin. The drugs are usually used as a short-term treatment to give a child confidence, or for nights spent away from home e.g. on a school trip. Drugs act more quickly than other treatments but the relapse rate is higher once treatment stops.

Enuresis alarms

A sensor pad placed on the mattress or a sensor attached to underwear or nightclothes, they work by going off when urine is released to wake the child. Ultimately this will sensitise the child to respond quickly and appropriately to a full bladder during sleep. Alarms have a success rate of 65-80 per cent and have a lower relapse rate than drugs, although they may be slower to take effect. They are particularly successful for heavy sleepers.

Absorbent sleepwear

Night-time protection in the form of absorbent sleepwear offers the chance to break the cycle of worry and anxiety many children feel after continuous mornings of wet sheets and damp skin, allowing them to start the day feeling secure, dry and happy.

Children have a choice of discreet absorbent night-time protection, available in ages 4-7 and 8-15 years:

  • Absorbent pyjama pants are made especially for children featuring underwear-like designs for boys and girls to keep sheets and pyjamas clean and dry. Designed to be worn discreetly under pyjamas and nightwear, they can be put on and taken off like normal underwear.
  • Absorbent sleep shorts are a new innovation in absorbent sleepwear, designed to look and feel just like real sleepwear. A plain blue shorts-like outer cover conceals a highly absorbent inner layer, held in place with soft elastic, offering children comfort and discretion.

Referring to a GP

You should refer anyone who reports the following to their GP:

  • A child who is still wetting the bed above the age of 10 years;
  • Anyone suffering from secondary enuresis;
  • Older children who suffer from ‘accidents’ both during the day and night;
  • Where the situation is causing severe distress;
  • Where other symptoms suggest type 1 diabetes;
  • Where symptoms suggest a urinary tract infection;
  • Any mention of blood in the urine or bloodstains on underwear;
  • Straining to pass urine or a very small or narrow stream of urine;
  • Where there is dribbling of urine, either constantly or just after urination.

Further information

www.drynites.co.uk
This website includes parent and child forums where customers can share advice within an intimate and anonymous environment, request sample registration and download a useful bedwetting podcast for further information and help.

www.eric.org.uk
The Enuresis Resource and Information Centre (ERIC) offers information and support, and sells products to aid night-time enuresis.

www.trusteric.org
This website is especially for young people aged 13-17 who experience occasional or regular episodes of bedwetting, daytime wetting or soiling.

References

 

  1. One in 10 children suffer from asthma (www.asthmauk.org.uk).
  2. Djurhuus JC. Definitions of subtypes of enuresis. Scandinavian Journal of Urology and Nephrology 1999; 33(Supp 202): 5-7.
  3. Backwin H. The genetics of enuresis. In Kolvin I, MacKeith RC, Meadow SR (eds). Bladder Control and Enuresis. Philadelphia: Lippincott, 1973.

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