Bed-wetting (Nocturnal Enuresis) FAQ

Is there something physically wrong with my child?
While bed-wetting can be a symptom of some underlying condition, such as an infection of the urinary tract, most children who experience bed-wetting do not have a serious physical aliment. Recent research shows that in some children, bed-wetting may be related to a lack of nighttime increase in antidiuretic hormone (ADH), the hormone responsible for the regulation of urinary output. This results in the nighttime overproduction of urine. Taking a complete history in combination with a physical exam should uncover any underlying physical cause responsible for the child's bed-wetting.

Should my child be allowed to participate in overnight activities, such as camp, sleepovers and family vacations?
Absolutely! The age when children wet their beds is a very important time to be involved in activities with peers and siblings. There are ways to "protect" the child at overnights. For example, have the child bring his own sleeping bag. It is important that the child feels secure enough so that she will not lose sleep for fear of wetting the bed. Sometimes DDAVP is used for special occasions, like sleepovers or camp, to ensure a dry night when it is most important to the child.

Is there a proper way to deal with a wet bed night after night?
Parents should not punish or blame the child; this could have a serious effect on his self-image. Parents should teach the child to take responsibility for remaking the bed and changing into dry pajamas. They should not humiliate the child by hanging the sheets out a window to dry, or use any other method of humiliation. A wet bed can be ignored but a child cannot.

Are there safe and effective treatments available?
Yes. Safe and effective treatments are available, including behavior modification, enuretic alarm systems and pharmacologic treatment.

What is nocturnal enuresis?
Nocturnal enuresis (or bed-wetting) is defined as unwanted urination at night by children past the age of 6 years. The bed-wetting may be ongoing or episodic, but the dry periods are unpredictable and never prolonged.
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How common is bed-wetting?
Bed-wetting is a very common condition affecting an estimated five to seven million children nationwide. Boys are more commonly affected than girls.
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What are the causes of bed-wetting?
While the causes of bed-wetting are not fully understood or agreed upon, bed-wetting does tend to run in families.

If both parents were bed-wetters, the child has a 70 percent chance of being a bed-wetter.

If one parent was a bed-wetter, the child has a 44 percent chance of being a bed-wetter.

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What is the impact of bed-wetting on the child?
Bed-wetting usually occurs during a critical stage in a child's life when he is establishing relationships with peers and siblings -- relationships that are critical for social development. If bed-wetting is not treated, a child's self-image can be affected. Mishandling of bed-wetting can make the situation worse for the child, which is often seen in poor school performance and antisocial behavior, such as declining to participate in group activities or "acting up."

It is important for the physician to encourage the child to express his feelings, fears and ideas. This allows the physician to correct whatever false notions the child may have about bed-wetting. The child's interpretations and reactions may be quite different from his or her family's.
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What are the treatments for bed-wetting?
Most children will eventually "outgrow" bed-wetting. Each year about 15 percent of the bed-wetters will stop bed-wetting. By the age of 18, at least one percent are still wetting the bed. If it is decided treatment is appropriate, a full description of the plan must be given to the entire family. Without the proper motivation and understanding of the plan, it will probably fail. The following treatment options can be used in the combination that works for the individual child.

Counseling the child
The child must be assured that bed-wetting is common. She is not the only one who wets the bed. The child must understand the treatment plan.

Counseling the parents
Parents need to know that treatment can take a while to work, possibly as long as six months. The parents must be encouraged to follow the treatment plan and to be patient, understanding and devoted. The child may wet the bed after a period of dryness. If so, the parents should be discouraged from scolding or punishing the child for wetting the bed. The parents should ignore the wet bed, but not the child. If problems come up before the next appointment, you can call us.

Alarms
Wet-bed alarms are moisture-sensitive and ring when the child wets. This wakes the child so that she can go to the bathroom. Initially, the child awakens after or during voiding. The child then learns to associate bladder fullness with a conditional response (i.e., awakening and avoiding bed-wetting).

Pharmacologic therapy
Two pharmacologic treatments are indicated for use in primary nocturnal enuresis: imipramine hydrochloride and DDAVP nasal spray (desmopressin acetate).

DDAVP nasal spray
DDAVP nasal spray (desmopressin acetate) acts by decreasing the production of urine during the night. DDAVP is actually a hormone called anti-diuretic hormone, or ADH, delivered in the form of a nasal spray that is used nightly. DDAVP has almost an immediate effect of reducing urine output, and therefore reduces bed-wetting. Success rates are as high as 70 percent, but most children experience a return to bed-wetting as soon as the drug is discontinued. DDAVP is effectively used for special occasions, like camp or sleepovers, when a dry night is very important to the child. Practice once or twice at home with the nasal spray beforehand.

Imipramine
Imipramine was initially used as an anti-depressant medication and is in the group of drugs known as tri-cyclic antidepressants. Imipramine is thought to relax the bladder muscles, allowing for greater filling along with less bladder sensitivity to filling. Imipramine may take a week or longer to start working and has the side effects of decreased appetite, irritability, headaches and constipation. All of these side effects are rare and go away when the medicine is stopped.
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Are there any approaches that don't work?
Restricting fluids, except for a mild fluid restriction as bedtime approaches, does not help develop better nighttime bladder control. Rejection, shame, and punishment because of bed-wetting does not help; it does increase the child's anxiety and lowers the child's self-esteem. Parents must realize that bed-wetting is not deliberate or controllable by the child.
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BIOFEEDBACK AND VOIDING RETRAINING : CHRONIC CONSTIPATION AS IT RELATES TO BED-WETTING : DETRUSOR INSTABILITY : GLOSSARY : HYDROCELE : INCONTINENCE : NOCTURNAL ENURESIS (BED-WETTING) : URINARY TRACT INFECTIONS : VESICOURETRAL REFLUX