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Nocturnal enuresis, or bedwetting, is one of the most common conditions in children that are brought to an urologist's attention. There is no clear-cut point at which it stops being "normal" for a child to wet at night, but parents tend to bring their children to medical attention at times determined by external social situations.

For example, children with nocturnal enuresis are often brought to the doctor when it is time for them to start attending school for the first time. Other common times for children to present for evaluation include ages when parents are ready for them to go on overnight trips away from home, when transitioning from elementary school to middle school, or when transitioning from middle school to high school.

How are children who wet the bed physically different from children who stop wetting the bed at a relatively young age? There are various theories about why nocturnal enuresis happens, including small bladder capacity, inability of the child's brain to be aroused from sleep by an urge to urinate, and a relatively overactive bladder.

The physical reasons in any given child are probably a combination of factors, but regardless it is essentially a highly restricted form of developmental delay. By "highly restricted," I mean that children who wet the bed tend not to have any other developmental delays.

I often explain to parents that children learn to walk, speak, or read at different ages. Likewise, children stop wetting the bed at different ages. One thing that parents can be reassured about is that it is extremely rare for a child to continue to wet the bed into adulthood. In 15 years of practicing urology, I have met exactly one person who never stopped wetting the bed. I met him in his early 40s, and I successfully treated him by surgically implanting a sacral nerve stimulator. I have encountered young people who stopped wetting the bed in their late teens, and in one case at age 20.

The take-home message for parents is that their child will stop wetting the bed eventually. Nocturnal enuresis is a delay in the development of the nerves that regulate bladder control at night, but it is a delay that does resolve on its own, given enough time. This does not solve any of the social difficulties that arise when a child wets the bed beyond ages when other children his age do not, but knowing that it will stop usually helps reduce stress levels.

When a child is brought for urologic evaluation for bedwetting, the single most important thing to determine is whether there are any other urologic or neurologic symptoms whatsoever other than bedwetting. Any daytime symptoms should prompt a careful examination and appropriate treatment--such symptoms may include daytime wetting, urgent urination, frequent urination, encopresis (staining of the underwear with feces), abdominal pain, burning with urination, problems with coordination or running, or urinary tract infections.

The treatment of daytime dysfunctional voiding is a topic for a different article, but suffice it to say that it can usually be successfully treated with relatively simple interventions, and nighttime wetting may also improve somewhat with these interventions. If daytime symptoms persist in spite of appropriate treatment, then there could be a more serious neurological condition that needs to be detected and treated.

In addition, it is important to establish whether the child has ever been dry at night. If a child was ever dry at night for a prolonged period of time (6 months or longer) and then began to wet the bed again, a careful history and physical may reveal medical or psychological factors that are contributing to the new problem of bedwetting.

In the vast majority of children, however, the problem is simple primary nocturnal enuresis; in other words, the child has never been dry at night, and has no daytime urologic symptoms whatsoever. My subsequent comments will be addressed to children in this situation.

As has been mentioned already, reassuring parents and child alike is the first and most important step in treatment of nocturnal enuresis. Reducing family stress surrounding bedwetting is vital because, quite frankly, most children are simply not going to stop wetting the bed until their bodies are ready to stop. When there is a great deal of stress, anger, and frustration about the bedwetting, if anything it tends to make thing resolve more slowly.

Another step in reducing family stress about bedwetting is to make it clear to parents and child alike that the child needs to take responsibility for as much of the clean-up that results from wetting the bed as possible. I usually explain to the child and parents that it is like brushing your teeth or going to be bathroom--selfcare items that children do for themselves.

Expectations need to match the age-appropriate abilities of the child, but in my experience, mothers in particular have a quite fine-honed sense of what their child can and cannot do. At the youngest ages, a child's involvement may be as simple as having a hamper into which to put their wet pajamas, and helping a parent strip the sheets from the bed. It goes without saying that a waterproof fitted sheet is a must.

As a child gets older, he or she can learn to strip the bed alone, put on fresh sheets, and do all of the washing and drying of wet sheets and pajamas. The goal is to get, as quickly as possible, to a point where other family members aren't affected by the bedwetting and hardly know that it is going on. This reduces considerably the stresses, embarrassment, and burdens of bedwetting--on the child, on the parents, and on siblings.

More controversial is the use of diapers or pull-ups. My own recommendation to parents is to try to avoid the prolonged use of pull-ups, in spite of their convenience. This is anecdotal, and I am not aware of formal studies on the subject, but modern diapers and pull-ups are so efficient at wicking wetness away from the skin that there is little or no discomfort involved for a child who wets at night. A child who is simply wearing pajamas will eventually get wet and uncomfortable. At a certain point in the night, wet clothing gets cold and will wake up the child. I believe that being uncomfortable and wet does, at a certain point in development, provide feedback to a child's brain that can speed along the process of becoming dry. This is an individual choice for parents to make.

There are a host of interventions that have been used to treat bedwetting. There are, for example, alarm systems that alert the child and parents when detecting wetness, but in my experience, they do more to disturb the parents' sleep than they do to stop bedwetting. Some parents find them helpful, but true success rates are low.

Two drugs that are commonly used are imipramine and DDAVP. The former is a medicine originally developed as an antidepressant that was discovered to have an effect on overactive bladders. The latter is a hormonal medication that cuts down on the amount of urine that the kidneys make during the night. Both have shown some success, but it is extremely common for these medicines not to have any effect whatsoever on the frequency and amount of bedwetting.

When a child is in the heart of primary nocturnal enuresis--that is, when the child has few or no dry nights in his or her life--none of the treatments commonly used are particularly effective. It is reasonable to give short courses of treatment for a couple of months to see if there is a dramatic decrease in wetting, but if there isn't a ready and noticeable response, I recommend stopping treatment and waiting until later. There is simply no point in leaving a child on these kinds of medications for prolonged periods of time if they aren't yielding significant results.

Any treatment is most successful when a child is having frequent spontaneous dry nights. When a child is starting to have dry spells--whether several nights a week, or a stretch of a week or two at a time--this is a sign that the child is getting closer to reaching developmental maturity with regard to nighttime bladder control. It is at this point that medications such as DDAVP and imipramine are most likely to have some significant positive effect. Many of the treatments and interventions that work are often treatments that are instituted around the time that a child was about to stop wetting the bed anyway.

This is why it is so important that parents understand the nature of the condition and be prepared for the long haul. Parents and children alike are done a disservice when they are given unrealistic expectations about what medications can do and when they are not prepared for the patience that dealing with nocturnal enuresis will, in most cases, require.

By Bradley Anderson, MD

Bradley W. Anderson was trained in general and urologic surgery at the University of Oklahoma, and is board certified in adult and pediatric urology. He is also a Fellow of the American College of Surgeons. He practices urology at St. Vincent Healthcare, a regional medical center in Billings, MT.
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Title Annotation:Urologist's Notebook
Author:Anderson, Bradley
Publication:Pediatrics for Parents
Geographic Code:1USA
Date:Sep 1, 2012
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