by Warren P. Silberstein, M.D.
06/02/97
updated 09/12/98
The medical term for bed wetting is nocturnal enuresis, but many refer to it simply as enuresis. The vast majority of bed wetters have never been dry for any prolonged period of time. Their condition is known as primary enuresis. As many of these children mature, the problem will simply go away. At 4 years of age 1/4 to 1/3 of children still wet their beds. Only 15 % of 5 to 6 years olds still wet their beds. With each year of age 15% of bed wetters will stop wetting so that by 15 years of age only 1% of children still wet their beds.
Secondary enuresis refers to enuresis that develops in a child who has already been dry for more than six months. There is a significantly greater risk that children with secondary enuresis may have a medical cause for their wetting. Any child who still wets his bed by age 6 should have a minimal medical workup consisting of a complete urinalysis and a urine culture. The need for further evaluation can be determined based on the results of the initial tests and the child's response to treatment.
Yes, there is treatment. Even though the vast majority of bed wetters would stop wetting on their own as they got older, there isn't a bed wetter alive who wouldn't rather stop right now if he could. Years ago enuresis used to be considered an emotional problem. It is true that emotional issues can contribute to bed wetting. Regression in response to psychological trauma or stress is certainly one cause for secondary enuresis. But most children with primary enuresis are emotionally healthy. Most of the bed wetters who have psychological problems have these problems because of the enuresis. It is embarrassing to wet the bed. Children who wet always fear that their horrible secret will get out. They think that they are the only ones who wet. They have problems with sleepovers and camp. Even if their parents never punish or berate them for bed wetting, and even if their parents provide positive emotional support, they can see the aggravation cleaning sheets causes for their parents, and they feel like failures because they know most kids their age are dry. Enuresis is very bad for a child's self esteem. If your child is a bed wetter he should look at Oh, no! I Wet the Bed Again, an article written for children about enuresis that explains what it is, what causes it, and what can be done about it. This article helps children who wet to realize they are not the only ones.
If your child is older than 6 years old and still wets his bed, you should consider having him evaluated by his pediatrician and discussing the various treatment options. Even if your child is younger, if his bed wetting is causing either him or you distress, you should discuss treatment with his pediatrician.
The oldest method of treatment is a medication called Tofranil (imipramine). Imipramine is an antidepressant. It is used to treat enuresis because it relaxes the smooth muscle of the bladder. About 75% of children who are treated with imipramine will become dry; however 50% of those children will relapse when the drug is stopped. Of those children, up to 75% may become dry again when the medication is reinstituted, but it may require higher doses, and discontinuation can result in recurrence of the bed wetting again. I have used imipramine successfully in a number of children (especially before an other medication became available) and never run into a problem with it, but imipramine is not my favorite treatment. First of all, the medication doesn't do anything to train the bed wetter to wake up to urinate or to stop the spontaneous emptying of the bladder in his sleep. Therefore, its success is primarily as a stopgap measure to keep a child dry until he matures out of wetting. Secondly, even though I've never had a patient run into problems with imipramine, its list of side effects is long and includes nervousness, sleep disturbance, fatigue, upset stomach, dry mouth, allergic reactions, bone marrow depression (decreased blood cell production), low blood pressure, and heart rhythm abnormalities.
DDAVP (desmopressin acetate) is a synthetic antidiuretic hormone. Antidiuretic hormone is produced in the pituitary gland and is part of the body's mechanism for controlling fluid balance. Antidiuretic hormone tells the kidneys to make the urine more concentrated so that the body retains fluids. Normally, urine is more concentrated at night during sleep so that the bladder doesn't fill as quickly during sleep as during the day and people don't have to urinate as frequently. It was found that some enuretic children don't concentrate their urine during the night. While that mechanism doesn't explain all enuresis, DDAVP is fairly effective for treating enuresis. It also has few side effects. The main side effects are headache, runny or stuffy nose, and nasal stinging. The medicine is a nasal spray, so it can be given to children who can't swallow pills. DDAVP has recently become available as a small, easy to swallow tablet for treating enuresis. The biggest problem is that it is expensive. There is also no good evidence to indicate that using DDAVP will change the body's normal rhythm and result in increased nighttime concentration of the urine after the medicine is stopped, so just like imipramine, there is a chance of relapse after discontinuing the medication. One big advantage of DDAVP is that it often works quickly and so it can be used intermittently, such as for camp or sleepovers.
My favorite method of treatment is the alarm system. The basic concept is that a sensor is placed in the underwear which will cause the alarm to ring at the first drop of urine. The purpose of the alarm is to wake the child up so that he will either stop wetting or go to the bathroom to urinate. This differs from waking a child periodically to urinate because the alarm only wakes the child when he starts to wet. The purpose is to train him to wake up in response to the bladder spasm that results in the bladder emptying in bed. This is a conditioned response similar to the one that Pavlov used in his experiments where dogs learned to salivate in response to the sound of a bell because the bell was always followed by food. The alarm system depends on following a whole program of positive reinforcement for success. Since many bed wetters are deep sleepers (which is postulated to be the reason they sleep through wetting their beds) the parents are likely to have to wake the child up at first and teach him to respond to the alarm. It is crucial for the child to understand and actively participate in the program because if he ends up feeling that the alarm is just telling his family that "he blew it" that would be counterproductive. I don't recommend the alarm for children less than 6 years old because they need to understand the whole program, but I have used it for younger children at the parents request and have had success in a bright child as young as 4.
Information is available about the following enuresis alarms on the Web:
I have used the following alarms with my patients:
We haven't talked a great deal about the causes of bed wetting because there isn't universal agreement about what causes it. There are probably multiple causes for enuresis, with no one cause applying to everyone who wets. Certainly having a small bladder capacity, or being a deep sleeper, or not concentrating your urine at night, can contribute to the problem, but there are children who have those situations who don't wet. An important factor is family history. About 85% of bed wetters have relatives who wet. In fact, a Danish study published in the July 1, 1995 issue of Nature Genetics, identified a genetic marker that was present in more than 90% of the families who had a history of primary nocturnal enuresis. Since many people are too embarrassed to talk about it, family members may not even know about it, but if they do, it would be helpful for the child to hear about the relatives who wet and their success stories about stopping.
There is no shortage of information about enuresis on the Web.
For a good, basic article for parents about bed wetting check out The Wet Set: What Parents Need to Know About Bedwetting.
The National Enuresis Society Homepage provides a comprehensive look at enuresis. The article is divided into sections with a linked table of contents at the beginning. The information includes Guidelines For Seeing a Doctor and Other Resources on the WWW.
The Pediatric Database (PEDBASE) entry is a technical outline for health professionals which includes epidemiology, differential diagnosis, pathogenesis, clinical features, medical evaluation, and management.
For a more personal approach which might include your specific situation, visit Dr. Greene's Housecalls and read the answers he's written to patients' questions about their problems with enuresis.
A psychiatrist's viewpoint as expressed in Facts for Families may be of interest to some of you. Articles are available in Spanish (Español) and French (Français).
Most Children Can Be Successfully Treated for Bedwetting is a news article. The good news is that most kids can be treated successfully. The bad news is that most parents don't believe their doctor can help and don't pursue it after the doctor tells them their child will probably outgrow it.
Don't forget to have your children visit KidsHealth.org's site to read Oh, no! I Wet the Bed Again.
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