Bed-wetting: An Overview of Nocturnal Enuresis

It's not unusual for children under the age of six to wet their beds now and again, even after having been toilet trained for a number of years. In fact, some children - boys especially - may continue to have the occasional wet bed episode even beyond their sixth year. It may surprise (not to mention relieve!) parents to find out that this is not that unusual, and it doesn't necessarily indicate a problem. But children who wet their beds more frequently may have a common childhood condition called "nocturnal enuresis";.

What is nocturnal enuresis?

Nocturnal enuresis is defined as involuntary urination at night, two or three times a week, in a 5 or 6 year old child - or at least once a week in an older child. A child who has primary nocturnal enuresis has never been dry at night for more than 6 months, whereas a child with secondary nocturnal enuresis only began nighttime bed-wetting after a period of at least six months of dry nights. Diurnal enuresis is defined as involuntary daytime urination at an age when control should have been achieved, usually by 3 or 4 years of age. Diurnal enuresis is considered to be different in nature and cause from nighttime wetting, so its treatment differs from that of nocturnal enuresis.

Bed-wetting is not a deliberate act or a sign of laziness. It's important to stress that when children wet their beds, whether they are enuretic or not, they should never be faulted, punished, humiliated, or scolded. An angry or frustrated response from a parent can damage the child's self-esteem, and even make the problem worse.

Children who wet their beds frequently should have a comprehensive medical examination by a doctor. A medical exam will help rule out any other possible causes of the child's bed-wetting, determine whether or not the child has enuresis, and identify the type of enuresis. Based on this examination, the child's physician can determine appropriate strategies for treatment.

Is nocturnal enuresis a serious health problem?

Nocturnal enuresis is generally considered a benign (non-health-threatening) condition that usually resolves itself on its own, though it may in some cases take years to disappear completely. However, while enuresis may be superficially perceived as a minor problem, it sometimes leads to serious psychological and social consequences for the child when it's dealt with improperly. The child may suffer embarrassment, guilt, loss of self-esteem, anxiety, alienation within the family, and troubled social development if the condition is not treated, or if the condition draws a negative response from the family. It's therefore important that parents understand their child's condition, and respond in a practical and effective way with the guidance of a health care professional. Patience, support, and a positive outlook are crucial aspects of successful treatment. In fact, bed-wetting often resolves itself on its own once the parents' and the child's anxiety is eased through an improved understanding of nocturnal enuresis.

What causes nocturnal enuresis?

The exact causes of enuresis are not fully understood, although there seems to be a number of contributing factors. Studies have suggested that in some cases genetic inheritance seems to play a role, with children of parents who had childhood nocturnal enuresis having a significantly greater chance of developing the condition than other children. In certain cases, psychological factors such as stress may play a role in causing or aggravating nocturnal enuresis. Other types of enuresis (such as daytime wetting, or daytime wetting in combination with nighttime wetting) may be caused by bladder dysfunction or instability. Nocturnal enuresis has also sometimes been linked to constipation. And recently, studies have suggested that in some enuretic children, there is diminished secretion of antidiuretic hormones (ADH) during the night, compared with children who stay dry throughout the night. ADH is responsible for regulating and restricting urine production in the body.

Is there a cure?

Although there is no single "cure" for enuresis, the good news is that - given time - the condition will usually clear up on its own. However, there are strategies which may help resolve the problem sooner rather than later, and with fewer negative consequences - though in any case parents have to exercise patience and support.

Treatment strategies include motivational approaches such as a reward system approach, in which the child receives positive reinforcement (such as praise or extra privileges) in reward for dry nights; behaviour modification approaches such as the enuresis alarm system, which gradually conditions the child to anticipate the need to urinate before actually wetting the bed; or medication therapy, which can help control wetting in extreme or exceptional cases. In cases where enuresis has been linked to constipation, the problem of enuresis may be cleared up by simply treating the constipation.

Practical suggestions often given to parents include bedtime fluid restriction, having the child urinate in the toilet before going to sleep, waking the child in order to urinate prior to the parents going to bed, and bladder exercises.

The various treatment strategies may be used alone, one after another, or in combination, depending on the type of enuresis diagnosed, and on each child's situation. Treatment strategies should be monitored and followed up by a health care professional.

Do diapers help?

This is a question shared by many frustrated parents. The good news is that most children do outgrow this problem, as night-time bedwetting(nocturnal enuresis) is thought to be caused by a temporary immaturity of bladder control during sleep. The key is what do we do in the meantime? The answer depends entirely on the age of the child and the degree of frustration of all involved. The main goal of treating children with bedwetting is making sure that they are not affected psychosocially. Diapers(or pull-up panties) are not usually considered as a part of a treatment approach, although there is an increasing number of advertisements promoting their use in children who wet the bed at night. If a child's self-image is affected, can't participate in sleepovers, or if the family is at their wits end, then we should definitely try to help stop the bed wetting. However, diapers, unlike other approaches, do not stop the bedwetting, but rather hide it. The fear is that diaper use in nocturnal enuresis sends a "message of permission" to urinate at night. Although the bed and sheets may be dry, the child still has urinated at night, but into a diaper. Although this approach may temporarily spare the need to change sheets and stop the associated night-time disruption, I believe that prolonged use of diapers may actually make the problem worse. In the short term, many will argue that diaper use will allow a child to participate in "sleep-aways" without the fear of embarrassment. But do not forget, that wearing a diaper (even a pull-up) may also be a source of ridicule by peers.

While diaper use may temporarily give the family and child a break, I do not advocate their prolonged or regular use in the treatment of children with nocturnal enuresis. I prefer to use other proven and effective methods described above. The specific treatment approach selected, depends of course on the age and individual situation.