Bedwetting in children

Abstract

Bedwetting, or nocturnal enuresis, is involuntary wetting of the bed during sleep, over which a child has no conscious control. Bedwetting is a common childhood problem that causes great distress to some families. Clear advice and reassurance may be all that is necessary, as most children become dry at night without any intervention. If intervention is required, simple effective treatments are available. This article aims to outline practical management of nocturnal enuresis and how to give effective advice and information to families.

The GP curriculum and bedwetting in children

Clinical module 3.04: Care of children and young people requires GPs to:

Manage and appropriately treat common and rare but important paediatric conditions encountered in primary care, such as psychological problems e.g. enuresis

Develop and apply the primary care consultation to bring about an effective doctor–patient– family relationship to enable parents or carers, children and young people to be routinely involved and supported in making informed decisions and choices about care, taking into account age and development, increasing autonomy with age, and the need for confidentiality balanced with the parents’ need for information and to receive information on medicines in a clear way that is appropriate to their understanding as children, young people and parents

Impact and extent of the problem

Parenting is fraught with challenges; for some bedwetting is one of these issues. The psychological and physical impact of bedwetting on children and their parents should not be underestimated. The young person may be teased by peers and become anxious about trips away or sleepovers with friends that often form part of a child’s normal social life.

Being dry at night can be considered developmentally normal from the age of 5 years and many children achieve this milestone long before their fifth birthday. However, bedwetting over the age 5 years is common; at 4½ years, 21% of children will still wet the bed up to 2 nights a week. This falls to 8% at 9½ years. A few children will wet the bed more often than twice a week; however, this is much less common with 8% and 1.5% having problems at 4½ and 9½ years old, respectively. In the past, treatment was often delayed until the age of 7 years. The National Institute for Health and Care Excellence (NICE) now recommends intervention from the age of 5 years (NICE, 2010).

Pathophysiology and risk factors

Multiple factors can contribute to a child experiencing bedwetting (see Box 1). In primary nocturnal enuresis, the affected child will have never been consistently dry at night. In secondary nocturnal enuresis, the affected child has achieved dryness for 6 months or more, but has had a reoccurrence of bedwetting. Making this differentiation is useful, as secondary problems have a higher probability of being related to organic disease, behavioural issues or emotional problems. It is also important to consider the possibility of maltreatment when no obvious cause is found. Nocturnal enuresis affects 45% of children where one parent has a history of bedwetting, increasing to 77% when both parents were affected (Backwin, 1973).

Box 1.

Factors increasing the likelihood of bedwetting.

• Family history (see main text for statistics)

• Male sex

• Developmental delay

• Obesity

• Attention deficit hyperactivity disorder

• Neurological diseases, e.g. Spina bifida, cerebral palsy

• Emotional stress and significant life events

• Dietary: Caffeine, artificial additives

In simple terms, when children have achieved dryness at night, the detrusor muscle distends as the bladder fills and this triggers a message to the brain, waking the individual and prompting a visit to the toilet. In addition, vasopressin hormone reduces the amount of urine produced by the kidneys overnight, so that bladder filling is reduced. Problems at various points in this process may affect the child's ability to achieve dryness.

Sleep arousal difficulties

The signal to the brain from the bladder may simply not wake the child. This can occur in deep sleep. This may be a normal variant, but can be caused by deep sleep resulting from pathology such as upper airway obstruction with sleep apnoea. Such obstruction can be caused, for example, by tonsillar enlargement. Neurological problems, such as spina bifida and cerebral palsy, may also interfere with the proper communication between the bladder and brain.

Urinary system dysfunction

The child may have a reduced bladder capacity. This can be secondary to constipation; stools stored in the rectum physically reduce the bladder’s storage capability. Alternatively, an overactive bladder is functionally small and unable to accommodate the normal overnight urine production without triggering bladder-emptying. An overactive bladder is often irritable and prone to frequent contractions. Fizzy drinks and caffeine are two of the most common bladder irritants. In addition, blackcurrant juice and drinks containing artificial colourings and flavourings may also stimulate the overactive bladder. Some congenital abnormalities of the urinary tract may cause bedwetting, e.g. ectopic ureter.

Polyuria

If the production of vasopressin is reduced, overnight urine production is increased and may simply overwhelm the bladder. Vasopressin levels can be reduced in response to stress and anxiety. Alternatively, the child may also be simply drinking too much. Diabetes mellitus is also an important cause of polyuria to consider.

Determining the cause

Taking a history

Taking a good history will, in most cases, reveal the likely cause of nocturnal enuresis. As mentioned earlier, determining whether the problem is primary or secondary allows identification of children likely to have an underlying cause for bedwetting. Most children will not have an underlying pathology. However, the most common underlying pathologies to rule out are constipation, urinary tract infection and diabetes mellitus.

If the parent is unable to give a clear description of the pattern and nature of the problem, consider providing them with a bladder diary to complete (a good downloadable one can be found on the Children’s Bowel and Bladder Charity website). Review the diary information to help determine exactly what problems the child has been experiencing. Box 2 gives suggestions for comprehensive history-taking.

Box 2.

Comprehensive bedwetting history.

• Has the child ever been dry? (Primary versus secondary)

• How many nights a week? (The more nights a week, the less likely is spontaneous resolution)

• How many times a night and amounts of urine? (Large volume in first few hours often idiopathic. Variable volume more than once a night consider overactive bladder)

• Does the child wake up? (Sleep arousal problem?)

• Are there daytime urinary symptoms? (Urgency, frequency and daytime wetting are more likely related to a secondary cause)

• What is the child's fluid intake like? (Volumes and kinds of fluid)

• Is the child constipated? (Reduced bladder capacity)

• Are there any other symptoms/concerns?

• Are there any behavioural issues, developmental problems, family problems or emotional issues?

• Is it easy for the child to access the toilet in the home?

• How is the bedwetting affecting the child and the family?

• Is there any family history of bedwetting?

Examination

Abdominal examination will allow bladder distension or gross constipation to be detected. Inspection of the genitals and examination of lower limb neurology may be useful if problems are suspected.

Investigations

Investigations should be kept to a minimum. NICE suggests urinalysis only if the bedwetting has begun in the last few days, if there are daytime symptoms, if the child is unwell or if there is reason to suspect a urinary infection or diabetes mellitus (NICE, 2010). In children with daytime symptoms, ultrasound examination of the urinary tract will exclude abnormal anatomy. This is normally organised in secondary care.

Simple advice for parents and children

Reassure and signpost

Reassure families that bedwetting is common and normally completely resolves spontaneously without intervention as the child or young person gets older. At age 16 years, only 1 in a 100 children still wet the bed. Families will be keen to know about simple, effective interventions.

The school nurse can be an invaluable resource. Families should be directed to the website of The Children’s Bowel & Bladder Charity (formerly ERIC - Enuresis Resource and Information Charity) (ERIC, 2017). This website is an excellent resource for professionals, carers and children, providing easy-to-follow advice and guidance. There are excellent special resources aimed at children. There is also a website selling useful products, such as waterproof bedding. In addition, a dedicated phone helpline offers help and advice on children’s bowel and bladder problems. Advice can also be given by Email. A useful decision aid can be found on the patient website to inform about possible bedwetting interventions (Harding, 2017).

Encourage (the right kind) of fluids

To avoid wetting the bed, children often start to restrict fluids. However, it is better to encourage children to drink regularly throughout the day (around six to eight glasses of fluids) and to explain that drinking helps normal, healthy bladder function. By filling, stretching and emptying the bladder during the day, normal function overnight is encouraged. Being well-hydrated also helps to reduce the risk of constipation. Encouraging children to drink the majority of their fluid intake during the daytime, and thus a lower intake in the evening, can lead to a reduction in overnight urine production.

Caffeine-containing drinks (tea, coffee, hot chocolate and cola) and fizzy drinks may exacerbate the problem. In addition, some juices containing artificial flavourings and colourings may make things worse. Advise families to avoid these drinks.

Toilet trips

Encourage children to empty their bladders regularly. It is normal for a child to go to the toilet between four and seven times in a day. Parents can help by reminding children to go to the toilet every 2 hours or so. Encourage children to ensure they fully empty their bladder. Ask them to check the colour of their urine, aiming for light yellow urine. If urine is dark, encourage increased drinking. Children should make sure they go to the toilet before bed, perhaps double voiding, to ensure complete emptying of the bladder.

Identified problems/contributing factors

Constipation should be treated, as it may be a cause of nocturnal enuresis. Encouraging fluids and a healthy diet is of key importance, but many children require treatment with simple laxatives. Treatment of an identified urinary tract infection may eliminate nocturnal wetting.

Importance of trial without nappies or pull ups

Families may be reticent to stop their children wearing protective underwear, due to the distress caused when children get wet, or because of the extra laundry that accidents inevitably produce. However, encourage parents to allow children to have nights without nappies or pull ups for at least a week every so often. The sensation of being wet may help the child to learn to be dry. It may wake the child, but will allow the child to learn when their bladder is full. Nappies and pull ups are often too efficient at drawing urine away from the skin thus preventing children from becoming familiar with this sensation.

Remove reasons not to use the toilet during the night

Ensure it is easy for the child to go to the toilet in the night. For example, any physical obstructions to bathroom access should be removed and use of the bottom bunk, night lights and other helpful measures should be encouraged. If the child needs a step or seat to use the toilet, ensure these can be accessed easily. Sometimes a trip to a bucket or potty in the bedroom may present less of a challenge in the middle of the night.

Lifting

Lifting is a short-term strategy for parents to manage bedwetting, but it will not treat the underlying problem. It may mean a child will wake up in a dry bed, but this will not be because they have learnt to be dry at night.

Reward charts for positive behaviours

Children are not aware they are bedwetting and therefore, punishment or telling children off will only cause distress. Nocturnal enuresis is beyond their conscious control and it is worth making sure that carers are fully aware of this fact. Reward charts can help; however, a child should not be rewarded for a dry night itself. Rewards should be given for helping to change wet bedding, for drinking well throughout the day or regular toileting. It is important to encourage parents and carers to make sure that the child or young person understands that wetting the bed is not their fault.

Alarms for bedwetting

A Cochrane review found that alarms have good long-term success in stopping bedwetting (Glazener, Evans, & Peto, 2005) and alarms are recommended by NICE as first line treatment (NICE, 2010). They can be purchased through The Children’s Bowel and Bladder Charity website for between £50 and £130, or should be available for hire through the local school nurse or children’s continence service. A sensor that detects urine is placed inside the child’s underwear and an alarm rings when the sensor becomes wet. The idea is to wake the child when the wetting starts so they are prompted to wake and go to the toilet or to learn to hold on to their urine. Hopefully, the child will begin to recognise the sensation of the bladder being full and be able to eventually wake independently of the alarm. Alarms are successful, but they do interrupt sleep and may take weeks to have a full effect. Initially, the carer may need to wake the child when the alarm goes off. Improvements may be slow at first and any reduction in the size of the wet patch, any increase in the length of time from sleep to alarm, and fewer wet nights are all signs of progress. Assessment of improvement should be arranged at 4 weeks and, as long as there is some improvement, the alarm should be continued until there have been 14 dry nights in a row. If at 12 weeks, there is no improvement, consider a break or the combination of the alarm and desmopressin as the next step. Reassure parents that if problems with bedwetting restart the alarm can be used again.

Desmopressin

Use of an anti-diuretic, such as desmopressin, has a good short-term success rate, but a higher relapse rate than use of enuresis alarms, and therefore NICE suggests desmopressin as a second line treatment (Glazener & Evans, 2002; NICE, 2010). Desmopressin acts as a surrogate for vasopressin and artificially reduces the amount of urine that the kidneys produce overnight. The drug can be used now and then as tool for managing sleepovers and holidays or in longer courses to try to end bedwetting. It is generally used in children over 7 years n age, but the British National Formulary (BNF) describes treatment from 5 years old (BNF, 2015).

Desmopressin comes in two oral preparations, one of which is sublingual (Desmomelts). The nasal spray is not recommended in general practice, due to the risk of hyponatraemia. The risk with the oral preparations is low and there is no need to carry out any routine monitoring. Children using desmopressin should be fluid-restricted for an hour before and 8 hours after they take the desmopressin. They should only take sips of water, if required. Fluid overload may precipitate hyponatraemia and subsequent seizures. Desmopressin should not be taken when the child is unwell, especially during episodes of diarrhoea or vomiting.

Desmomelts are convenient, as they can be taken without water and dissolve under the tongue. The starting dose is 120 mcg, which should be taken 1 to 2 hours before bedtime. If there is no response after 1 to 2 weeks, the dose can be increased to 240 mcg. The response should be assessed at 4 weeks. If successful, continue up to 12 weeks and then pause to assess the outcome.

Desmotabs, the alternative oral preparation, should be swallowed (can be crushed) and the dosing starts at 200 mcg at 1 to 2 hours before bedtime, increasing to 400 mcg if the lower dose is not working. Again, treatment should be withdrawn for at least a week at 12 weeks to assess the effect.

Overactive bladder

If daytime symptoms are a feature alongside nocturnal enuresis, these should be addressed first. Treating these may lead to disappearance of the night-time disturbance. Anticholinergics can be useful in managing the overactive bladder in children as in adults. Oxybutynin can be used successfully. This is usually started in secondary care.

Referral

Children should be referred to secondary care if bedwetting is not improving despite simple advice, a trial of an alarm and if appropriate, desmopressin therapy. It may be appropriate to refer those with daytime symptoms or those who are suffering psychologically to a specialist clinic. Specialist centres may use the tricyclic, imipramine as third line treatment if the patient has not responded to anything else. This is not recommended in general practice, due to the propensity of the drug to cause significant side effects.

Key points

Almost every child becomes dry at night, eventually, with simple advice and without treatment

Intervention can be considered as early as 5 years old and often speeds up the attainment of dryness at night

Alarms are the most effective intervention to support permanent dryness

Desmopressin is safe and effective for short-term use but less likely to have long-term benefits

Desmopressin can be used effectively as an adjunct to the alarm

The Children’s Bowel and Bladder Charity website is an excellent resource for families and professionals

References

Backwin, H. (1973). The genetics of enuresis. In I. Colvin, R. McKeith, & S. Meadows (Eds). Philidelphia, PA: Lipincott.

BNF. (2015). British national formulary, 70th edition. London, UK: BMJ Group and Pharmaceutical Press.

ERIC. (2017). The Children's Bowel & Bladder Charity. www.eric.org.uk.

Glazener, C., & Evans, J. H. (2002). Desmopressin for nocturnal enuresis in children. Cochrane Database of Systematic Reviews, 3, art. no.: CD002112. doi: 10.1002/14651858.CD002112.

Glazener, C., Evans, J. H., & Peto, R. E. (2005). Alarm interventions for nocturnal enuresis in children. Cochrane Database of Systematic Reviews, 2, art. no.: CD002911. doi: 10.1002/14651858.CD002911.

Harding, M. (2017). Bedwetting treatment options. Retrieved from https://patient.info/decision-aids/bedwetting-treatment-options.

NICE. (2010). Bedwetting in under 19s. Retrieved from www.nice.org.uk/guidance/cg111/resources/bedwetting-in-under-19s-pdf-35109384397765.

RCGP. Clinical module 3.04: Care of children and young people. Retrieved from www.rcgp.org.uk/training-exams/gp-curriculum-overview/online-curriculum/caring-for-the-whole-person/3-04-children-and-young-people.aspx.