Bedwetting (Nocturnal Enuresis)

What is nocturnal enuresis?

Bedwetting (nocturnal enuresis or nocturnal incontinence) is a condition when there is involuntary (unintentional) urination more than two times per month during sleep beyond 5 to 6 years of age. It is the one of the most common childhood problems. In the US more than 5 million children suffer from bedwetting and even though the problem improves with age, many children and a few adults persist to have episodes of bedwetting. Bedwetting, a mere developmental delay, is seldom due to physical or mental disorders. The primary treatment is counseling of parents regarding protection and improvement child’s self respect (as bedwetting is socially embarrassing). Behavioral therapy (bedwetting alarms), drug therapy and surgery (rarely) are required.

What are the symptoms?

The age varies at which children can control bladder function. Only 15% children suffer from bedwetting beyond 5 years of age. Almost 95% children can remain dry at night. Involuntary (unintentional) passage of urine (wetting of bed) at night at least twice per month. In a few children, bedwetting is accompanied with other symptoms indicating an underlying serious medical problem.

  • Pain during urination (due to infection)
  • Snoring (due to sleep apnea)
  • Pink urine (due to infection)
  • Increased thirst (due to diabetes)

What causes bedwetting?

In most cases bedwetting is due to developmental delay. It is classified into two types :

  • primary (the child has never been consistently dry during night), and
  • secondary (initially the child was dry for a period of months, but starts to wet bed).

There are different causes responsible for primary and secondary enuresis.

Primary nocturnual enuresis

  • Small bladder: not yet fully developed to hold nighttime urine.
  • Incomplete development of nerve control over bladder

Secondary nocturnal ensuresis

  • Inadequate hormone production: some children produce inadequate anti-diuretic hormone (ADH) at night.
  • Urinary tract infection: bacterial invasion of the urethra and bladder mainly.
  • Sleep apnea: interruption of breathing due to enlarged tonsil may lead to bedwetting
  • Stress : severe illness
  • Diabetes mellitus
  • Night terrors, anxiety, abuse or neglect.
  • Congenital (since birth) defects in the structure of urethra, injury or tumor at the lower region of spinal cord (nerve damage)

Who is at risk?

Although girls also face problems of bedwetting, boys are more commonly affected.  A family history of bedwetting is a major risk factor. Children with attention deficit hyperactive disorder (ADHD) are more likely to experience bedwetting.

How is bedwetting treated?

Bedwetting eases with age in most children. Proper counseling of parents (caregiver) and a wait-and watch-approach is important as some parents may become concerned after just one or two such incidents. Bedwetting children already suffer from embarrassment and low self esteem often due to parental punishment and shaming of the child and parents need to be advised against this reaction. The condition is to be handled with care, sympathy and attention.

The treatment of bedwetting should be directed at the cause when diagnosed in secondary enuresis.

  • Behavioral therapy: Bedwetting alarms are devices that sense wetness and set the alarm off. Ideally the child wakes up, stops urination in mid-stream and goes to the toilet. These are highly effective but take a little longer time to show full effect (at least 12 weeks). Change of sleep and wake pattern may be helpful.
  • Drug therapy:
    – Desmopressin are artificial substitute for anti-diuretic hormone (ADH) (reduce urine production at night).
    – Antidepressants (like imipramine, nortriptyline) reduces nocturnal urine production.
    – Anticholinergic drugs relax the bladder muscle thereby increasing bladder volume and reducing contractions.

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