If your child wakes up in the morning, soaked in urine, and you stand helpless and frustrated, this article is designed for you. Everything you wished to know and didn’t know whom to ask. This guide includes information on the causes for bedwetting and better ways to cope with the problem. We will cover many of the FAQs, discuss some commonly held myths and misconceptions about bedwetting, and provide information on the various treatments that are available.
Enuresis, the clinical term for bedwetting, is defined as involuntary urination after ages four to five and may be either nocturnal, diurnal, or both. An enuretic is an individual who persists in daytime or nighttime wetting past an early age. There is a distinction in the literature between Primary Enuresis, a child who has never stopped bedwetting or was dry for only a short period of time, and Secondary Enuresis, a child that was dry for at least six months and relapsed.
Enuresis is one of the most prevalent and frustrating disorders of childhood. A child is expected to sleep through the night without wetting the bed between the ages of two and four. However, at age four, 25% of children still wet the bed; at age five, 20%; at age six, 15%; at age ten, 8%; at age fourteen, 4%; and at age eighteen and over, 2% of the population are still bedwetters.
Bedwetting is more common among males than females; approximately two-thirds of enuretics are males, while one-third are females. As the age progresses, the proportion changes and is gradually equal in adolescence. Among individuals ages seventeen and up, two-thirds of enuretics are females, while one-third are males.
Some of the possible explanations for this gender difference is that girls mature faster than boys in early ages, while boys close this gap in later ages. No explanation was found for the higher proportion of females in older ages (seventeen and up). It is possible that in those ages we might find more emotional factors that affect bedwetting in females compared with males.
There is overall agreement among researchers that bedwetting has a clear hereditary element. Among parents of children with bedwetting who came to our clinics, 75% reported that one or both parents or siblings wet the bed in childhood. When we examine the second genetic circle (grandparents, uncles of first degree, nephews), we find that more than 90% have a history of bedwetting.
One shouldn’t conclude, however, that this genetic factor indicates the existence of a medical problem. Bedwetting is characterized by being unable to recognize the signal that is being sent from the filled bladder to the brain during sleep. As a result, instead of contracting the sphincter muscle, the child relaxes the bladder and starts to urinate. This may be corrected by learning preventive measures.
Occasionally, I’m asked by parents, “If there is a genetic factor, how can treatment help?” My answer is that there is no relationship between the genetic factor and the treatment’s chances of success. The purpose of the treatment is to correct the malfunction in the reflex system.
Some parents who had bedwetting problems until adolescence and outgrew the issue with no treatment avoid seeking treatment for their enuretic child. They assume that when the child reaches adolescence, the child will also outgrow bedwetting. There is no basis for this assumption; unfortunately, there is no guarantee that a child will stop wetting the bed with no treatment. Moreover, even if the parents could be assured that the child will outgrow bedwetting at adolescence, there is no justification to let the child suffer from bedwetting during childhood. Bedwetting affects a child’s quality of life, and timely treatment improves the quality of life.
The conventional train of thought among both parents and many pediatricians is that bedwetting is a medical or psychological problem. Often, the patient undergoes a comprehensive and unnecessary medical assessment with no findings. However, a medical, neurological, or urological problem is only the primary diagnosis among 1% of enuretics. A psychological cause, such as family problems, social adjustment, or fears, is a factor among an additional 10% of patients.
In fact, the majority of enuretics (90%) do not have either anatomical or psychological problems. For most enuretics, the primary source of the issue is unusually deep sleep. These are normal, healthy children who have not learned to activate the appropriate reflex system during sleep. Typically, when a person sleeps and pressure is built up inside the bladder, a signal is sent to the brain. Among enuretics, the signal is not recognized by the subconscious reflex system and instead of contracting the sphincter muscle, which is the circular muscle that keeps the bladder closed, the child relaxes the muscle and urinates during sleep.
Among parents of enuretics, 97% report that their child is an unusually deep sleeper (based on a study with 30,000 parents). Parents describe attempts to walk their child to the bathroom during the night akin to dragging a sack of potatoes. They report that their child is disoriented, does not sense being taken, and in the morning has no recollection of the event.
Among enuretics, some individuals who suffer from involuntary drops of urine will discharge during the day. This typically happens in children ages four to eight.
Dribbling generally happens when the child is busy in an activity that requires mental concentration (e.g., watching TV, playing computer games). The child does not recognize the signal from the bladder, relaxes the sphincter muscle, starts to urinate, and stops immediately by contracting the sphincter muscle. The consequences of this behavior are the constant wet spots on the child’s clothes.
Many parents of young children are familiar with the dribbling problem - when involuntary drops of urine will discharge during the day. This typically happens in children age four to eight. This problem is relatively easy to treat through specific exercises combined with Cognitive Behavioral treatment, helping the child to recognize signals from the filled bladder traveling to the brain and to respond accordingly.
A less familiar problem is dribbling during sleep. The child does not recognize the signal from the bladder, relaxes the sphincter muscle, starts to urinate, and stops immediately by contracting the sphincter muscle. The consequences of this behavior are the wet spot on the child’s clothes which generally doesn't reach the sheet.
On one hand, this is a good sign, since the child corrects himself by stopping the flow of urination; it means that his subconscious restraint mechanism during sleep is partially functioning. From a learning point of view, this is a much more advanced condition compared to a child who wets himself completely (which means that the child has no learned skills). Having said that, from an Enuresis specialist point of view, this is one of the most difficult conditions for bedwetting treatment. In those cases, treatment with a bedwetting alarm is useless since the very small amount of urine will not activate the alarm. The specialist has to be very creative and to consider different approaches which will be suitable for such cases. From my experience, the treatment for this child takes longer than the usual treatment. Sounding counter-intuitive, the easiest cases to deal with are of children that wet completely every night.
Unfortunately, many treatments are advertised on the internet and in health magazines with high price tags and little or no research to back them up. So what really works? How to stop bedwetting quickly and effectively?
Various types of bedwetting alarms are available. The common feature of these alarms is that the alarm sounds in reaction to the first drop of urine as a result of the closed electrical circuit. In addition, they are all battery operated. Beyond this, there are substantial differences.
Basically, there are three types: alarms called buzzers that are connected to the body, wireless buzzers, and the “bell and pad” type.
Buzzers—Bedwetting Alarms that are connected to the body
The bedwetting alarm is attached to the child’s pajamas and connected by a wire to a small moisture sensor, which is placed inside underwear near the child’s sexual organ.
It is inexpensive but has some disadvantages. Some of the alarms are unsafe. The metal sensor can become corroded because of the acidity of the urine (ph.) and may cause bruising to the skin. The child’s movement in bed can also cause skin irritation due to rubbing. Some children are resistant to wires connected to their body. As the alarm is attached to the body, the child can unintentionally disconnect it. In some cases, the sound emitted from the buzzer is not strong enough to activate the reflex system. Moreover, in some cases, the child’s blanket covers the alarm and dims its sound.
The wireless buzzers—Bedwetting Alarms that are not connected to the body
The difference from the typical wired buzzers is that wireless buzzers use a radio transmitter placed on the sensor plate on the lower abdomen near the child’s sexual organ. A radio receiver is installed in the alarm, which is attached to either the child’s pajamas or placed next to the child’s bed. When the child wets the bed, radio waves are transferred from the transmitter to the receiver, and the alarm is activated.
A simple question should be asked: Is it safe to place a radio transmitter near the child’s sexual organ?
Bell and pad alarms
Bell and pad bedwetting alarms are composed of two parts: the control unit (alarm) and a plastic detector pad, which is placed on the bed under the sheet. The pad is attached to the alarm by a slim wire, which does not disturb the user in bed. The bell and pad alarms are more efficient, safer, and more convenient than ordinary buzzers. This type of alarm costs more since as it is more expensive to manufacture compared with other types of alarms.
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There have not been any new developments in pharmacology for bedwetting since the early ’80s when the latest drug was developed. The drug Desmopressin Acetate (marketed as DDAVP Nasal Spray, DDAVP Rhinal Tube, DDAVP, DDVP, Minirin, and Stimate Nasal Spray) is an anti-diuretic hormone that is most commonly prescribed for enuresis.
In 2007, however, the FDA posted an alert that Desmopressin intranasal formulations should no longer be prescribed for the treatment of primary nocturnal enuresis. Desmopressin works by limiting the amount of water that is eliminated in the urine. A healthy body needs to maintain a balance of water and salt (sodium). If the sodium levels fall too much (Hyponatremia), a person may have seizures and, in extreme cases, may die. Children treated with Desmopressin intranasal formulations for primary nocturnal enuresis were found to be particularly susceptible to severe hyponatremia and seizures.
Other drugs for enuresis are Imipramine and Oxybutinin. While the advantages of medication are its easy administration and that considerable progress is seen during the initial stages of drug usage, there are disadvantages. In addition to the side effects of the drugs, there is a very high relapse rate (60%-90%) when the patient stops using the medication.
A number of alternative treatments including Homeopathy, Reflexology, Acupuncture, Shiatsu, Hypnosis, Fluid absorbed diets and other methods have been tried but by and large they have not been shown to have successful outcomes.
Psychotherapy has only been found to be effective when the primary source of the problem is a psychological one. The treatment in those cases does not focus on the enuresis itself but on the psychological causes for the behavior. Psychotherapy for a child without psychological factors for enuresis might cause damage as the lack of progress will increase the sense of failure and frustration.
Behavioral Treatment is considered the most effective therapy for bedwetting. The child undergoes a learning process that is designed to teach him to activate the continence mechanism. The child sleeps with an enuresis alarm which starts to ring when the child starts to urinate. The purpose of the ringing is to activate the reflex system and create a learning process.
Unfortunately, many parents, who use this device, terminate the treatment after a short period of time because they claim that their child does not wake up when the buzzer goes off. This is a common misconception; the goal of the buzzer is not to teach the child to wake up at night but to teach him to restrain himself. When the child does not wake up, the buzzer acts on his subconscious reflex mechanism. The buzzer is an essential component, to measure the reflex response and asses the child response to the treatment.
Treatment with a bedwetting alarm is the only treatment that has been found to be effective with 40-50% of patients.
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Comparison of treatment methods
Knowing the causes of bedwetting is not enough. It is essential that parents understand what it is like to be a child with a bedwetting problem and understand how to stop bedwetting in an effective way. Since it is a genetic issue, many parents have suffered from bedwetting themselves. Even this is not enough preparation to deal with their child’s issue.
What is going in an enuretic child’s mind? The following story will illustrate the typical situation.
I received a phone call from an ex-patient who is twenty-five years old. He told me that when he was nine years old he came with his parents to my bedwetting clinic. His parents accused him of not trying hard enough to deal with the problem, and then he reminded me of my response to his parents: “What do you want from him? Why do you blame him? He does not wet the bed on purpose; he doesn’t feel when he is wetting the bed.” The young man said, “For the first time in my life, I felt that someone understood me.” Although many years had passed since this meeting, he remembered every single detail from this session and was so grateful. By the way, he outgrew bedwetting after only three months of treatment.
If parents will realize what is going on in their child’s mind, they will certainly act differently by showing understanding, sensitivity, empathy, and support.
For both parents and children, bedwetting can seem like an incurable problem. Children may feel humiliated or defeated. They may not be able to participate in normal activities, such as visits away from home or sleep-away camp. In extreme cases, enuresis can be seen as an obstacle among young adults who are interested in dating and marriage.
It is important to know that bedwetting is treatable. This is not an insurmountable obstacle; rather, with some time and care, you will be able to find the appropriate treatment method for your child. Most important is to believe in your child and build their self-confidence on the way. Nothing can more easily demonstrate the great relief former enuretics feel when they defeat this problem than their own words:
M. female, age sixteen, treated with her sisters ages fourteen and eight, wrote:
I find no words to describe my joy…(I have) stopped bedwetting and today I wake up completely dry. This is a wonderful feeling. To all the boys and girls who read my letter, listen to me, don’t give up. Believe in yourselves. I believed and succeeded. You should try too. You will see that one day you will stop bedwetting and it will be great. I wish with all my heart that soon you will wake up clean and dry. Believe me, it is wonderful.
N. female, age eleven wrote:
Neither you nor anyone else can imagine how happy I am that I stopped bedwetting. It isn’t easy for me to express myself … Finally, I can say, I did it.… Before the treatment I couldn’t sleep away from home. My younger sister ceased bedwetting before me and it really upset me. Finally, this is the most wonderful thing that happened in my life.
Some children who suffer from bedwetting have enlarged adenoid and polyps. Sometimes the removal of the enlarged polyp will cause the child to stop bedwetting. One shouldn't jump to the wrong conclusion that enlarged adenoid and polyps are the cause for bedwetting. Many bedwetters do not have enlarged polyps and many children with enlarged polyps children do not have a bedwetting problem.
So what is the relationship between bedwetting and enlarged adenoid and polyps? Enlarged adenoid and polyps are contributor factors in the causes for bedwetting since the airflow (Oxygen) is disturbed and it affects the depth of sleep. It is very similar to obesity which also affects the airflow. Sometimes, the adenoid's removal leads to dryness at night. However, in most cases it doesn't solve the problem.