Bedwetting, in most cases, stems from deep sleep. Many parents report about attempts to treat their child with a bedwetting alarm (enuresis alarm). Everyone in the house woke up except the wet child. In Dr. Sagie’s bedwetting clinics, 97% of the parents reported that their child is a very deep sleeper. Nevertheless, the child responded positively to the comprehensive treatment despite the deep sleep. A very common misconception about treatment with a bedwetting alarm is that thepurpose of the alarm is to teach the child to wake up at night to go to the bathroom. This is not true. The purpose of treatment with an alarm is to condition the reflex system, which is subconscious; therefore, the child waking to the alarm is not a compulsory condition for success. The child learns subconsciously to connect between involuntary micturition to the unpleasant alarm response and the waking up and walking to the toilet. When the child does not wake to the alarm, the parents are instructed to do some essential activities that are vital for the learning process (reflex conditioning). About 40% to 50% of patients will stop bedwetting by using a bedwetting alarm. For most patients, however, the alarm is insufficient, and other therapeutic techniques must be added to the treatment. Treatment with an alarm has to be short (no longer than five to six months). Otherwise, the child gets used to the alarm, and the deterrent effect disappears. Continuation of the treatment with the alarm means “more of the same.” It causes the child to be frustrated and disappointed and undermines the child’s confidence in being able to succeed. Prolonged failure of the treatment might affect future success. The starting point of possible future treatment might be influenced by high skepticism and low motivation. To sum up, self-wakening by the child to the alarm is not a compulsory condition for treatment success. Treatment solely by the alarm will be insufficient in most cases.
When treating a patient with bedwetting, there are many characteristics that the therapist has to take into consideration: the patient’s age, gender, bedwetting frequency, day control, and more. Treating a five-year-old who wets the bed every single night and dribbles during the day is different from treating a twelve-year-old who wets the bed once a week. Moreover, response to the treatment is different from one patient to another. It can be fast, slow, unstable, and regressive. The therapist’s response should be tailored accordingly. Even the patient’s attitude to the treatment and the parents’ collaboration is a very important factor that has to be taken into consideration by the therapist. During treatment, many situations occur, including moments of despair when progress is slow, a patient’s loss of confidence, and many additional scenarios that require different approaches, strategies, and responses by the therapist. This is what makes THERAPEE™ so unique. We, in Dr. Sagie’s bedwetting clinics, identified and gathered together every scenario that we’ve faced in our bedwetting clinics with more than 30,000 enuretic patients since 1984. We defined every possible profile of enuretic patients by personal parameters. We developed numerous sophisticated and complicated algorithms. By using those algorithms, we are able to give a similar response to the one that we give in our clinic.
We use a “virtual chart” in which parents supply information regarding treatment. The system analyzes the provided data, and a specific algorithm chooses the right response, which is given to the patient by a video clip or a sequence of video clips. In those clips, the “virtual therapist” (in fact, a real bedwetting specialist) will address the patient and the parents, give feedback concerning the patient’s progress, immediate reinforcements, assignments, and analyze statistical reports. To sum up: when you buy THERAPEE™, you are not purchasing a CD with instructions that are supposed to be suitable for every patient with bedwetting regardless of age and condition. You purchase a comprehensive tailor-made treatment that duplicates Dr. Sagie’s successful multimodality face-to-face treatment for bedwetting.
There are various types of bedwetting alarms. The common feature across 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 3 types: Alarms that are connected to the body called buzzers, wireless buzzers and the “bell and pad” type.
When parents consider if and when they should seek treatment for their enuretic child, they should take into consideration some parameters and conditions: Child’s age: four years old and up. Maturity: Children four to five years old are mature for their age and able to understand and concentrate on simple tasks. Motivation: Children are disturbed by being bedwetters. They are sad when they wake up wet and happy when they are dry. They express their desire to stop bedwetting but sometimes don’t express their distress verbally, and parents shouldn’t assume that they are apathetic to the problem. Unstable bedwetting frequency: For some children, bedwetting frequency is inconsistent and changes from time to time. Those are the most difficult cases for treatment due to the instability of the phenomena. It is recommended to start treatment when frequency increases. Seasonal bedwetting: Some children are dry or almost dry during summer and wet during winter. It is recommended to begin treatment immediately after autumn. Parents’ readiness: Parents have a crucial role in the treatment process and should be ready to invest time and effort. For example: to wake up during the night, to supervise the daily tasks (exercises), and more. Treatment can fail due to parents’ lack of readiness. Causes of bedwetting: Behavioral treatment should not be considered when there is a medical problem related to enuresis, such as permanent urinary tract infections; frequent epileptic seizures; problems related to the spinal cord, such as spina bifida; and more. Behavioral treatment should not be considered when the child is suffering from emotional stress or has psychological problems as a result of acute trauma (loss of a close relative; exposure to a threatening event, such as physical or sexual assault; involvement in a car accident; violence within the family; conflicts between the parents; and more). In these cases, enuresis should not be treated, and treatment should be focused on the causes rather than the enuretic symptom. Some parents look at bedwetting as a personal failure and are highly motivated to treat the child even if the child is not ready yet and is not troubled by the problem. An attempt to force treatment in such cases might create unnecessary tension between the child and the parents, and the treatment will end in failure.
Most children will outgrow bedwetting spontaneously with no treatment between the ages of two and four. At age four, 25% still wet the bed; at age six, the scope of the phenomenon decreases to 15%; and at age twelve, only 4% to 5%. The problem is that we cannot predict if and when bedwetting will stop. When we see gradual decreased frequency (providing the parent does not take the child to the toilet while the child is asleep), it is recommended to wait before seeking treatment. In cases when there is no significant decrease in frequency, it is recommended to apply for treatment. When I’m asked by parents why not wait for spontaneous dryness with no treatment, I reply with a question: “If you were promised that your child will stop wetting the bed within two to three years, is it justified to let the child suffer for so long, to wake up every morning to a wet and smelly bed, and to avoid sleeping away from home?” I think the answer goes without saying. Having said that, in many cases, when there is no psychological problem, it might develop due to bedwetting. The child’s self-esteem and self-confidence can be affected. The child invests a lot of energy trying to answer such questions as: What’s wrong with me?, Why does this happen only to me?, Why can’t I control my body? The child tries to conceal the problem. Most children who suffer from bedwetting think they are among a very few who have the same problem, and it might lead to guilty feelings. Bedwetting also affects the child’s quality of life. It can make childhood miserable. I believe that as parents we should do our utmost to help our child solve this problem.
Parents, sometimes as a result of lack of understanding or misleading guidance, wake up the child during the night and take the child to the bathroom. This act disrupts the learning process. It creates an illusion of success (the child wakes up dry in the morning because of being awakened by the parents), and this affects the chances of success.
Most clinics consider enuresis a medical problem. The patient is given a comprehensive and potentially unnecessary medical assessment with no findings. The treatment model is often based on drug therapy (mostly Desmopressin, DDAVP). We might see some progress while the child is medicated but should expect a relapse (60% to 90%) when the patient stops using the drug. The drugs sometimes have side effects.
When it is effective, results are fast
High relapse rate after stopping drug usage
Possible side effects; see FDA Alert
The drug is expensive
Drug treatment is recommended in the following circumstances:
When the child sleeps outside the child’s home
When the child is not cooperating; drug treatment requires no motivation or effort
When the family is incapable of participating in behavioral treatment
When behavioral treatment is unsuccessful, drug treatment can be combined
Drug treatment is not recommended before ages six to seven.
The behavioral treatment with the bedwetting alarm does not alter the child’s sleep patterns. The change that takes place is that the child will learn, during sleep, to identify the signal from the pressured bladder to the reflex system in the brain. As a result, the child will act in one of two ways:
Contract the sphincter muscles during sleep without waking up. This will alleviate the pressure inside the bladder.
Wake up to urinate in the toilet.
When bedwetting does not occur every night, it means that the learning system is functioning partially. When the child wets the bed every night, it means that the learning system does not function at all. There can be more than one reason for certain wet nights. Some of the possible causes are high fluid consumption before bedtime, fatigue, weather changes, cold nights, bad mood, mental tension, illness, and many more.
We request our enuretic patients to record the time of the nighttime accident during the treatment with bedwetting alarm. Why is this so important? The time of wetting is one of the tools that we use in order to assess the patient’s progress and to determine the prognosis. Our sleep goes through different stages during the night. The first third of night is characterized by a great portion of deep sleep (sleep stage 4). As the night progresses, we experience lighter sleep compared to the first hours. Many parents who have tried to wake their child in the first couple of hours of sleep onset will testify how difficult is to wake the child. When the child wets early at night, it means that the restraint mechanism didn’t function. When the bedwetting accident occurrs at a later stage of the sleep, it means that the restraint mechanism functioned properly for quite a few hours and failed only in a later hour. In simple words, the later the bedwetting accident occurs, the better. When the accidents occur toward morning we can predict with a great degree of certainty that the child is on the right path to stopping bedwetting.
Quite often during the bedwetting treatment process, excited parents report me that their child woke up during sleep and went to the bathroom to empty their bladder. This excitement is quite understandable since their child had never before woke up on his or her own. While that is a wonderful accomplishment, it isn’t a compulsory requirement to becoming dry. Parents and professionals as well, mistakenly assume that in order to be dry, the individual must learn to wake up at night to go to the bathroom. In order to be dry, the child has to learn to recognize the signal from the filled bladder to the subconscious reflex system in the brain and to respond accordingly – either to wake up and to go to the bathroom or to hold himself while he is asleep by contracting the sphincter muscle.
During the last phase of the bedwetting treatment, when the child is completely or almost completely dry, we see 3 possible situations:
The child sleeps through the entire night and doesn’t wake up.
The child wakes up every night and goes to the bathroom to empty his bladder.
Some nights, the child wakes up and some nights he sleeps through the whole night.
All three of these situations are good with no preference of one over the other. However, the reason why one occurs rather than the other depends on few factors:
The amount of urine in the bladder. As the night progresses, more urine is accumulated in the bladder and consequently the signal from the bladder to the brain is stronger and can cause the child to wake.
The stage of sleep: when the signal from the bladder is sent during stage of the deepest sleep (stage 4 – Delta), the chance of waking up is low. When the signal is sent during lighter sleep (stages 2 and 3), it is easier to wake up.
There are substantial individual differences in sleep patterns.
Bladder’s volume; when the volume is small the necessity to wake during sleep is higher.
The nerves activity; children with irritable overactive bladder will tend to wake up more often at night.
Having said that, it really doesn’t matter if the child wakes at night or not, as long as he stays dry.