Bedwetting in Children

Introduction and Risk factors

Bedwetting or involuntary passing of urine during sleep is quite common in children. In most cases it spontaneously resolves without any treatment as children grow up. However it is still worrisome for the children and their families because it causes inconvenience and embarrassment. It is not due to kidney disease, laziness or naughtiness of children.

What percentage of children suffers from bedwetting and at what age does it normally stop?

Bedwetting is common especially under the age of 6 years. At the age of 5 years, bedwetting occurs in about 15 to 20 % of children. With increasing age, there is a proportionate decrease in the prevalence of bedwetting: 5% at 10 years, 2% at 15 years, and less than 1% in adults.

Which children are more likely to suffer from bedwetting ?

• Children whose parents have had the same problem in childhood.
• Those with delayed neurological development which reduces the child’s ability to recognize a full bladder.
• Children with deep sleep.
• Boys are affected more often than girls.
• Increased psychological or physical stress may be the trigger.
• In a very small percentage of children (2%-3%), medical problems such as urinary tract infection, diabetes, kidney failure, pin worms, constipation, small bladder, abnormalities in the spinal cord or defect in the urethral valves in boys, are responsible.

Treatment

Investigations are performed only in selected children when medical or structural problems are suspected. The most frequently performed tests are urine tests, blood glucose, X-rays of spine and ultrasound examination or other imaging tests of the kidneys or bladder.

Bedwetting is completely involuntary and is not done intentionally. Children should be reassured that bedwetting will stop or be cured over time. They should not be scolded or punished.

Initial treatment for bedwetting includes education, motivational therapy and change in habits of fluid intake and voiding. If bedwetting does not improve with these measures, bedwetting alarms or medications may be tried.

• The child must be thoroughly educated about bedwetting.
• Bedwetting is not the fault of the children so they should not be blamed or admonished about bedwetting.
• Take care that no one teases the child for bedwetting. It is important to reduce the stress the child suffers due to bedwetting. The child’s family should be supportive and the child should be reassured that the problem is temporary and it is sure to be corrected.
• Use training pants instead of diapers.
• Ensure easy access to the toilet at night by properly arranging night lamps.

• Keep an extra pair of pajamas, bed sheet and a towel handy, so that the child can change bed linens and soiled clothing conveniently if he wakes up due to bedwetting.
• Cover the mattress with plastic to avoid damage to the mattress.
• Place a large towel underneath the bed sheet for extra absorption.
• Encourage daily bath in the morning so that there is no urine smell.
• Praise and reward your child for a dry night. Even a small gift is an encouragement for a child.
• Constipation must not be neglected, it should be treated.

• Limit the amount of fluid the child drinks two to three hours before bedtime, but ensure adequate fluid intake during the day.
• Avoid caffeine (tea, coffee), carbonated drinks (cola) and chocolate in the evening. They can increase the need to urinate and aggravate bedwetting.

• Encourage double voiding before bed. First voiding at routine bedtime and second voiding just before falling asleep.
• Make it a habit to use the toilet at regular intervals throughout the day.
• Wake the child up about three hours after he falls asleep every night to void urine. If necessary, use an alarm.
• By determining the most likely time of bedwetting, the waking time can be adjusted.

• The use of bedwetting or moisture alarms is the most effective method for controlling bedwetting and is generally reserved for children older than 7 years of age.
• In this alarm a sensor is attached to the child’s underwear. When the child voids in bed, the device senses the first drops of urine, rings and wakes up the child. The woken up child can control his urine until he reaches the toilet.
• The alarm helps in training the child to wake up just in time before the bedwetting problem.

• Many children with bedwetting problems have small bladders. The goal of bladder training is to increase the capacity of the bladder.
• During day time children are asked to drink a large quantity of water and told to hold back urine in spite of the urge to pass urine.
• With practice, a child can hold urine for longer periods of time. This will strengthen the bladder muscles and will increase bladder capacity.

Medications are used as a last resort to stop bedwetting and are generally used only in children over seven years old. These are effective, but do not “cure” bedwetting. These provide a stopgap measure and are best used on a temporary basis. Bedwetting usually recurs when the medication is stopped. Permanent cure is more likely with bedwetting alarms than with medications.

A. Desmopressin Acetate (DDAVP): Desmopressin tablets are available in the market and prescribed when other methods are unsuccessful. This drug reduces the amount of urine produced at night and is useful only in those children who produce a large volume of urine. While the child is on this medication, remember to reduce evening fluid intake to avoid water intoxication. This drug is usually given before bedtime and should be avoided at night when the child has, for any reason, drunk a lot of fluids.

Although this drug is very effective and has few side effects, its use is limited because of its prohibitive cost.

B. Imipramine: Imipramine (a tricyclic antidepressant) has a relaxing effect on the bladder and tightens the sphincter and thereby increases the capacity of the bladder to hold urine. This drug is usually used for about 3-6 months. Because of its rapid effect, the drug is taken one hour before bedtime. This drug is highly effective, but because of frequent side effects it is used selectively. Side effects may include nausea, vomiting, weakness, confusion, insomnia, anxiety, palpitations, blurred vision, dry mouth and constipation.

C. Oxybutynin: Oxybutynin (an anticholinergic drug) is useful for daytime bedwetting. This drug reduces bladder contractions and increases bladder capacity. Side effects may include dry mouth, facial flushing and constipation.

The family of a child with bedwetting should immediately consult a doctor if the child:

• Has a day time bedwetting problem.
• Continues bedwetting after the age of seven or eight years.

• Starts bedwetting again after at least six months of a dry period.
• Loses control in defecation or passing stools.
• Has fever, pain, burning and frequent urination, unusual thirst, and swelling of the face and feet.
• Has poor stream of urine, difficulty in voiding or needs to strain when urinating.