Bedwetting

Source: Institute for Quality and Efficiency in Health Care
It is not that unusual for children and even teenagers to wet their bed sometimes, but people do not like talking about it. By the age of five, most children either sleep through the night without wetting the bed, or wake up when they feel that their bladder is full. But this routine may only develop later on: 1 out of 6 children aged five sometimes do not realize that their bladder is full until it is too late. By the time the child has woken, their bed is already wet.
Bedwetting can be very troubling – not only for the child, but also for the family – especially if it happens often. It is considered to be “bedwetting” (medical term: nocturnal enuresis) if children aged five and over still wet the bed without there being a recognizable physical cause.
This problem usually goes away on its own over time. But until that happens, there are some things that parents can do to help their child and make it easier on themselves. Systems for waking the child provide the most effective help against bedwetting over the long run, but medication can also help in the short term. Each of these approaches has its pros and cons, and some will require patience.


 

Causes

The main reason why some children and teenagers wet the bed is because they do not wake up when their bladder is full. Instead, their bladder muscles relax, emptying the bladder while they are still asleep. Children do not wet the bed on purpose. They simply do not notice that their bladder is full. There is good reason to believe that bladder control mechanisms develop more slowly in children who wet their bed. To be able to control their bladder, the child’s brain has to be able to detect and process nerve signals from the bladder, and they have to learn which signals mean that it is time to wake up. It also takes some time to develop control of the bladder muscles.
Genetic factors also apparently play a role in how long it takes for children to stop wetting the bed. Comparisons between families have shown that more than half of children who wet their beds have other family members who were also affected by this problem. Some researchers believe that specific genes that influence the production of the hormone vasopressin during the night might be involved. Vasopressin, also called antidiuretic hormone (ADH), makes the kidneys produce less urine at night. It is also possible that genes influence how deeply someone sleeps or the basic tension in their bladder muscles.
Some things may make bedwetting more likely, for example if the child has digestion problems or drinks cola or other caffeinated drinks just before going to bed. Usually the amount a child drinks before going to bed has little influence on whether they wet the bed. It is more important that the body produces enough vasopressin for the kidneys to switch to “night levels” of urine production.
There are a number of other possible causes of bedwetting. Although they are uncommon in children, they may still need to be checked by a doctor:

• Sleep apnea: In sleep apnea, breathing sometimes stops for a short time, which causes a brief drop in oxygen supply to the brain. During this time, bladder control can be lost temporarily.
• Nocturnal polyuria: Here the kidneys produce a lot more, not less, urine at night.
• Diabetes: Sometimes bedwetting and larger amounts of urine are early signs of diabetes.
• Urinary tract abnormalities: In this case the child usually also wets themselves during the day.

Frequency

Many children just wet their bed once or twice a month, while others do so several times a week. Bedwetting is more common among boys than it is among girls.
The problem almost always goes away on its own over time. Bedwetting is still a problem for

• about 7 out of 100 children at age seven,
• about 5 out of 100 children at age ten,
• 2 to 3 out of 100 teenagers between the ages of twelve and fourteen, and
• only 1 to 2 out of 100 teenagers over the age of 15.

A child might stay dry for months or years at a time and then suddenly start wetting the bed again. This is called “secondary enuresis.” It may be a sign that the child is under emotional stress – for instance due to changes within the family, like the birth of a sibling, or because of family problems.
Secondary enuresis might also have a physical cause such as a kidney or bladder infection, or diabetes.

Diagnosis

When families seek medical advice for a bedwetting problem, the doctor first tries to find signs of possible causes by talking with the child and their parents. After a talk about the child’s medical history, the doctor performs a physical examination to determine whether the child’s bladder and bowel are working properly and whether his or her urinary tract has developed normally. A urine sample may also be analyzed to rule out other causes, such as a urinary tract infection.
It can also be helpful to keep a diary where you record the number of toilet trips per day, the average amount of urine and the maximum time between two trips. You could also record symptoms such as difficulty starting or stopping urination. Keeping track of things like meal times, school recesses, play activities or unusual events might help you see connections that were not obvious before.

Treatments

There is no shortage of products or advice when it comes to bedwetting. But only a few of these approaches have been proven to work. Research has shown that electronic alarm systems, such as alarms in underwear and special mats, are helpful over the long run. These systems detect wetness and then set off an alarm to wake the child up.
Medication has a lower success rate than alarm systems, and is less suitable for young children. It has a fast effect, but only for as long as it is taken, so it is not a long-term solution. But it can help if the child needs to stay dry for a short period of time – for example when sleeping somewhere else for a few nights.
The medications that have been proven to work are the hormone-like drug desmopressin and some tricyclic antidepressants, which are also used to treat depression.


There is a big market for products and remedies designed to help with bedwetting. Some of these products work, but many are overpriced and advertised with false claims. Because just about every child will eventually make it through the night without wetting the bed on their own, it is difficult to tell whether a particular approach actually helped, or whether the child’s bladder control developed on its own during that time.
Research has shown that only a few of these approaches are helpful. In particular, these include electronic alarm systems such as alarm sensors in the child’s underwear or on special mats, as well as certain types of medication. It is important to keep in mind that none of these methods can guarantee that a child will stop wetting the bed sooner, but some can help in at least some children.
When is it a good idea to consider treatment? Many children who still wet the bed at the age of five end up stopping on their own by the time they are seven. The problem often becomes more urgent when a child starts school. As well as the child’s age, other factors also play a role when deciding for or against treatment: How much of a problem is the bedwetting for the child and parents? Does the child want to stop wetting the bed? Is he or she willing to give treatment a try?
If a child’s self-confidence is noticeably affected by the bedwetting, treatment may be a good idea even if the incidents are quite rare, or if the treatment only leads to a small improvement. And there is little point in trying a treatment if the child does not want to, or is not yet mature enough.

Behavioral approaches

When dealing with a bedwetting problem, parents and children usually try out a simple behavioral approach first. The aim is to help children learn to better control their bladder without too much trouble. There are a number of different approaches, including:

• Reward systems such as a “sun and cloud” calendar, where the child draws a picture of a sun after a “dry” night and a cloud after a “wet” night.
• Precautionary trip to the toilet: Besides the obvious trip to the bathroom before going to bed, parents can take their sleeping child out of bed and to the toilet, or wake them at a certain time so they can go on their own.
• Limit drinks before bedtime: Some parents try to get their child to stop wetting the bed by making sure that the child does not drink much, or not at all, in the evening.
• Bladder training: The child tries to hold their urine in for as long as possible during the day. This is supposed to increase the volume of the bladder and help the child learn what a full bladder feels like.

There are just a few small studies on the effectiveness of simple behavioral approaches for bedwetting – so it is not clear whether they actually help. But reward systems, precautionary trips to the toilet and bladder training may be better alternatives than not trying to help the child at all. It is also possible to combine some of these methods.
Regardless of whether a behavioral approach is used or not, it is important not to scold the child or put them under pressure by using punishment.

Electronic alarm systems

Electronic alarm systems detect wetness and trigger an alarm if the child’s bladder starts to empty. The alarm is designed to wake the child as soon as the very first drops of urine come out. This way the child can stop the urine flow and then go to the toilet – on their own or with the help of their parents. Over time, the child should learn to wake up whenever their bladder gets too full, before the alarm goes off.
There are various types of bedwetting alarm systems, including underwear with built-in sensors, mats with built-in sensors, and mini-alarms that can be put inside the child’s underwear or pajamas. Some systems work with light signals or vibrations, and others are wireless. In Germany, the costs of certain alarm devices are generally covered by statutory health insurers, as long as they have been recognized as a medical aid and are prescribed by a doctor. Bedwetting alarms have to be used for several weeks.
Bedwetting alarms are the most effective approach for dealing with bedwetting, and there is relatively good proof that they are effective in the long term too. Different types of alarms have now been tested in more than 50 studies involving over 3,000 children and teenagers.
This research has shown that, while using an alarm system, more than 60 out of 100 children stayed dry for at least 14 nights in a row. In comparison, only about 4 out of 100 children who did not use an alarm system stayed dry.
Some children started wetting the bed again when they stopped using an alarm system, but more than 40 out of 100 children stayed dry for weeks or months after they stopped using it. Only 1 out of 100 children who had not used an alarm stayed dry for good.
But it may take up to four weeks to see results.
The studies did not find that either bed mats or bedwetting alarms in underwear were more effective than the other, but children and teenagers seem to prefer using the underwear.
One reason why bedwetting alarms do not always work is because some children sleep very deeply, and do not wake up when the alarm sounds or when their parents try to help them. In that case the alarm does not help the child, but rather disturbs his or her family.
Children are less likely to start wetting the bed again if, after successful treatment with a bedwetting alarm, a second phase of training follows in which the now-dry child drinks more than usual before going to sleep. In this way he or she can learn to wake up quickly enough, even with a very full bladder.
Trying out bedwetting alarms takes quite a lot of time and motivation. Medication may seem like an easier option. But the advantage of alarms compared to medication is that children usually stay dry even after they stop using the alarm. There is also no need to worry about side effects, which medication may have. But bedwetting alarms interrupt sleep, which can make the child (and the rest of their family) feel tired the next day.

Medication

Bedwetting problems can also be treated with medication. However, only two groups of medication have been shown to stop bedwetting, at least temporarily: the hormone desmopressin and tricyclic antidepressants. Both need to be prescribed by a doctor. But the effect of these medications usually only lasts while they are being taken. Some children start wetting the bed again after they stop taking them.

 

Desmopressin

Desmopressin works in a similar way to the hormone vasopressin, which is made naturally in the brain at night to reduce urine production. However, the effect does not continue after treatment stops.
Desmopressin is usually taken as a tablet at bedtime, at a dose of 20 micrograms per day. In studies, about 19 out of 100 children stayed dry for at least 14 days in a row while taking this dose, compared to only 1 out of 100 children who took a dummy medication (placebo).
About 5 out of 100 children who take desmopressin tablets have side effects such as nausea and headaches. Most of these arise because the children have too much water in their bodies. To avoid these side effects, children and teenagers should not have more than one glass of a drink in the evening while they are on desmopressin. This is also important to prevent a rare but serious side effect called water intoxication. This happens if too much water stays inside your body. Early signs of water intoxication include nausea, vomiting and dizziness.
Desmopressin has a relatively fast effect and may already start to work the first time it is taken. So it can sometimes be helpful – for example, when it is used to avoid bedwetting if the child is spending the night at a friend’s house. It is best to try this medication out in advance to make sure that it works and that the dose is correct. Desmopressin can also help if a child sleeps so soundly that the alarm does not wake them up.

 

Tricyclic antidepressants

The second kind of medication used to treat bedwetting is tricyclic antidepressants, also referred to as “tricyclics.” Although they are mainly used in the treatment of depression, they are also approved for the treatment of bedwetting. Tricyclics shorten the dream phases of sleep (REM phases), increase the production of vasopressin, and affect the bladder muscles.
One antidepressant that has been quite well studied in the treatment of bedwetting is the drug imipramine. About 22 out of 100 children who took imipramine in studies stayed dry for at least 14 nights in a row, compared to 5 out of 100 children who took a dummy medication. Like desmopressin, tricyclics usually only work for as long as they are taken.
About 17 out of 100 children who take tricyclics have side effects like low blood pressure, a racing heartbeat, dry mouth, constipation, sweats, nausea, tiredness or insomnia. Tricyclic antidepressants should be kept away from children because an overdose can be life-threatening.

Other medications and therapies

Sometimes other medications are recommended to help with bedwetting, but there is not yet any reliable evidence that they work. Also, most of these drugs have not been approved in Germany for the treatment of bedwetting problems. One example is the sedative diazepam, which also has many side effects and can lead to dependency.
Combining different drugs– such as a tricyclic antidepressant and an anticholinergic – is another option. But this combination has not been tested enough, so it is not possible to say for sure whether it can help or what kinds of side effects might be expected.
Complementary or alternative medicine therapies like medicinal plants, chiropractic treatment, homeopathy, hypnosis and acupuncture have not been shown to be effective for bedwetting. Many of these therapies have only been tested in initial studies, making it difficult to draw strong conclusions.
It is also not yet clear whether children might benefit from various forms of psychotherapy.

Everyday life

Many parents and children already feel better knowing that bedwetting is not abnormal, and a lot of other families have to deal with it too – and that the problem will most likely go away on its own.
One practical way of making everyday life easier is being well-prepared for accidents at night – like protecting the child’s mattress with waterproof rubber mats or covers, and having fresh sheets and bedding on hand. Then everyone can get back to sleep quickly.
It is important to have the child shower in the morning and put on fresh clothes to avoid an unpleasant smell. This can help prevent negative reactions from friends or at school. To get rid of the urine odor in bed linen and clothes, things like baking soda or eucalyptus oil can be used in the wash.
It is important to encourage the child, and not scold or punish them.


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