The term enuresis is the one doctors use when talking about bed-wetting. The definition of this is “inappropriate voiding of urine at an age when control of micturition is to be expected.” (Micturition is passing of the urine.) Most children achieve bladder control by the age of three years, after they have learned to walk. By the age of three and a half, about 75 per cent are dry day and night.
Bed-wetting is a major social problem, and is cause for childhood despair, parental annoyance and often doctor worry. The thought of the daily chore of having to launder two sheets fills many parents with despair, and likewise, growing children hate the uncomfortable sensation of waking up with wet sheets and the smell of urine that accompanies it.
Doctors speak of primary enuresis, meaning it has persisted from babyhood. This contrasts with the term secondary enuresis, starting after the child has enjoyed some time when there was no problem.
At the age of five, the condition is usually primary, having persisted from birth. From the age of six years onwards, it is frequently of the secondary type. The problem is more prevalent in boys than girls, more frequently seen with the firstborn, and more prevalent in children of working-class parents.
About 10 per cent of the bed-wetters are also daytime wetters (called diurnal enuresis). However, a reassuring fact of life is that with or without treatment, “most enuretic children will be dry by the age of 15 years.” A few adults still suffer from the problem, and occasionally it may come on after a drinking session.
Often there are multiple causes for the problem. It seems to run in families. It may occur in both of twins, and there is often a family history of late bladder control. It has been found that children tend to pass their urine more often, particularly during the day, but that the total volume of urine passed is no more than a non-enuretic child.
Stress can be a precipitating factor, and this is often noted in those with secondary enuresis. Frequently the disability will arise following some mentally traumatizing situation, often domestic, such as moving house and changing school, having a new arrival in the family and similar situations. However, despite the occasion of stressful situations, the child is often not overtly stressful, and appears capable of coping quite well psychologically. More likely these are registered at the subconscious level.
There may be certain organic causes, and these should always be checked by the doctor. Certain anatomical abnormalities may occur, and infections (either producing symptoms or not) are relatively common. In recent years it has become apparent that many children have mild urinary-tract infections without symptoms.
This is termed silent bacteria. The only way for this to be detected is for urine samples to be pathologically examined. Sometimes the medical examination will include X-rays if these are considered necessary, but they are often unrewarding in yielding further information. The urine is checked for sugar, for some may be undiscovered diabetics. Occasionally a rare medical disorder such as spina bifida may occur, but in the main, the majority of children show no medical abnormalities. If one is found, it is usually treated by the appropriate form of medication until cured.
The majority of children can be successfully treated, provided a little time, effort and patience are expended both by the doctor and parents. If 75 per cent of children are dry by the age of three and a half, it means that a lot are still bed-wetters after this age, and anything to reduce this figure quickly is worth the effort.
There should be no suggestion of mental inferiority in bed-wetting children, for often these children are mentally equal to or brighter than their peers. The headmistress of a large children’s boarding school was once asked if she objected to having bed-wetters at her school.
“Certainly not,” she replied. “Most of the scholarships are won by children who are or were bed-wetters.” This might be salutary encouragement for parents dealing with the problem.
Often close medical supervision is essential, particularly in the early stages. Finding a doctor who has the time and interest is often particularly rewarding, and is sensed by both child and parent.
Excessive scolding and remonstrating by the parent will aggravate the situation and do little to encourage the child, who is already troubled by guilt and mental stresses. Encouragement is the ideal. Keeping a calendar on which the dry nights are marked in big red prominent crosses is a good idea.
Giving a reward for the dry nights often helps. If this is done, to avoid jealousy it is worth giving a little reward to the other children on these occasions also for their “encouragement” or on some similar pretext.
The value of this in the one to two hours prior to bedtime Scolding a child rather than offering encouragement often aggravates the problem of enuresis.
It is foolish to allow the child unlimited fluid intake, such as a couple of glasses before bedtime. But moderate restriction only is suggested. Lifting the child out for urination when the parents go to bed is also of dubious value, but is done and is probably worthwhile. The child does not always wake completely, but soon becomes accustomed to the routine, and will void at the appropriate place when not fully conscious.
This sometimes helps. The child is made to void every hour for the first few days, and this is supervised closely. Then the interval is increased by half-hour segments until the child is voiding only five to six-hourly. At this point the bed-wetting sometimes stops abruptly, to the delight of everyone, especially the patient.
Enuresis Medicinal Therapy
In the main this is not satisfactory. The only families of medicines of any use are the tricyclic antidepressants. Imipramine and amitriptyline have been used, and if success is forthcoming this is usually noticed quite rapidly. For the five- to twelve-year-old, one 25 mg tablet at bedtime (or the syrup equivalent) is given, double the dose for older children. If there is no improvement after a fortnight, the dose is usually doubled. Sometimes a morning dose is added, but usually a single evening dose is adequate. In some this produces constipation and drowsiness, but seldom to a degree that has made its discontinuation necessary.
Relapses are common when the medication is stopped. For this reason the treatment is usually continued for three to four months or more. Medication must be given under the supervision of the doctor. It should be given only after appropriate examination, and a full understanding of its uses and probable benefits and drawbacks. Although many other medicines have been used over the years, most are completely valueless.
The Pad-and-bell Alarm System
Over the past several years this method has deservedly become very popular. It is probably the most universally successful method at present available.
Basically it consists of two metal sheets that are placed on the mattress, separated by cotton material between. If the child voids, the urine causes a circuit to be completed and an alarm to sound, so waking the patient, who then gets out of bed to turn off the alarm, and voids in the appropriate place at the same time. The bed must be remade after each episode and the apparatus dried.
This is probably a minor nuisance factor, but alerts the child to what has happened, and also has a beneficial reflex effect on the mind. Since the original pad-and-bell device was invented, many other variations have become available. Now, extremely compact gear is readily available at modest cost, with a small electrode being clipped on to the child’s nappy (or underpants) leading to the battery-powered alarm. Even the passing of a few drops of urine will activate the alarm. Nocturnal disturbance is minimum, and disruption of the bedding is also minimum. Various devices are available, usually via the doctor or the local pharmacist.
The results are generally excellent.
According to a London report, “In a well run clinic over 60 per cent of children can be cured of enuresis. Most of these children achieve a cure after 10 – 15 bells – that is, between two and 10 weeks after starting to use the alarm. Relapse can be treated with a second course of the alarm.”
It is imperative, for success, for both doctor and parents to show interest in the system, and make every effort to encourage the patient and to enlist full support. This will ensure the best results. If done in a half-hearted, grudging manner, results will not be nearly as good. Ideally the child should own the apparatus, and these are available at fairly modest cost. Some prefer to hire them, but using second-hand equipment already used by many others is distasteful to some.
The pad-and-bell system is usually unsuited to children below the age of five. It is most effective about the age of seven or more.
Failure is due to quite definite reasons in most cases, most of which may be overcome. Some children flatly refuse to lie on the device at first, but with encouragement and persuasion may acquiesce. The parents may incompletely understand the way it is to be used, or fail to take the time and make the effort to read the directions fully and work out the simple mechanism. In some cases other children in the room may object to the alarm.
The equipment must be cared for properly, kept clean and properly serviced if faults occur, which are not very likely. Sometimes buttock rashes occur if the child persistently sleeps through the alarm.
Once more, keeping records, parental enthusiasm and the help and encouragement of the older children in the family will all help the bed-wetter psychologically. Relaxation therapy is also used successfully by some doctors.
The happy result is that the great majority can now be successfully and fairly quickly cured – mostly forever.