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Enuresis

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.

Enuresis Causes

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.

Enuresis Treatment

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.

Avoid Stress

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.

Fluid Restriction

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.

“Interval Training”

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.

Bedwetting

Gaining consistent control of bladder and bowel during daytime hours is a significant milestone for a toddler or preschooler. For many children, keeping the bed dry at night is a more elusive goal, one that might not be reached until quite a bit later in life. Children who still wet the bed at night well into their grade-school years too often take an emotional beating and in some cases, a physical beating because of this problem – which is not under their conscious control. One of the greatest problems faced by bed-wetting children is a parent with unrealistic expectations that every child should be completely dry, day and night, by the age of three. To deal with bed-wetting effectively and supportively, it is important to understand some basic realties of nighttime bladder function in children.

Bedwetting Definition

Enuresis is the involuntary passage of urine into the bed or clothes at least once or twice per month in a child who is at least five years of age.

A child with primary enuresis has never contained consistently dry through the night for more than six to twelve months. A child with secondary enuresis has achieved consistent nighttime bladder control for six to twelve months and then for some reason lost it.

Bedwetting Causes

Only about 1 percent of children with enuresis will be found upon medical examination to have an underlying disease or disorder such as a urinary tract infection, diabetes, significant constipation, a congenital abnormality of the urinary tract, or a disturbance in the central nervous system. When evaluating persistent bed-wetting, a child’s physician will consider these physical possibilities (which usually have other manifestations) and carry out appropriate studies if necessary.

In the other 99 percent of children with enuresis, the problem may involve one or more of the following. (Clinicians are not in complete agreement about the relative importance of each of these factors.)

Delayed maturation. During infancy, the bladder automatically empties six to eight times per day when a certain volume of urine is present. As a child matures, this emptying reflex is inhibited (held in check) by the central nervous system, so that he can hold larger amounts of urine and eventually release it voluntarily. In general, control is achieved earlier by girls than by boys. By the age of three, most children can consistently postpone urinating during waking hours. However, the ability of a child’s central nervous system to inhibit emptying of the bladder during sleep may lag behind daytime control by months or even years. By the age of five, as many as 10 to 15 percent of children are not consistently dry in the morning.

  • Small functional bladder capacity. A normal child can usually voluntarily hold urine in an amount of ounces equal to his age in years plus two. (A six-year-old child, for example, should be able to hold about eight ounces of urine.) If a child cannot hold at least the same number of ounces as his age, this decreased capacity may contribute to enuresis.
  • Increased formation of urine during the night. Hormone called vasopressin, which is produced by the pituitary gland, reduces urine production by the kidneys. An increased amount of this hormone is normally secreted during the night cutting the rate of urine production in half. Some bed wetters apparently do not secrete more vasopressin during the night and produce more urine than their non-bed-wetting peers. A similar rest may occur, regardless of vasopressin levels, if a child consumes liquids before going to bed.
  • Difficulty awakening when the bladder is full. With the general patterns of sleep are similar in both bed-wetting and non-bed-wetting children, many parents observe that their child with enuresis will “sleep through anything” and seems very difficult to awaken during the night.
  • A family history of enuresis. Due to many of the factors contributing to bed-wetting having inheriting physiological basis, it should not be surprising that this problem often runs in families. Enuresis seven times more common in children whose fathers were bed wetters and five times more common if the mother had this problem. If both parents were bed wetters, the likelihood that the child will have enuresis is greater than 75 percent compared to a 15 percent chance if neither parent was a bed wetter.

Bedwetting Evaluation

If your child is wetting the bed repeatedly after their sixth birthday, an evaluation by your child’s physicist is a reasonable first step. (Very often this problem can be addressed during a routine checkup.) A careful history and a physical examination will be performed, with any appropriate laboratory studies (such as analysis). A culture of the urine will be taken if there is concern about an infection. In most cases elaborate agnostic tests are not needed. But if the initial assessment raises concerns about the structure or function the urinary tract, your child’s physician will want to evaluate further.

If a child develops secondary enuresis – that is, he is being consistently dry in the morning for more than six months and then begins wetting the bed again, a bladder infection or diabetes might be manifested in this way.

How to Stop Bedwetting

First and foremost, remember that for the vast majority of children with enuresis will eventually resolve on their own as their central nervous system matures. (Each year after the age of six, 15 percent of children who still have enuresis, spontaneously stop wetting at night.) Enuresis is not of disobedience or weakness of character. Steps can be taken to eventually reach one of two satisfactory goals: Your child holds urine through the night and then voids into the toilet or potty-chair in the morning, or your child awakens during the night when his bladder is full and voids into the toilet or potty-chair.

The following measures may help a child with enuresis:

  • Encourage fluid intake during the day and discourage drinking liquids after the evening meal or within two hours of bedtime. If your child wants a drink before bed, limit intake to one or two ounces.
  • Have your child empty his bladder just before he goes to bed.
  • Encourage your child to get up during the night to urinate. A child who feels that his only goal is to delay emptying his bladder until morning may fail repeatedly. Giving verbal cues before bed (“Try to get up and use the toilet if your bladder feels full”), leaving the light on in the bathroom, or providing a potty-chair near the bed can help. To a degree that is appropriate for his age, let him participate in the cleanup process when the pajamas and bed are wet. This should be presented not as punishment but as a matter-of-fact routine. This can include rinsing out his pajamas and underwear and taking a quick bath or shower in the morning if he smells of urine. Sheets can be left open to air dry but should be washed when they have a disagreeable odor. A dry towel placed under the child’s bottom may help reduce the amount of laundry. A school-age child who wakes up wet during the night can change his own pajamas and place a dry towel over the wet area of the sheet. (Dry pajamas and towel should be made readily available in his room.)
  • Some experts believe that specific measures can increase the functional capacity of a child’s bladder. Younger bedwetters who visit the bathroom frequently during the day can be encouraged to go less often. Children older than six or seven can be encouraged to try increasing the bladder’s capacity by a simple exercise of waiting to use the toilet for at least ten or fifteen minutes after feeling the urge to go. This should only be done if the child is a willing participant and will be most helpful with a child who has a small bladder capacity. (To check his capacity, have him hold his urine as long as he can and then void into a measuring cup. Take the best of three measurements of his bladder capacity, which in ounces should equal his age in years plus one or two.)
  • Protect the mattress with a plastic cover.
  • Offer praise and perhaps a smiley-face sticker on the calendar when he has a dry night or awakens and uses the toilet.
  • Avoid expressing dissatisfaction, dismay, or anger when he’s wet in the morning.