By Patrick S. O’Hollaren, M.D.

If you or someone you know has a child with nocturnal enuresis, better known as bedwetting, you know it can be a stressor not only on the child, but on the entire family.

To start, let’s define some terms:

• Primary Nocturnal Enuresis: Bedwetting that has always been a problem.
• Secondary Nocturnal Enuresis: Bedwetting that started back up after at least six months of steady dryness at night.

There are several issues regarding the child’s history that will help a physician care for the nighttime wetter. These include:

1. Has the bedwetting always been a problem?
2. In an average week, how many nights would the child have wetting problems?
3. At what age was the child toilet-trained (out of diapers) during the day?
4. Is there a family history of bedwetting in a sibling(s) or either parent?
5. Does the child have wetting problems during the day?
6. Is there a history of constipation?
7. Is there a history of urinary tract infections, poor urinary stream, urinary frequency or urgency?

The Workup

A careful physical exam is vital to the evaluation. This includes checking for any abdominal abnormalities, looking at the area of the low back and tailbone and evaluating the genitals including the urethral opening. A general physical exam including vital signs and a urine sample also is necessary.

It is important to analyze the urine for any abnormalities and check for infection. Children can have urinary tract infections with few or no symptoms. An X-ray called a KUB evaluates the bowels for signs of constipation and checks the spine for any abnormalities. A kidney and bladder ultrasound tells us if the kidneys are the proper size and checks the drainage system to the bladder to rule out obstructions. It also looks at the bladder before and after voiding to assess how well the bladder is emptying.

It is also important to assess psychosocial stressors as contributing factors. These include changes in the child’s routine, divorce/remarriage, death, significant illness, new sibling, a move, etc.

Other causes of urinary incontinence can be infection, neurologic issues such as tethered cord (tension on the spinal cord) and constipation which pushes on the sensitive bladder floor. There also is a condition known as dysfunctional voiding, which is a learned problem that can result in only partially emptying the bladder. Children tend to be infrequent voiders and this can lead to overstretching of the bladder muscle, irritation of the bladder and possibly poor emptying and leakage due to bladder instability.

In general, 15 to 20 percent of all children wet the bed until age 5, so bedwetting through the fifth year is considered normal. Nighttime wetting can vary widely between siblings. The vast majority of bedwetters have what I like to think of as a bladder that is temporarily lagging in its maturity compared to the rest of the body. Most children will gain their continence over time.

Treatment

• For urinary tract infections, antibiotic treatment and further evaluation with studies of the urinary tract are prescribed.
• You can take infrequent voiding out of the picture by placing the child on a strict timed voiding schedule. There are voiding reminder watches available to help.
• Remove constipation from the equation by having the child undergo a bowel cleanout and maintenance regimen. There are easy child-friendly cleanout alternatives available over-the-counter.
• Avoid caffeine as this can increase bladder irritability.
• If there are any signs or symptoms of a possible neurological cause, seek proper neurological evaluation. Some symptoms include back pain, leg pain and an unusual running/walking gait.
• Cutting off fluids after 6pm, voiding just prior to bed and the one-time wakeup technique for an additional void by the child when the parents go to bed can help.
• For psychosocial stressors, psychological evaluation and/or counseling may be helpful.

There are medications which can decrease nighttime wetting under certain circumstances. Some decrease the urine output of the kidneys and others calm down the bladder muscle. These can be helpful but are not long-term fixes. Nighttime alarm systems also can be helpful in training the bladder to function as a better reservoir.

In the vast majority of cases, bedwetting can be treated with an organized approach working with the child’s primary care provider and occasionally with the help of pediatric specialists.

Patrick S. O’Hollaren, M.D., is director of Pediatric Urology at Legacy Emanuel Children’s Hospital

July 31st, 2010 | Category: Health and Safety, Past Articles, Sleep