Sometime around the age of three, children typically begin to exhibit bladder control during the day and make the transition from diapers to toileting. For most children, nighttime bladder control follows. The term enuresis—often thought of as the technical term for bedwetting—refers to the continued involuntary passage of urine after an age at which control is expected.
When daytime wetting persists beyond the age of four, or nighttime wetting persists beyond the age of six, the child is considered to have primary enuresis. When the ability to stay dry has developed normally and without intervention but is followed by a period of wetting that lasts for three months or more, the child is considered to have secondary enuresis. The distinction between these two types is based on the child's physiological ability to control his or her urinary output. In cases of primary enuresis, this ability is usually compromised. In cases of secondary enuresis, the child often has no physical problems impairing bladder control, but may be reacting to some emotional or psychological issues. Most cases of enuresis—about 90%—are of the primary type.
Enuresis may interfere significantly with social and emotional aspects of normal development. Consider the plight of the 10-year-old who still wets the bed regularly. He or she may avoid activities such as camping out or attending pajama parties because of the potential humiliation of wetting in the presence of friends and acquaintances. Bedwetting may also present a Stressor to family functioning with daily loads of sheets, blankets, and pajamas to be washed. Limited laundry facilities or
Children may also develop a sense of failure and helplessness with regard to the inability to control nighttime wetting. In fact, some studies have shown that bedwetters show lower scores on indices of self-esteem and tend to underachieve compared to non-bedwetting peers. More importantly, these same studies showed that successful treatment of enuresis is associated with increased self-confidence and outgoing behavior at school.
Who becomes enuretic? Approximately 10% of six-year-old children wet their beds. By age 10, about 5% of children have primary enuresis, and 2% continue to show the disorder after puberty with cases persisting into adulthood. Genetics probably play a role in who becomes enuretic. Most children with primary enuresis have a relative—either a parent or an aunt or uncle—who wet the bed as a child. Many parents report that their bedwetting child is an extremely sound sleeper compared to their other children, an observation not supported by recent studies that suggest that parents' impressions may be due to the fact that they are not trying to wake their other children during the night. In fact, bedwetting may occur in any stage of sleep.
What causes enuresis? On occasion, enuresis turns out to be the result of a serious medical condition that causes increased urinary output, such as diabetes or sickle-cell anemia. A small number of enuretic children have a history of snoring and may have episodes of sleep apnea (interrupted breathing) that contribute to their bedwetting. Most cases of primary enuresis, however, are caused by smaller than normal functional bladder capacity and bladder irritability.
Functional bladder capacity is the number of fluid ounces that can be held in the bladder before one feels an urge to urinate as the result of wavelike contractions of the bladder. These contractions push fluid down past the inner sphincter muscle, a ring-like muscle that keeps the bladder closed when it is tensed. Normally, contractions are triggered when the bladder is full. However, in children with small functional bladder capacity, contractions are triggered by a smaller amount of fluid. Children who also have irritable bladders experience more and stronger contractions than normal at this lower volume. Both bladder contractions and the action of the inner sphincter are involuntary, that is, they are not under conscious control.
Only the action of the outer sphincter muscle is under voluntary control. We normally use this muscle to hold back urination in between the first urge of bladder contractions and the time that we are able to get to a bathroom. In deep sleep states, however, voluntary muscles relax. If a child reaches his or her functional capacity and experiences bladder contractions while the outer sphincter is relaxed in deep sleep, bedwetting may occur. This is not a problem for a child with normal bladder capacity. However, the enuretic child with a small functional bladder capacity and an irritable bladder is unable to hold the fluid that accumulates during a 10-12 hour nighttime sleep. When this child's functional bladder capacity is reached and many intense contractions push fluid beyond the relaxed outer sphincter, bedwetting occurs.
Although the most common causes of primary bedwetting are physical, psychological factors may also be involved. It can become a complex cycle as the child and family react to the bedwetting in ways that might exacerbate the problem.
The causes of secondary enuresis can be more difficult to pinpoint. It is a common reaction in children who have experienced trauma and may persist even after the incidents of physical, sexual, or emotional abuse have ceased. Even normal developmental changes in the family or the child's situation may result in a period of secondary enuresis, such as the bedwetting associated with the birth of a younger sibling or a child's entry to kindergarten. Bedwetting will resolve in most cases when the underlying emotional issues have been adequately addressed.
Can primary enuresis be treated? Yes. Many myths have surrounded the challenge of treating enuresis, dating from A.D. 77 when Pliny the Elder recommended feeding supplements of boiled mice to enuretic children. Fortunately, modern research has clarified factors that contribute to the causes of enuresis, thereby outlining the components of sound treatment.
Unfortunately, old myths occasionally appear in contemporary professional advice and health plan policy. One such myth is "Enuresis is a self-limiting condition, and treatment is not necessary." While some children do grow out of enuresis, without intervention a substantial number remain enuretic into adolescence and a smaller number into adulthood. "Don't drink anything after dinner." While the enuretic child should not drink a quart of soda before bedtime, excessive curtailing of liquids can be counterproductive by prompting an urge to urinate at even lower volumes of bladder pressure. Another common myth is "He could stay dry if only he tried harder." While motivation must be a part of any thorough treat ment program, it is difficult for effort alone to accomplish anything when one is fast asleep.
No treatment plan should begin without a thorough evaluation designed to identify factors contributing to the problem. The basic assessment should include a complete physical examination, urinalysis and a urine specific gravity, evaluation of the urinary stream, neurologic examination, the assessment of bladder habits (e.g., the amount and frequency of urine produced each day,
The treatment program that follows may include the use of wetness alarms to heighten the child's awareness of the signals that his or her bladder is full, exercises to increase sphincter control and bladder capacity, pharmacological interventions for short-term use, and psychological support. The use of wetness alarms combined with exercises to improve sphincter control and increase bladder capacity provides the best long-term treatment results; reported success rates have ranged from 65-85%.
Wetness alarms condition the child to awaken at the sensation of impending urination, especially when they are paired with sphincter control exercises. By awakening the child with a loud noise immediately upon urinating, the child eventually awakens prior to the sound and is able to urinate in the bathroom. The alarm can also be used during daily exercises as a signal to interrupt the stream of urination, helping the child to learn an association between "hearing the buzzer" and "holding it."
Increasing functional bladder capacity by consuming a large amount of fluid and then waiting as long as possible before urinating is another component to being able to sleep through the night and remain dry. How much fluid should a child be able to retain? A child's normal bladder capacity in ounces may be estimated by adding two to the child's age in years. Martin Scharf recommends measuring the child's output during bladder stretching exercises twice weekly to chart improvement in the bladder capacity. Long-term success in treating enuresis is always accompanied by significant increase in bladder capacity that is evidenced in decreased frequency of daytime urination regardless of the type of treatment program used.
Pharmacological agents have been used to treat enuresis, which provide good results in the short-term while the child is taking the medication, but poor effectiveness once the drug is removed. Desmopressin acetate (DDAVP) is an antidiuretic hormone that is administered by nasal spray. One drawback to DDAVP is that it is effective when nasal passages are clear and absorption is maximal, making it useless during cold and flu season. Imipramine (Tofranil) is an antidepressant that also has anticholinergic effects, that is, it suppresses the body's response to the neurochemical acetylcholine, thereby reducing bladder irritability. Both DDAVP and Imipramine have spontaneous success rates of about 70-75%, and are often prescribed for children going on camping trips or in need of a short-term treatment. As with any drug, there can be side effects, warranting careful monitoring of dosage and administration.
Finally, treatment programs must attend to the psychological needs of the child and family. Providing information, setting realistic goals, structuring reinforcement, and addressing any of the child's negative feelings engendered by his or her experience with enuresis will enhance the effectiveness of any treatment method. Richard Ferber stresses the need for responsibility training and reinforcement in helping the child take responsibility for staying dry through reinforcement rather than punishment. With reinforcement and support, the child is able to take pride in his or her accomplishments as wetness begins to decrease in amount and frequency.
Successful treatment of enuresis is seldom an overnight event. Progress is often slow and hampered by relapses. Parents who are well informed and able to maintain positive attitudes in support of their child are better able to help the entire family cope with the problem of enuresis.
SUPPLIERS OF WETNESS ALARMS
Alarms are often available at drug stores, pharmacies, or medical supply stores. There are several different types, and a range of prices. Product descriptions may be obtained from the following companies:
Koregon Enterprises, Inc.
Address: 9535 SW Sunshine Ct., Suite 100
Beaverton, OR 97005
Telephone: (800) 544-5240
(Manufacturers of Nite Train'r)
Nytone Medical Products, Inc.
Address: 2424 S. West
Salt Lake City, UT 84119
Telephone: (801) 973-4090
(Manufacturers of Nytone.)
Address: 1595 Soquel Dr.
Santa Cruz, CA 95065
Telephone: (408) 476-3151
(Manufacturers of Wet-Stop.)
Azrin, N. H. and V. A. Besalel. A Parent's Guide to Bedwetting Control. New York: Pocket Books, 1981.
Ferber, R. Solve Your Child's Sleep Problems. New York: Simon & Schuster, 1985.
Schaefer, C. K. Childhood Encopresis and Enuresis. New York: Von Nostrand Reinhold, 1979.
Scharf, M. B. Waking Up Dry. Cincinnati: Writer's Digest Books, 1986.
Koff, S. A. "Estimating Bladder Capacity in Children." Urology 21, 1988, p. 248.
Kolvin, I., R. C. MacKeith, and S. R. Meadow, Eds. Bladder Control and Enuresis. London: Heinemann Medical Books, 1973. (Especially the following chapters: "How Children Become Dry"; "Conditioning Treatment of Nocturnal Enuresis: Present Status"; and "Nocturnal Enuresis: The Importance of a Small Bladder Capacity.")
Rushton, G. "Enuresis." Clinical Pediatric Urology. P. O. Kelalis, L. R. King, and A. B. Belman. Eds. Philadelphia: W.B. Saunders, 1992.
—Doreen Arcus, Ph.D.
University of Massachusetts Lowell