Pediatricians are seeing an increase in day and nighttime wetting since the start of the Coronavirus pandemic. It may be due to an increase in anxiety and depression among children or could also be caused by constipation as a result of reduced physical activity. Increasing physical activity can help relieve both constipation and stress in kids. However, in some cases bedwetting may be a sign of an underlying medical condition. Read on to find out more about causes and symptoms of bedwetting and what can parents do about it.
What is enuresis?
Enuresis in Latin means "in urine”. In pediatrics practice, the term enuresis is commonly used for nocturnal enuresis or bedwetting during sleep at nighttime. Bedwetting during the day is called diurnal enuresis and bedwetting at night is called nocturnal enuresis. Nighttime wetting is more common than daytime wetting.
By 5 years of age 90 to 95% children achieve bladder control or continence of urine for day and nighttime. So, nocturnal enuresis is defined as urinary incontinence during sleep in a child five years or older.
What are the types of bladder control problems in children?
Enuresis without any other symptoms is considered monosymptomatic and has two main types - primary and secondary.
- A child with primary enuresis has wet the bed since he or she was a baby, (i.e. bladder control has never been attained).
- Enuresis is secondary if the child has been dry for six months or more and then restarts wetting the bed at night time. This is usually the result of a stressful event in the child’s life like divorce of parents or a medical problem such as constipation.
Non-monosymptomatic enuresis is when there are other symptoms such as daytime accidents, increased frequency, urgency or pain on voiding. This is usually pathologic and needs evaluation by a specialist doctor.
How common is enuresis?
Bedwetting (nocturnal enuresis) is fairly common in children and most children grow out of it as they get older. It affects 5% to 10% of all 7-year-old children, an estimated 5 to 7 million children in the United States and it is more common in boys. In most of these children, enuresis is monosymptomatic and they have no other associated symptoms other than wetting bed at nighttime.
It is important for parents to understand that enuresis is in most cases involuntary and usually doesn’t happen because the child is too lazy to get out of bed to go to the bathroom.
What causes enuresis?
Some of the common factors that cause enuresis include:
- Genetic factors – parents who had enuresis as children are more likely to have children with enuresis. A child’s chances of wetting the bed are about 1 in 3 when one parent was affected as a child. If both parents were affected, the chances that their child will wet the bed are 7 in 10
- Small bladder
- Recurrent urinary tract infections or urinary tract malformations
- Hormonal factors - inadequate amount of antidiuretic hormone is produced. This is the hormone that reduces urine production.
- Developmental disorders such as ADHD
- Psychological factors - This is more common with secondary enuresis and is considered a regressive symptom in response to stress or trauma (e.g., parental divorce, sexual abuse, trauma at school, hospitalization, neglect)
- Sleep disorders - An abnormally deep sleep pattern, sleep apnea may cause enuresis.
- Constipation, a common problem in children, can also cause bedwetting, usually secondary enuresis.
- Diabetes - Some children with type 1 diabetes may have bedwetting as a symptom at the start of their illness.
What are the signs and symptoms of bladder control problems in children?
In addition to wetting the bed or underwear, other symptoms may include:
- Urgency - the urgent need to urinate, often with urine leaks
- Frequency - urinating 8 or more times a day
- Infrequent urination - emptying the bladder only 2 to 3 times a day, rather the usual 4 to 7 times a day
- Incomplete emptying - not fully emptying the bladder during bathroom visits
- Holding and other maneuvers - squatting, squirming, leg crossing, standing on tiptoes, crossing the legs, pressing the heel or hand into the perineum.
Nighttime - Nighttime wetting is normal for many children. For kids 5 years and up, signs can include:
- Never being dry at night
- Wetting the bed 2 to 3 times a week over 3 months or more
- Wetting the bed again after 6 months of dry nights
In addition, take your child to a doctor if there are symptoms of bladder infection such as pain or burning when urinating, cloudy, dark, bloody, or foul-smelling urine, increased frequency, strong urges to urinate but passing only a small amount, pain in the lower belly area or back, crying while urinating, extreme thirst during the day, swelling in the feet or ankles, and fever.
When should you seek medical help for your child about bedwetting issues?
Most children achieve some degree of bladder control by the age of 4, usually during the daytime first. Night-time bladder control typically takes longer to achieve. By the age of 5, almost 90 to 95% of children will achieve nighttime control of urination, so generally after the age of 5, parents should start doing simple things (see below) to help children achieve nighttime control. By 7 years of age about 90% of children can control their bladder both day and night, so after 7 years of age parents should get more aggressive in helping the child.
To summarize, you should check with your child’s pediatrician if:
- Your child is 7 or older and wets the bed 2 to 3 times a week.
- Your child is 4 or older and experiences daytime wetting.
- Your child was previously continent.
Reasons for proactive management include the distress caused to child and family, difficulty of “sleeping over” on holiday or at friends’ houses, social withdrawal, reduced self-esteem, and potential disturbance of the child’s and the parents’ sleep architecture that may have an impact on daytime functioning and health.
How is enuresis diagnosed?
For most children, the doctor will start with:
- Taking an enuresis-focused history (the onset, duration, and severity of enuresis; presence of daytime wetting, constipation, genitourinary symptoms, and neurologic symptoms; family history of enuresis; patient medical and psychosocial history; and details of previous treatment).
- Conduct a complete physical examination.
- Order a routine urine test (urinalysis) to rule out urinary tract infection, kidney disease or diabetes. The doctor may sometimes request an ultrasound of the kidney and bladder.
It is also useful to record a diary of how much the child drinks and how much urine he or she passes. This should include recording the time and amount of fluids your child drinks, as well as the number of times the child urinates, including the amount urinated, if possible.
How is enuresis treated?
Most children outgrow bedwetting without treatment. However, when treatment is recommended, it often starts with behavioral interventions, for example:
- Limiting fluid intake in the hours before bed
- Avoiding sugary and caffeinated drinks, especially late in the day
- Waking the child at night to attempt to urinate
- Bladder training (e.g., increasing bladder capacity by delaying urination for extended periods, pelvic floor and sphincter control exercises)
- Using positive reinforcement for dry nights
- Implementing a 'cleanliness training' - having the child change the bedding in the event of an accident. However, it is important to not use don’t use it as a punishment.
If the behavioral interventions fail even after 3 to 6 months, enuresis alarms are typically used before using a drug/medicine based treatment. For the families who are not sufficiently motivated to use the alarm, who have recently used the alarm (correctly) without success or who are considered unlikely to comply with alarm treatment, medications such as Desmopressin (it decreases urine production at night when taken at bedtime) are prescribed for children 7 years or older.
Managing enuresis - tips for parents
It is important for parents to understand that bedwetting is completely involuntary and that a child should never be punished for it. Bedwetting is almost never due to laziness, a strong will, emotional problems, or poor toilet training. Here are some tips from The American Academy of Pediatrics (AAP) to support your child:
- Do not blame your child. Remember that it is not your child's fault.
- Let your child know it's not his or her fault and that most children outgrow bedwetting.
- Be sensitive to your child's feelings and remind him or her that they are not alone, other children too wet the bed.
- Protect the bed. A plastic cover under the sheets protects the mattress from getting wet, smelling like urine and making it easier to clean.
- Let your child help. Encourage your child to help change the wet sheets and covers. It can also keep your child from feeling embarrassed if the rest of the family knows. However, it is important not to use it as a punishment.
- Set a no-teasing rule in your family. Do not let family members, especially siblings, tease your child. Let them know that it's not your child's fault.
- Take steps before bedtime. Have your child use the toilet and avoid drinking large amounts of fluids just before bedtime.
- Try to wake your child up to use the toilet 1 to 2 hours after going to sleep to help your child stay dry through the night.
- Be positive. Reward your child for dry nights. Offer support, not punishment, for wet nights.
- Keep a diary for your child's daily urine and bowel habits.
- Finally, don’t hesitate to speak with your child’s pediatrician about bedwetting. It is understandable for parents to want reassurance that their child's bedwetting is not caused by an underlying medical problem.
*This article provides a general overview and may not apply to everyone. Talk to your pediatrician to find out if this information applies to you and to get more information on this subject.
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