Bedwetting Is Very Common In Children, Especially Boys

Question: Our nine-year-old son has been toilet-trained since he was three. However, he still wets his bed almost every night. This has become a very embarrassing problem for him and our family. He will not invite his best friends for sleepover. We are afraid of discussing this with other family members. We have tried everything, like waking him up before we go to bed, and not letting him drink after supper. Nothing seems to help. Can you please give us some suggestion.

Answer:

What you have described is a condition called “primary nocturnal enuresis.” What it means is that this bedwetting started since he was toilet-trained. He is not able to wake up in the middle of the night, when his bladder is full, to urinate. This is actually not that uncommon, although children and parents are too embarrassed to talk about it.

Medical research has shown that about 20% of five-year-olds wet their beds at least once a month. The great majority of them are boys. This number will decrease by about 15% every year, so that by the time children reach teenage years, very few of them still wet the bed regularly. Some of them, however, continue to wet on occasion.

The central problem of bedwetting is the child not able to wake up to the sensation of a full bladder and go to the toilet to urinate. Many parents report that their children sleep too deeply or too soundly. It often takes 5 to 10 minutes to awaken them, and even then they still appear to be in a “zombie state,” not fully alert to go to the washroom.

It has also been estimated that almost 85% of children with daily bedwetting have small functioning bladders. The small bladder is not able to hold the normal amount of urine produced until morning. This is especially true for those who wet every night, several times a night, since birth. Some of them also have to urinate fairly frequently during the day.

This problem of bedwetting is often hereditary. If one of the parents were bedwetters when small, there is almost a 50% chance of the child having the same problem. If both parents were bedwetters, the chance increases to 75%.

Many parents wonder whether bedwetting is a psychological problem. Generally, this is not the case, although stress can make it worse. More importantly, children do not wet the bed on purpose, rather they just can’t help it. Nobody enjoys sleeping in a soaked bed, not even children!

My suggestion for you is to go to your family doctor and explain about your concern. Generally, we recommend reassurance if the child is 5 to 7 years of age. Many of them will improve within one to two years. They may still have accidents, but the problem may not happen every night. However, by 9 or 10 years of age, if the child still wets every night, this requires evaluation and management plan in collaboration with the child and family.

Your family doctor needs to ask you more questions to make sure that there is no other cause for bedwetting. These are rather uncommon, but they need to be “ruled out.”   Your doctor may also decide to refer him to a paediatrician or urologist who deals with this problem more frequently.

Although we understand the cause of bedwetting, managing it is not as easy. For some parents, limiting fluid intake after supper will reduce the amount of urine produced at night, resulting in fewer bedwetting episodes. This, however, does not help everyone, including your son.

The most important issue is for the child to be able to sense the full bladder, and wake up to urinate in the toilet. Many specialists believe that unless this is achieved, bedwetting will continue. For most children, this maturity of the brain will happen sooner or later. Parents, however, can offer some help along the way.

Some children actually know that they have a full bladder, but are just too afraid to go to the toilet. Having a night-light in the hallway, or move the child to a bedroom closer to the bathroom, can be helpful. If your son still wears a pull-up in bed, remove it. Pull-ups can be useful for camps, but it does not prevent bedwetting.

Get your son involved in his management. Make sure he helps to clean up the bed in the morning after an accident. However, do not put any blame on him if it does happen. Children with bedwetting are under tremendous social pressure. He should be told that the problem has a lot to do with his small bladder, but he can help by trying to get up at night when he feels his bladder is full. Marking down the dry nights on a calendar can help to track successes and provide encouragement.

Some specialists have designed elaborate ways of awakening children at night to prevent bedwetting. The basic principle is to wake the child by turning on the light, calling his/her name, touching, or by using an alarm clock. It is important to make sure he is awake enough to walk to the bathroom to urinate. It is totally useless if parents have to carry a sleeping child to the bathroom. This will not help with bedwetting.

By awakening your son and getting him to urinate in the toilet before he wets his bed, you can potentially stop his problem completely. If he has already wet the bed when you wakes him, try half an hour earlier the next night. Sometimes an “enuresis alarm,” available from pharmacies, can help by wakening with a loud noise or vibration. However, unless your son can wake up to the alarm, otherwise it won’t work.

Medications have been used, with variable success according to different physicians and studies. Imipramine (Tofranil) has been used for many years. It is safe by itself, although accidental overdose is very dangerous, and can even be fatal. Therefore, this medicine needs to be placed in a child-proof bottle, and preferably locked away. It works by relaxing the bladder and reducing contraction, thereby increases the bladder volume. It is especially helpful if there is frequent urination in daytime.

Another newer medicine is called Oxybutynin (Ditropan). It works in a similar way, although experience with this medicine is more limited. It does not have the same dangerous side effect as Imipramine when overdosed.

Another approach is to use a synthetic hormone called DDAVP. This hormone is normally produced by the pituitary gland. It works by reducing the amount of urine produced at night, so that we don’t have to urinate nearly as often as the day. Most of us have normal amount of DDAVP, including those children who wet the bed. However, by giving extra DDAVP as a pill or a nose spray at bedtime, it can further reduce the amount of urine. As a result, many children given DDAVP will become dry while on the medicine. Unfortunately, when it is stopped, many will relapse with the same problem. More importantly for many families, this medicine is very expensive.

Use of medications in combination with awakening at night to urinate will produce the best result. However, if you are worried about using medications daily, you can use them on special occasions, like camping, school trips, or sleep-overs.

I hope you have gained some new insight into this very common paediatric problem. You should discuss this in detail with your doctor before deciding what is the best for your son and your family. Good luck!