Nocturnal enuresis in children

Bedwetting or ‘nocturnal enuresis’ is involuntary urinating during sleep. Bedwetting is generally considered to be normal in children younger than five years of age, but may still be a cause for concern in parents and carers of young children.¹

Bedwetting is common and is thought to affect between 15% and 20% of children at five years of age, approximately 2% to 3% of teenagers and 0.5% to 2% of adults.²

Risk factors

There are many risk factors associated with bedwetting. Studies have reported a genetic link and therefore children whose parents wet the bed are more likely to experience bedwetting themselves. 

Boys are more likely than girls to wet the bed, as are children who are slower to achieve daytime bladder control and children who suffer from constipation, faecal incontinence or developmental delay. 

Obesity is also a risk factor with approximately 30% of obese children wetting the bed. Psychological or behavioural disorders can also have an impact. 

Bedwetting occurs in 20% to 40% of children with disorders such as attention deficit hyperactivity disorder (ADHD), autism spectrum disorder, anxiety, depressive, and conduct disorders.^{1, 2}

Primary bedwetting

Primary bedwetting without daytime symptoms is a term for a child who has never achieved sustained continence at night and does not have daytime symptoms. Primary bedwetting without daytime symptoms is thought to be caused by sleep arousal difficulties. This includes an inability to recognise the sensation of a full bladder or bladder contractions, polyuria and/or bladder dysfunction where the child has a small bladder capacity or an overactive bladder.³

Primary bedwetting with daytime symptoms is a term for a child who has never achieved sustained continence at night and has daytime symptoms such as urgency, frequency, daytime wetting, abdominal straining, or poor urinary stream, or pain passing urine. 

Primary bedwetting with daytime symptoms is usually caused by disorders of the lower urinary tract such as overactive bladder, structural abnormalities of the urinary tract, neurological disorders such as cerebral palsy, chronic constipation or urinary tract infection.³

Secondary bedwetting

Secondary bedwetting is a term for bedwetting which occurs after the child has been dry at night for more than six months. Secondary bedwetting usually has an underlying cause, such as diabetes, urinary tract infection, constipation, or behavioural or emotional problems.³

Most children who wet the bed without daytime symptoms become continent by adolescence. Bedwetting resolves spontaneously in 5 to 10% of affected children each year. Spontaneous resolution is thought to be much rarer in children who wet the bed most nights and not just sporadically. About 1% of children continue to wet the bed into adulthood.⁴

Psychological implications

Bedwetting can have a deep impact on the child’s emotional and social wellbeing as well as their behaviour. Children with bedwetting may feel guilt, shame, humiliation, victimisation or loss of self-esteem, and that they are different from other children. The child may avoid social activities, such as sleepovers or school trips. The child may also have higher than average levels of oppositional behaviour and conduct problems.¹

Bedwetting can be stressful for the parents or carers of the child because of the additional work and cost of caring for a child with bedwetting. The cost of caring for a child with bedwetting can be considerable (for example the cost of extra laundry, extra bed sheets, mattress replacement, pull ups) which can have a significant effect on family finances.

Assessing a child who is bedwetting

Determine the type of bedwetting by asking if there are any daytime symptoms such as urgency, frequency (more than seven times a day), daytime wetting, abdominal straining or poor urinary stream, pain passing urine or passing urine infrequently (fewer than four times a day). Determine whether the child previously had been dry at night without assistance for six months.¹

For children younger than five years of age, ask whether daytime toilet training has been attempted and if not determine the reason for this. Consider assessing for constipation, as undiagnosed chronic constipation is a common cause of wetting and soiling in younger children.¹

Determine the reason for the consultation, for example ask whether short-term treatment (for a sleepover or school trip), or long-term treatment is required.

Assess the pattern of bedwetting, frequent bedwetting is less likely to resolve spontaneously than infrequent bedwetting. Ask how many nights a week bedwetting occurs, how many times a night bedwetting occurs, if there seems to be a large amount of urine, at what times of night does the bedwetting occur and if the child wakes up after bedwetting.¹

Assess the child’s fluid intake throughout the day and ask whether the child or the parents or carers are restricting fluids. Inadequate fluid intake may mask an underlying bladder problem, such as overactive bladder disorder and may impede the development of an adequate bladder capacity. 

Consider asking the parents or carer to keep a diary of the child’s fluid intake, bedwetting, and toileting patterns for two weeks. This may also involve weighing nappies or pull-ups to understand how much urine the child is passing at night, compared with during the day.¹

Assess the home situation, ask if there is easy access to the toilet at night and whether the child shares a bedroom as this may affect the decision to use an alarm. Assess whether the child and parents or carers are willing or able to take part in behavioural interventions, such as using an enuresis alarm.¹

Ask whether the parents are finding it difficult to cope with the burden of bedwetting or if they are expressing anger, negativity or blame towards the child, in order to determine if they need support.¹

Include the child in the assessment (where appropriate), ask whether the child thinks there is a problem, what they think the main problem is and what the child hopes the treatment will achieve.¹

If the child is experiencing daytime problems assess the pattern of daytime symptoms including whether symptoms occur only in some situations, if the child avoids toilets at school or other settings and if the child goes to the toilet more or less frequently than their peers.¹

If the child has been previously dry for more than six months and has then started wetting the bed ask when the wetting started, aim to determine if it could be related to a systemic illness such as a urinary tract infection or a change in circumstance such as bullying or abuse. Consider performing urinalysis if the bedwetting started in the past few weeks, the child has signs of ill health or there is a history, signs or symptoms of urinary tract infections or diabetes.¹

Assess for any underlying cause such as constipation, diabetes, urinary tract infection, behavioural, emotional or family problems or child maltreatment. Child maltreatment should be considered if the child is reported to be deliberately bedwetting, the parents or carers are seen or reported to punish the child for bedwetting despite professional advice that the bedwetting is involuntary, and if the wetting continues despite adequate assessment and management, without an underlying medical explanation or difficult circumstance such as bereavement or parental separation.⁵

Managing bedwetting

Explain to the child and their parents or carers that bedwetting is not the child’s fault and the child should not be punished. Explain that bedwetting occurs because the volume of urine produced at night exceeds the capacity of the bladder to hold it and the sensation of a full bladder does not wake the child. 

Reassure the child and their parents or carers that almost all children (99%) become dry given time even without treatment and that bedwetting resolves as children get older because they develop an increased bladder capacity, and/or produce less urine at night or learn to wake to the sensation of a full bladder.¹

Advise that during the day the child should use the toilet to pass urine at regular intervals and before sleep (between four and seven times in total). Caffeine-based drinks should be avoided before going to bed. A healthy diet should be encouraged. There should be easy access to a toilet. Waterproof mattress and duvet cover, absorbent quilted sheets, and bed pads can be helpful. 

Parents and carers should take a neutral attitude to bedwetting and minimise the child’s embarrassment. Older children may prefer to change their bedding themselves during the night to avoid household disruption and embarrassment.¹

Lifting or waking the child during the night (at regular times or randomly) does not promote long-term dryness. Waking may be useful as a practical measure in the short-term only. Self-instigated waking may be useful for young people with bedwetting who have not responded to treatment.¹

Positive reward systems may be offered to children who have some dry nights and to children using an enuresis alarm. Advise that rewards may be given for drinking recommended levels of fluid during the day, using the toilet before going to bed, engaging in management eg. taking medication or helping to change sheets. Do not recommend systems that penalise the child or remove previously gained rewards.¹

Bedwetting alarms can be used for children who wet the bed frequently. Alarms are usually recommended for children aged over seven years, but is dependent on the individual child’s level of maturity. Bedwetting alarms sense wetness using sensors which are placed either in the child’s bed or underpants and wake the child when they begin to urinate. The eventual aim is for the child to wake before the alarm goes off. Alarms can take months to have an effect and do not work for all children.¹

Where a rapid onset or short-term improvement is required, ie. for sleepovers or school trips, desmopressin can be prescribed. Desmopressin is taken at bedtime and reduces the amount of urine the body produces at night. 

Many children, but not all, will experience a reduction in wetness. It is important to advise that fluid intake is restricted to sips only from one hour before taking desmopressin until eight hours afterwards – a total of one regular glass of water may be drunk in this time. 

Fluid restriction is required to prevent fluid overload and hyponatraemia, which can lead to convulsions. The use of NSAIDs such as ibuprofen should also be avoided as they can also cause fluid overload.¹

 Information on sources of support should be given to parents including website www.drydawn.ie

References

1. National Clinical Guideline Centre. Nocturnal enuresis: the management of bedwetting in children and young people. Published 2010. Available from: https://www.nice.org.uk/guidance/CG111 [Accessed March 1, 2017]. 
2. Caldwell P, Nankivell G, and Sureshkumar P. Simple behavioural interventions for nocturnal enuresis in children (Cochrane Review). Published 2013. Available from: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD003637.pub3/pdf [Accessed March 1, 2017]. 
3. European Association of Urology and European Society for Paediatric Urology. Guidelines on paediatric urology. Published 2013. Available from: https://uroweb.org/wp-content/uploads/22-Paediatric-Urology_LR.pdf [Accessed March 1, 2017].
4. American Psychiatric Association. Diagnostic and statistical manual of mental disorders: DSM-5. Published 2013. 
5. NICE. Child maltreatment: when to suspect maltreatment in under 18s. Published 2009. Available from: https://www.nice.org.uk/guidance/cg89. [Accessed March 1, 2017]