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When is Bedwetting a Problem?

Bedwetting in Kids

There are differing definitions between the World Health Organization and the American Academy of Pediatrics regarding children who wet the bed at night. Generally, nighttime bedwetting occurs when children over 5 or 6 years of age wet the bed while sleeping at night. This problem occurs for at least several nights and lasts for longer than 1 month. It is more frequently seen in boys than girls and generally decreases with age. (1) Even so, nighttime bedwetting is one of the most common problems in the pediatric population. The problem can persist with older children and into adulthood. It is projected that those with 5 or more wetting episodes per week have only a 50% chance of not bedwetting in adulthood. (5)

child in bed next to a teddy bear

Causes of Nighttime Pediatric Bedwetting

Children who wet the bed at night can be divided into two categories. Overall, the most common cause of nighttime bedwetting (80%) occurs without any known lower urinary tract structural problems or daytime wetting accidents. (2) While this problem has been researched for more than 40 years, the cause is not yet fully understood. It is thought to be a problem that consists of several problems. The issues are generally thought to be small bladders, excessive nighttime urine production, and a bladder that is more active than it should be at night. Other problems are thought to be bladder training problems and not awakening to bladder signals that it is time to urinate. (2) Scientists have found out that children with nighttime wetting problems are more difficult to wake up when family members try to wake them at night. They also have lower than normal periods of motionless sleep, take longer to fall asleep at night, and that children with nighttime bladder urination problems generally have more fragmented sleep than children without the disorder. (1) Interestingly, bedwetting children have similar sleep architecture as children without bedwetting and that it can occur in any stage of the sleep cycle. However, children who wet the bed are more difficult to arouse than non-bedwetting children. (2) These sleep issues can lead to daytime tiredness, depression, low self-esteem, and attention/focus problems.

Other less common causes of nighttime pediatric wetting can be linked to:

  • Emotional or physical trauma

  • Diabetes Mellitus

  • Recent illness

  • Medication Side Effects

  • Rare Disorders (Ehlers-Danlos, Scoliosis, Sleep apnea, etc)

  • Interruption of Normal Routines

  • Constipation

  • Hormone Problems 

  • Structural disorders with the lower urinary tract (bladder and/or ureters)

  • Fears (of the dark, parental disapproval, etc)

How is It Diagnosed?

The diagnosis of nocturnal enuresis or nighttime bedwetting is a parent-led diagnosis. There is no specific test or imaging that can diagnose the disorder. The symptoms of nighttime bedwetting are fairly straightforward with the child needing to have several incidents of unintentional wetting at night. It cannot be better explained with another mental health or medical condition. Medications, constipation, trauma, and other medical conditions may cause similar symptoms and must also be ruled out for proper diagnosis of this disorder.

family with the doctor

Medicine Used to Treat Bedwetting

Treatment options for nighttime symptoms may involve medication management. Typically, the plan with bedwetting problems is to eliminate other causes of nighttime urination. Next, expert providers work with the family to increase the size of the relatively small bladder as well as increase bladder-brain signaling. Medications, such as desmopressin, can help reduce or eliminate nighttime bedwetting. The big problem with desmopressin is that the problem typically comes back once the medication is stopped. (3)

Unfortunately, the failure rate of medications such as desmopressin can be upwards of 60%. (4) This means that it does not provide long term relief of the problem. Other medications can be initiated with desmopressin treatment failures but do carry increased risks of side-effects compared to the relatively safe and low side effects of desmopressin.

Non-medication Approaches to Bedwetting Treatment

As stated above, the treatment medication of choice for nighttime bedwetting is desmopressin. However, with its potentially high failure rates and high incidence of bedwetting recurrence when medication is withdrawn, desmopressin is not considered the first-line therapy for nighttime bedwetting. (1) The treatment method that is considered as a first-line treatment for bedwetting incidents is a bedwetting pad or alarm. The reason bedwetting alarms are preferred is because desmopressin and nighttime wetting alarms have similar success rates. However, families typically have an easier time using alarms. (1) Even with higher adherence rates, alarms will only translate to an approximate 50% remittance of nighttime bedwetting at six (6) months. This is because the alarm is not always successful in the attempts to treat the brain-bladder signaling issue. More importantly, alarms fail to treat all of the factors relating to nighttime wetting.

Smiling little boy who is outside

How Do I Stop Bedwetting?

In order to achieve the highest resolution rates, all the factors with bedwetting must be addressed. Toilet training, reducing the amount of fluid intake discussions, monitoring bowel movements and sleep cycles, and nutrition status are important factors to go over with your child's provider. The most important issue to address, however, is the how the brain responds to bladder signaling at night. Our providers focus on how to get the brain to recognize the signal better. In addition, our experts will address excessive nighttime urine production, a bladder that is more active than it should be at night, and not awakening to bladder signals that it is time to urinate. Improvements in these measures will lead to much higher success rates than alarms or medication alone. 

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