Bedwetting (Nocturnal Enuresis)
Bedwetting (Nocturnal Enuresis) Information
There are differing definitions between the World Health Organization and the American Academy of Pediatrics regarding nighttime bedwetting. Generally, nighttime bedwetting occurs when children over the age of 5 or 6 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 into adulthood. It is projected that those with 5 or more wetting episodes per week have only a 50% chance of bedwetting in adulthood. (5)
Causes of Nighttime Bedwetting
Nighttime bedwetting 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 disorder has been researched for more than 40 years, the etiology has yet to be clearly defined for the most common cause of nighttime bedwetting incidents. It is thought to be a problem that consists of several issues interplaying. The issues are generally thought to be 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. (2) The reason(s) this is occurring is still unknown but scientists have uncovered that children with nighttime bladder urination problems generally are more difficult to arouse (or wake up), 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 bedwetting can occur in any stage of the sleep cycle. However, bedwetting children 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 bedwetting can be linked to:
Emotional or physical trauma
Medication Side Effects
Rare Disorders (Ehlers-Danlos, Scoliosis, Sleep apnea, etc)
Interruption of Normal Routines
Structural disorders with the lower urinary tract (bladder and/or ureters)
Fears (of the dark, parental disapproval, etc)
How is Bedwetting 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.
Medication Treatment Approach to Bedwetting
Treatment for nighttime bedwetting symptoms may involve medications. Typically, the first part of evaluation and treatment is used to eliminate other causes of nighttime bedwetting and work to provide increased capacity to the bladder as well as increased bladder-brain signaling. Medications, such as desmopressin, can help reduce or eliminate nighttime bedwetting but the incidence of recurrence once the medication is withdrawn is high. (3)
Unfortunately, the failure rate of medications such as desmopressin can be upwards of 60%. (4) 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 primary 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 with clear evidence-based improvement in the condition and the method that is considered as a first-line treatment for bedwetting incidents is an alarm. This is because desmopressin and nighttime bedwetting alarms have similar success rates but following protocol is higher for alarms. (1) Even with higher adherence rates, bedwetting 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, but even more so, alarms fail to treat all of the factors relating to nighttime wetting.
In order to achieve higher resolution rates, all the factors revolving around the bedwetting must be addressed. Other therapies and approaches to nighttime bedwetting center around the current issues causing the bedwetting, which consist of: 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 alone.