Nocturnal Enuresis (Bedwetting): A Guide For Parents

Understanding Enuresis  

Enuresis (also called nocturnal enuresis, nighttime incontinence, bed-wetting, or enuresis) is an involuntary or accidental release of urine while asleep. 

It is a common condition in young children who are still developing bladder control. Nocturnal enuresis (bedwetting) is not a failure of toilet training but a normal part of the child’s development. It is not a serious condition, and most children outgrow bed-wetting around 4 to 6 years of age. However, enuresis can sometimes affect older kids, teenagers, and adults with an underlying medical condition. 

By definition, enuresis is when anyone over the age of 7 wets the bed at least twice per week for at least three months in a row.

Primary Enuresis vs Secondary Enuresis

Primary nocturnal enuresis refers to bedwetting in a child who has not been dry for at least 6 months. Secondary enuresis refers to bedwetting that occurs after a period of nocturnal dryness lasting at least 6 months (meaning, it occurs 6 months to years after someone has learned to control their bladder at night).  

Difference Between Incontinence and Enuresis

Continence is the ability to hold urine in the bladder until it is socially appropriate to void (pass urine). Urinary incontinence is the loss of this ability. Nocturnal enuresis is a type of urinary incontinence. It is called nighttime incontinence and refers to a loss of bladder control during sleep. 

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What Are The Causes of Enuresis?  

Why Children Have Enuresis

Small children may wet the bed at night because they have a small bladder that is still developing. In other words, the child's bladder capacity may not be enough to hold all the urine the body makes at night. 

In addition, a child’s bedwetting may be due to the nerves responsible for bladder control not being fully mature. As a result, the child, especially if they are a heavy sleeper, may not have awareness of a full bladder and may not wake up from sleep when their bladder is full.

Possible Causes of Enuresis: Medical and Psychological

As noted, most children overcome bedwetting by age 7. However, some older children, teens, and adults can have problems with nighttime bladder control. Wetting the bed at night in children, teens, and adults may be due to an underlying condition such as:

• Diabetes insipidus: Antidiuretic hormone (ADH), also called vasopressin, is a hormone that regulates fluid and salt in the body. Some people do not make enough ADH or their kidneys do not respond to ADH. Lack of ADH is called diabetes insipidus (water diabetes). It can cause symptoms such as excessive thirst and excessive urination, which can lead to loss of nighttime control of the bladder in some children and adults.

• Diabetes mellitus: In children who do not usually wet the bed, enuresis or bed-wetting can be the first sign of diabetes mellitus type 2 (high blood sugar). Other symptoms of diabetes type 2 may include polyuria (passing large amounts of urine), polydipsia (excessive thirst), tiredness, and weight loss.

• Urinary tract infections (UTIs):  A UTI can cause symptoms such as pain with urination, frequency, and urgency (difficulty controlling the urge to urinate). This can lead to daytime accidents and bed-wetting.

• Overactive bladder (OAB): OAB is a condition in which the bladder contracts involuntarily, leading to frequency, urgency, nocturia, or nocturnal polyuria (waking up at night to urinate). This can sometimes result in bedwetting or enuresis.

• Urinary tract abnormalities: A narrowing or blockage in the urinary tract, for example, from bladder or kidney stones, can cause enuresis. Rarely, structural abnormalities in the urinary tract (for example, an ectopic ureter) or nerve problems can lead to bed-wetting.  

• Benign prostatic hyperplasia (BPH): Some men with BPH (an enlarged prostate gland) develop urinary incontinence and adult bedwetting. 

• Constipation: Hard and dry stools in people with chronic constipation can affect the muscles involved in bladder and bowel control. This can lead to bed-wetting problems. 

• Obstructive sleep apnea (OSA): Bed-wetting can be a sign of OSA, a condition in which there is sleep-disordered breathing. Swollen or irritated tonsils can cause sleep apnea in children. In older people, narrowing of the upper airway due to obesity can cause this problem. Other symptoms of OSA include loud snoring. 

• Neurological disorders: Neurogenic bladder refers to brain, spinal cord, or nervous system problems that cause trouble with controlling the bladder. It can be the result of neurological diseases such as stroke, Parkinson’s disease, multiple sclerosis, spinal cord injury, spina bifida, and hydrocephalus (fluid accumulation in the brain).

• Medication side effects: Many medications can cause urinary incontinence or enuresis by increasing urine production, relaxing the bladder muscle, or causing drowsiness. Examples include:

  • Diuretics (water pills) such as furosemide (Lasix), hydrochlorothiazide (Microzide, Oretic), triamterene with hydrochlorothiazide (Maxzide), and bumetanide (Bumex). 

  • Sedatives and anti-anxiety medications such as diazepam (Valium), lorazepam (Ativan), and chlordiazepoxide (Librium).

  • Opioid narcotics such as oxycodone (Percocet), morphine, and meperidine (Demerol).

  • Antihistamines such as chlorpheniramine (Chlor-Trimeton) and diphenhydramine (Benadryl).

  • Alpha adrenergic antagonists such as doxazosin (Cardura) and terazosin (Hytrin).

Risk Factors for Nocturnal Enuresis

For unclear reasons, enuresis (bed-wetting) is twice as common in boys compared to girls. Other risk factors for nocturnal enuresis include:

• Stress and anxiety: Periods of stress can trigger bed-wetting in some children. For example, moving to a new neighborhood, starting at a new school, getting a new sibling, dealing with bullies, or family issues like divorce. 

• Family history: Children whose parents were bed-wetters are more likely to wet the bed themselves. This is also true if other children in the family wet the bed when they were younger.

• Attention-deficit/hyperactivity disorder (ADHD): Children with ADHD are more likely to be bed-wetters than those without ADHD. 

Nocturnal Enuresis Symptoms  

Damp, soggy, or wet sheets and pajamas are the most common sign of nocturnal enuresis or bed-wetting. Additionally, when a child wets the bed, especially an older or school-age child, there can be embarrassment. An embarrassed child may attempt to hide wet sheets, not want to talk about it, or worry about it. Bed-wetting is a treatable condition and should be evaluated by a healthcare provider if it continues beyond age 7.

Diagnostic Criteria and Tests

There is no target age to complete bladder training. Most kids no longer wet the bed by age 5. Some children continue to wet the bed between ages 5 and 7. Only a small number of children wet the bed after age 7.

The diagnostic criteria for nocturnal enuresis (bed-wetting) is when children wet the bed after age 7 at least two times per week for a minimum of three months in a row.

Your child’s doctor can make a diagnosis of nocturnal enuresis (bed-wetting) based on their symptoms. They will also obtain a complete medical history and family history and perform a physical exam. 

Diagnostic tests may be necessary in some cases to find out the underlying cause of bed-wetting in older children. These may include: 

• Urine tests such as urinalysis and urine culture and sensitivity to look for signs of a urinary tract infection or diabetes.

• Imaging tests to check for structural abnormalities in the urinary tract.

Treatment and Management for Bed Wetting

Behavioral and Lifestyle Changes for Bladder Control

Here are some tips to reduce incidents of enuresis (bed-wetting) and prevent skin rashes due to bed-wetting: 

• Limit fluid intake in the evenings. But remember, it’s important to stay well hydrated, so have your child drink water and other fluids during the daytime. Also, if your child is participating in sporting activities in the evening hours, don’t limit fluids on those days. 

• Avoid caffeine. Caffeine is a bladder irritant and is not recommended for children under 12 years of age. Keep in mind that many diet colas and energy drinks contain caffeine. 

• Encourage double voiding before bedtime. Ask your child to pass urine when they start their bedtime routine and again just before they fall asleep. Place a small night light in the room and remind your child to use the toilet at night when tucking them in. 

• Urge regular bathroom visits: Remind your child to urinate throughout the day, ideally every 2-3 hours. 

• Use positive reinforcement: An older child or teenager may benefit from positive thoughts, such as imaging they stay dry at night.

• Keep the genital area dry to prevent rashes: Wet underwear can cause skin rashes. Make sure your child changes out of wet clothing in the morning. Rinse and dry the genital area. Use a protective cream or ointment before bedtime (petroleum jelly or a medicated cream recommended by your child’s doctor) on the areas of skin exposed to urine.

Alternative Therapies for Bedwetting

Complementary or alternative medicine approaches for treating bedwetting include hypnosis, chiropractic therapy, acupuncture, and herbal treatments. However, there is no scientific proof that these methods are effective.

Medical Treatments and Interventions  

Most children outgrow bed-wetting without needing any treatment. If your child has occasional bed-wetting and is not particularly embarrassed by it, it can probably be managed with lifestyle changes (see above). It is important, however, to see your child’s doctor for an evaluation so that they can rule out an underlying cause or medical problem such as enlarged tonsils, constipation, or diabetes.

If lifestyle changes do not help or your child continues wetting the bed frequently or is upset or worried by it, it may be necessary to treat bedwetting with moisture alarms and/or medications. Treatment options for bed-wetting include:

Moisture Alarms for Bedwetting

A moisture alarm is a small, battery-operated device that can be purchased over the counter at drug stores. It consists of a moisture-sensitive pad that is placed on your child’s bedding or pajamas. An alarm goes off when the pad becomes wet. The idea is that the alarm will wake the child up as soon as they start leaking urine, so that the child urinates in the toilet. However, in children who are deep sleepers, another person may need to wake them up when the alarm sounds.

It can take 1 to 3 months for bedwetting alarms to start being effective. On average, children need to use a bedwetting alarm for 4 months before they have dry nights without the alarm. Moisture alarm therapy is an effective method of treating bed-wetting in many children and does not carry the risk of medication side effects. 

More information is available from the International Children’s Continence Society (ICCS).

Medications for Bedwetting

Your child’s doctor may prescribe a medication if lifestyle changes do not prevent bedwetting. Options include:

• Desmopressin (DDAVP): This medicine slows urine production at night. It comes in the form of an oral tablet and is approved for use in children 6 years of age and older. The nasal spray is not recommended for the treatment of bedwetting due to potentially serious side effects. Desmopressin (DDAVP) can cause problems if your child drinks too much liquid. Also, this drug should not be used if your child has fever, nausea, or diarrhea. Get your free desmopressin coupon.

• Oxybutynin (Ditropan XL): This medicine is an anticholinergic drug and can be used to treat bedwetting in children with a small bladder. It reduces bladder contractions and increases bladder capacity. Oxybutynin (Ditropan XL) is especially useful in children who have daytime wetting (incontinence or accidents in the daytime) in addition to enuresis (bedwetting). Doctors usually prescribe this medicine if other treatments don’t help. Save at the pharmacy with your free oxybutynin coupon.

Some children need to take more than one medicine to control bedwetting. Stopping treatment may also cause the bedwetting episodes to return. Your child may need to continue medication until bedwetting ends on its own—the age at which this happens can be different in every child. 

Managing Enuresis in Older Children and Teens

If an older child or teenager’s doctor (pediatric urology specialist) has ruled out an underlying medical condition as the cause of enuresis (bedwetting), then the above-listed lifestyle changes, moisture alarms, and medicines can help. 

Supporting Children and Families  

Emotional and Psychological Support  

While younger children may not feel embarrassed by bedwetting, it can affect a person’s mental health and self-esteem when they are older. That’s why it’s important to proactively treat nighttime wetting in the teen years. Psychological support, mental health care, treatment of any underlying medical problem, lifestyle changes, and medications can stop bedwetting in older kids and adolescents.

Emotional problems and traumatic events can cause older kids and teenagers to start wetting at night, long after they are toilet trained. It’s important to seek care from a mental health professional if this is the case. 

Some of the things to avoid doing if an older kid or teenager has bedwetting problems include:

• Do not scold the child. Bed-wetting is not the result of laziness. Yelling or reprimanding the child can further hurt their self-esteem and confidence. 

• Do not embarrass the child by discussing their wetting the bed with others.

• Do not compare the child to other children in the family.

• Do not withhold liquids in the daytime. Children need to stay well hydrated for good physical and mental health. 

• Do not expect instant results when you take steps to stop bedwetting. 

Effective Communication With Your Child’s Doctor

It will help to bring the following information to the appointment with your child’s doctor when seeking treatment to prevent bedwetting:

• How much fluid your child drinks every day, especially in the evening hours

• Bladder and bowel habits

• Recent stressors

• Family history of bedwetting

• List of current medications

Frequently Asked Questions  

Can Bedwetting Affect Teenagers?

While bedwetting is uncommon in children above age 7, it can sometimes affect older children and teenagers. If an older kid starts bedwetting after being dry at night for more than 6 months, it’s important to see the child’s doctor to find out if there is an underlying medical problem.

What is Adult Enuresis?  

Adult enuresis is wetting the bed at night (involuntary release of urine during sleep) in an adult. It is a type of secondary enuresis that starts after a person has been dry at night for years. There is usually an underlying medical problem that causes adult enuresis. 

How Did Soldiers Get Enuresis?

Studies have shown that soldiers, especially men above 55 years of age, are up to three times more likely to develop urinary incontinence and enuresis, compared to men without military exposure. Possible reasons for this include underlying medical problems and psychological issues such as post-traumatic stress disorder (PTSD) related to deployment in war zones.