Enuresis (Bed Wetting or Urinary Incontinence)

What is Enuresis (Bed Wetting or Urinary Incontinence)?

Enuresis, or bedwetting, is considered a disorder related to bodily waste elimination. It’s often diagnosed in children who wet the bed or have difficulty controlling their urine. This disorder is quite common and is often seen in children’s clinics or clinics that specialize in urinary issues.

What Causes Enuresis (Bed Wetting or Urinary Incontinence)?

Bedwetting, or enuresis, often doesn’t have a clear reason behind why it occurs. In children, bedwetting can be associated with constipation or problems with their brain development. Other potential causes for bedwetting include heavy sleep causing difficulty in waking up to go to the bathroom, slow development of bladder control, small bladder size, and a decrease in a hormone called vasopressin that helps to control urine production. There are also some medical conditions or medicines that have been linked to bedwetting.

Certain factors can increase the likelihood of bedwetting, such as high levels of stress, a low income family, parents splitting up, a new baby brother or sister, and if family members have had problems with bedwetting too. It’s interesting to note that if one parent used to wet the bed, their child has a 44% chance of also wetting the bed, and if both parents used to wet the bed, that chance increases to 77%. But, no specific gene has been found that directly causes bedwetting. Researchers have found some potential links to genes on chromosomes 8, 12, 13, and 16.

Lastly, constipation can also lead to bedwetting. This happens because the build-up of stool can put pressure on the bladder.

Risk Factors and Frequency for Enuresis (Bed Wetting or Urinary Incontinence)

Enuresis, commonly known as bedwetting, is quite common among children. Around 20% of 5-year-old children experience bedwetting. It’s most often diagnosed when the child is around 7 years old. For this age group, the number of children wetting the bed is about 5% to 10%. In adults, however, this number goes down to roughly 2%. Boys are more likely to experience enuresis than girls.

• About 20% of 5-year-olds experience bedwetting.
• The condition is most commonly diagnosed in children who are around 7 years old.
• Between 5% and 10% of 7-year-olds wet their bed.
• Approximately 2% of adults still have episodes of bedwetting.
• Bedwetting is more common in boys than girls.

Signs and Symptoms of Enuresis (Bed Wetting or Urinary Incontinence)

The Diagnostic and Statistical Manual of Mental Disorders (5th edition, DSM-5) lists enuresis—or bedwetting—as an elimination disorder. Here are the criteria that doctors use to diagnose this condition:

• The individual frequently wets the bed or clothes, whether intentionally or unintentionally.
• The issue is clinically significant, which means either:
  • This happens at least twice a week for a consistent period of three months
  • Significant distress is experienced
  • There’s a considerable impact on academic, social, or other aspects of their daily functioning
• The person is at least 5 years old or at an equivalent developmental level.
• The issue is not due to a medical condition like seizure disorders, diabetes, or urinary tract infection, or substances like diuretics or antipsychotics.

Enuresis can be classified into different types:

• Nocturnal-only: The individual only wets the bed at night during sleep.
• Diurnal-only: The person only has accidents during waking hours, also called “urinary incontinence.” This can be further divided into:
  • Urge incontinence: The person urinates frequently due to an increased urge to do so.
  • Stress incontinence: The individual experiences incontinence during instances of increased abdominal pressure (like while laughing or sneezing).
  • Voiding postponement: Delay in urination in certain situations, like in public places.
  • Giggling incontinence: Accidents occur during laughter.
• Nocturnal and diurnal: The person experiences bedwetting both during sleep and waking hours.

There’s also ‘primary enuresis’ where a person has never achieved continence, and ‘secondary enuresis’ where a person had control but then lost it.

Medical professionals need to know more than just the standard medical, surgical, and family histories. They also need to understand the person’s toilet training, nutrition, and sleep habits. It’s crucial to ask about any family history of enuresis and ask questions that rule out other conditions like urinary tract infections, constipation, seizures, diabetes, or sleep apnea.

Keeping a log of when and how much the individual urinates can help assess the situation. The log should include the volume of urine, the number of wet nights or days, fluid intake, the urge to urinate, and bed and wake times. This should ideally be recorded for at least three consecutive days.

A physical exam can also provide valuable information. This might involve checking vital signs, doing a neurologic exam, and examining the tonsils, suprapubic area, abdomen, genitalia, and lower spine.

Testing for Enuresis (Bed Wetting or Urinary Incontinence)

For suspected urinary tract infections, a urine test is often needed. If an anatomical issue is believed to be the cause, a bladder scan, a test to measure the flow of urine (uroflowmetry), or an ultrasound after urination might be necessary. If the ultrasound shows anything unusual, further tests such as a voiding cystourethrogram (a specialized X-ray of the urinary tract), a cystoscopy (a procedure to see inside the bladder and urethra), or urodynamic studies (tests to measure how well the bladder, sphincters, and urethra are storing and releasing urine) may be considered.

If a sleep disorder is suspected, a sleep study is recommended. For those experiencing difficulty waking up from sleep, it’s important to investigate if obstructive sleep apnea (a sleep disorder causing breathing to repeatedly stop and start during sleep) could be the cause. The Epworth Sleepiness Scale, a questionnaire to measure daytime sleepiness, should be completed before ordering a sleep study.

For patients taking the medication imipramine, it’s recommended to measure the drug’s level in the blood to ensure it doesn’t reach a dangerous level and is working effectively. The effective drug level (therapeutic index) for imipramine should be higher than 60 ng/ml.

In cases where seizures are a concern, an MRI of the brain and an electroencephalogram (a test to detect abnormalities related to electrical activity of the brain) may be performed.

If constipation may be the problem, an abdominal X-ray would be helpful.

Treatment Options for Enuresis (Bed Wetting or Urinary Incontinence)

Treatment for childhood bedwetting often starts after the age of 7, as many children naturally grow out of this phase.

Non-Medication Treatment

The first step in managing bedwetting involves reassuring parents that this is a common issue and most children will gradually stop wetting the bed. Some parents prefer waiting and observing before starting any treatment.

A positive first step in the treatment of bedwetting is the bell and pad method, which is an alarm that rings when a child starts to wet the bed. This method has shown a 75% success rate and it’s recommended to keep using it until the child has between 21 to 28 dry nights. However, for this method to work, the child must be able to wake up when the alarm goes off. For some children, waking them up at set times during the night might be beneficial. Another helpful approach can be limiting the amount of fluids a child drinks before bedtime.

Bladder training can also be beneficial. This approach involves your child trying to hold their need to urinate for increasingly longer periods of time. This method is especially useful for children who urinate both during the day and night. Before these behavior changes can be introduced, it’s important that both the caregiver and child are motivated to participate in the treatment process. If not, motivational therapy might be required or the treatment can be delayed until the child is more willing.

Medication Treatment

While medications can be used as a treatment option for bedwetting, it’s important to note that they have a higher chance of relapse compared to the bell and pad method. But firstly, it’s crucial to treat any underlying problems, such as constipation, that might be exacerbating the bedwetting situation.

Desmopressin, an artificial form of a hormone that reduces urine production, has shown beneficial results. Studies reveal that about half of the children on this medication show improvement, with 1 in 4 children reaching a state of complete dryness. However, upon discontinuing this medication, there is a risk of bedwetting returning, so a gradual reduction of the medicine is recommended.

Imipramine is another medication often used for bedwetting. This medicine works by relaxing the bladder muscles, reducing their contractions, and therefore helping decrease bedwetting. This medication is typically prescribed in increasing doses until an effect is seen, after which doctors recommend periodically decreasing the dose. Some children might experience side effects like dry mouth.

There are also several other medications that aren’t officially approved for treating bedwetting, but still get used off-label, such as oxybutynin, clonidine, propranolol, and other tricyclic antidepressants.

Interestingly, some children start to improve even before starting the medication treatment, simply by engaging with medical professionals and understanding that there are strategies to manage bedwetting.

What else can Enuresis (Bed Wetting or Urinary Incontinence) be?

Before doctors can diagnose a child with enuresis, or bedwetting, they need to check for several other potential causes and conditions that could be at play:

Let’s start with the child’s development. Children typically start to stay dry during the day at about 2 years old, and at night when they’re around 3. By the age of 4, most can use the toilet by themselves. However, some children still wet the bed at age 5. Since these are normal stages of development, doctors won’t diagnose enuresis in a child under 5 years old.

There are also some medical conditions that can cause a child to wet the bed. These can include:

• Urinary tract infection (UTI)
• Diabetes (both insulin-dependent and water diabetes)
• Inflammation of the urethra
• Seize disorders
• Sickle cell disease
• Sleep apnea
• Problems with bladder nerve control (Neurogenic bladder)
• Birth defects of the spine (Spina bifida)
• Sleep disorders
• Birth defects of the urinary tract
• Overactive thyroid (Hyperthyroidism)
• Constipation
• Central hormone abnormality
• Delayed bladder maturation
• Decreased bladder capacity
• Neurodevelopmental disorders

It’s especially important to check for seizures, as they can cause bedwetting during an episode.

Some medications can also cause bedwetting, including selective serotonin reuptake inhibitors (SSRIs), bupropion, water pills (diuretics), and some antipsychotics like risperidone.

There are also other conditions, or comorbidities, that can be related to enuresis. These include Attention deficit hyperactivity disorder (ADHD), neurodevelopmental disorders, and some psychiatric conditions, usually with secondary, rather than a primary form of bedwetting.

What to expect with Enuresis (Bed Wetting or Urinary Incontinence)

Remission, or the reduction or disappearance of symptoms, is more common in younger children and girls as compared to older children or boys. However, people with certain factors may face a poorer outlook. These include having another mental health condition, difficulties with language, family stress, a smaller bladder, testicular disorders, or being a heavy sleeper.

Possible Complications When Diagnosed with Enuresis (Bed Wetting or Urinary Incontinence)

Kids who wet the bed usually feel a lot of stress, embarrassment, and shame. They might also get infections or rashes in their genital or urinary tract area from the wetness. Buying diapers, pull-ups, or replacing stained bedsheets and mattresses can also cost a lot of money. In some situations, bedwetting can continue into the teenage years and even into adulthood.

Common Issues:

• Stress, embarrassment, and shame
• Infections or rashes in the genital or urinary area
• The cost of diapers, pull-ups, and replacing stained bedding or mattresses
• Bedwetting continuing into adolescence and adulthood

Preventing Enuresis (Bed Wetting or Urinary Incontinence)

If patients and their families have any questions, they should ask their healthcare team. This team can help them understand the most likely cause of the bed-wetting (enuresis). They will explain the benefits and risks of different treatment options, as well as other alternatives.

Parents should understand that bed-wetting is common, not done on purpose, and usually gets better over time. It’s important to know that children can feel stress and experience low self-esteem if they’re punished or feel ashamed due to bed-wetting. Therefore, parents should avoid blaming their children for it. To help manage the situation, parents can reduce the amount of liquids their child drinks in the evening. It’s also beneficial to encourage children to use the bathroom frequently during the day and before they go to sleep.