What is Nocturnal Enuresis?
Enuresis is a condition where a child older than 5 years involuntarily wets the bed at least two times a week for three months or more. It is the most common complaint relating to urinary problems in children. Enuresis can be primary or secondary. Primary enuresis happens when the child hasn’t been able to stay dry during the night for at least six months. Secondary enuresis starts after the child has managed to stay dry at night for at least six months.
Apart from this, enuresis may be clustered as monosymptomatic, which means it’s the only symptom, or non-monosymptomatic, which means it’s associated with other urinary symptoms such as urgency or daytime incontinence.
To be clear, the International Children’s Continence Society defines enuresis as a condition where wetting happens at night. They no longer use the term ‘diurnal enuresis’ for daytime incontinence.
Bedwetting at night, or nocturnal enuresis, is not a harmless condition. It can negatively impact the child and their family. Often, children are unfairly punished for this, which puts them at risk of physical and emotional harm. Many children with this condition may feel isolated, suffer from low self-esteem, and may struggle with their schoolwork. Understanding this common yet often misunderstood condition is crucial.
What Causes Nocturnal Enuresis?
Enuresis, or bedwetting, is thought to be caused by a mix of factors. It appears to have a strong genetic link, meaning it often runs in families. It may also be affected by related health issues and by the level of development of certain parts of the brain that control the bladder.
While specific genes related to bedwetting have not been identified yet, research suggests that it is most likely passed down through families by a rule of inheritance known as “autosomal dominant.” This means that if a parent has the condition, their child has a 90% chance of also having it. For example, studies have found that if one parent had experiences with bedwetting as a child, their children have about a 44% chance of also going through bedwetting. This chance goes up to 77% if both parents had experiences with bedwetting.
Previously, mental health or emotional factors were thought to be the main causes of bedwetting. Now, experts believe these factors are not the root cause but may occur because of the stress and discomfort bedwetting can cause.
Bedwetting can also be associated with various other conditions, including:
- Constipation
- A blockage in the urethra, the tube through which urine leaves the body
- An ectopic ureter, where a tube from the kidney to the bladder is not in the normal position
- Cystitis, an inflammation of the bladder
- Diabetes insipidus, a rare condition that can cause excessive thirst and urination
- Sleep arousal disorders, which might interrupt normal toilet routines during sleep
- A small bladder that can’t hold as much urine
- An overactive bladder, which can lead to frequent or sudden urges to urinate
Risk Factors and Frequency for Nocturnal Enuresis
Enuresis, or bedwetting, is a condition that affects people of all ages and cultures, although the number of people it affects changes with age and gender. For example, 15% of 7-year-olds, 10% of 10-year-olds, 2% of teenagers and 0.5 to 1% of adults have the condition. It’s more common in boys up to the age of 10, with three times more boys than girls affected. From age 10 onwards, boys and girls are affected more equally.
Also, 20 to 30% of people with enuresis have a psychological, behavioral, or psychiatric disorder. This rate is double the rate in the general population. The most frequent disorder seen in these patients is attention deficit and hyperactivity disorder. It’s thought that a common sleep problem might connect these two conditions. People with this combination of conditions might also have autism, oppositional defiant disorder, or mood disorders.
There’s also evidence that there is link between breathing problems during sleep and enuresis. People with this collection of symptoms have higher levels of a specific body chemical which leads to increased urination. Other suggested causes of enuresis in these patients include an ineffective response to the need to wake up due to broken sleep from breathing problems, and bladder stimulation as a result of increased effort to breathe to compensate for a blocked airway. When these patients have their tonsils and adenoids removed, they often stop wetting the bed completely, or do so a lot less often.
People with sickle cell disease also have a higher chance of having enuresis.
Signs and Symptoms of Nocturnal Enuresis
Nocturnal enuresis, also known as night-time bedwetting, is identified through a careful review of the patient’s history and a thorough physical examination. Initially, the doctor has to determine if the bedwetting is a new issue or has been ongoing. They will look for patterns, such as the number of incidents per night and per week, and ask about factors like caffeine and nightly fluid consumption. Questions are also asked about significant urine production at night, excessive thirst, pain when urinating, urgency and frequent need to urinate, day-time bedwetting, abnormal urine flow, and constipation.
In cases where a child urinates in small amounts frequently throughout the night, it could indicate an overactive bladder or small bladder. The doctor will also enquire about a family history of enuresis, recurring urinary tract infections (which could suggest underlying bowel or bladder issues), sleep issues, snoring, or sleep-disordered breathing. They will also ask about the use of long-term medications since certain drugs can cause secondary enuresis. It’s equally crucial to screen for psychological or behavioral problems, including attention deficit and hyperactivity disorder, learning disabilities, and understanding the child’s development history.
In most children with nocturnal enuresis, the physical examination doesn’t show abnormal findings. However, the doctor will check for signs like a distended bladder, constipation, abnormalities in the male phallus or female urethra, unusual muscle tone, abnormal sensation or reflexes, and skin changes that might suggest hidden spinal defects.
- Is the bedwetting new or ongoing?
- Occurrences per night and per week
- Caffeine and fluid intake at night
- Significant urine production at night
- Excessive thirst
- Pain when urinating
- Urinary urgency and frequency
- Day-time bedwetting
- Abnormal flow of urine
- Constipation
- Family history of bedwetting
- Recurring urinary tract infections
- Sleep disorders or snoring
- Use of long-term medications
- Screen for psychological or behavioral problems
- Determine the child’s development history
- Check for physical abnormalities like distended bladder, constipation, and abnormal muscle tone
Testing for Nocturnal Enuresis
Usually, a urine test is all that’s needed for diagnosis as it can indicate specific conditions. For example, changes in urine concentration could indicate diabetes insipidus, the presence of sugar in the urine could point to diabetes mellitus, and signs of nitrites, a chemical that comes from bacteria, and white blood cells could signal an infection.
However, if bed-wetting is not the only symptom, or if the treatment is not working as expected, further tests may be required. These could include a renal and bladder ultrasound, which is a non-invasive test using sound waves to create images of these organs, measuring the amount of urine left in the bladder after urinating, checking the speed of urine flow, studying the bladder’s function, or testing the function of the rectum and anal sphincter with an anorectal manometry.
Treatment Options for Nocturnal Enuresis
When someone has this common condition, the approach to treatment depends on the person’s specific issues. It’s important to start treatment early, ideally before the age of six. The chosen treatment should consider the main cause of the condition, and any other health factors. It’s essential to think about the person’s and their family’s willingness to follow through with the treatment. This can greatly affect its success.
If the person also has constipation, this should be addressed first. It’s also essential to treat any mental or behavioral health issue that could hinder treatment success. The first step usually involves changing certain behaviors. This could include limiting liquids 2 hours before bed and not having dairy 4 hours before bedtime. Also, it’s crucial to go to the bathroom before going to bed.
An alarm system can be a highly effective treatment. It teaches the person to wake up when they feel the urge to go to the bathroom. Parents should let the person wear regular underwear instead of diapers. If the alarm goes off, meaning the device senses moisture, they should wake the person up if they did not wake up on their own. The person should then go to the bathroom. This method best works in older children who are motivated to stay dry at night. Successful treatment with the alarm system typically takes 3 to 4 months to see results.
Medications can also be used to manage the condition while waiting for natural improvement. These are typically considered if behavioral changes and the alarm system have failed to bring improvements. The first choice is usually a synthetic drug. This works by reducing urine production at night. However, people with a bladder condition or daytime incontinence may not respond well to this medication.
Combining the medication with the alarm system can result in a nearly perfect success rate. The medication should be taken 30 minutes before bedtime. Ongoing treatment should be paused after six months to see if the condition has resolved. The medication is typically well-tolerated with few side effects. However, it’s crucial not to overhydrate during treatment. Too much fluid intake can lead to low sodium levels. Also, this treatment should be avoided when the person has conditions that may disrupt electrolyte balance, like fever, gastrointestinal losses, or after strenuous exercise.
Anticholinergic agents can be added for people who don’t respond to the primary medication. Overactive bladder or small bladder capacity patients may respond better to these. Oxybutynin is the most commonly used medication from this group.
Lastly, a type of antidepressant is an alternative choice for older individuals who’ve not responded to other treatments. It works on various factors, including brainstem function, bladder spasm prevention, increasing the release of hormones that affect urine production, and suppressing stages of sleep most associated with bedwetting. Note that the treatment’s success rate is not high, particularly for long-term effectiveness after stopping medication. It also carries potential side effects, especially cardiac abnormalities, liver damage, and depression of the nervous system. Before commencing this therapy, some experts suggest checking for conditions that can affect the heart.
As with any medication, it’s important for parents to store these safely, out of reach of children. This is to prevent accidental overdose, which can lead to serious side effects.
What else can Nocturnal Enuresis be?
When diagnosing bedwetting (enuresis), doctors must first rule out certain conditions. These include:
- Bladder dysfunction caused by infections or conditions affecting the nervous system,
- Unintentional urine leakage due to problems with the physical structure of the body, and
- Excessive urination resulting from conditions like diabetes, consuming an excessive amount of fluid or diuretics, or the use of certain medications.
What to expect with Nocturnal Enuresis
Enuresis, or bedwetting, often resolves itself over time, with about 15% of those affected overcoming the condition each year. Despite this, the condition can greatly impact the quality of life. Children who wet the bed often face emotional and physical mistreatment. They can struggle with feelings of low self-esteem and may perform poorly in school.
The most effective treatments for bedwetting include alarm therapy and medications like imipramine and desmopressin. But even with treatment, progress may be slow and up to 20% may continue to struggle with the condition into adulthood.
Possible Complications When Diagnosed with Nocturnal Enuresis
Enuresis, or involuntary urination, is known to lower the quality of life for both the child suffering from it and their family. It has also been linked to lower self-esteem, mood issues, and heightened stress levels. Moreover, children with enuresis often experience difficulties in their social interactions with friends.
Quality of Life Issues Related to Enuresis:
- Decreased quality of life for the child and family
- Lower self-esteem
- Mood problems
- Increased stress
- Challenges in socialization with peers
However, effective treatment of enuresis has been shown to improve the quality of life for these children.
Preventing Nocturnal Enuresis
It’s important for families to receive advice on the suitable and unsuitable ways to manage bed-wetting in children. Those taking care of children with this condition should also understand how it typically evolves over time, what treatment options are available, and the potential problems that can occur if treatment is delayed.
