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Nocturnal Enuresis

By: Ma. Jocelyn A. Niere-Quidlat, MD, FPPSNocturnal Enuresis

Bladder control training is one of the challenges that parents have to grapple with when it comes to raising children.  Hence it is not uncommon for parents to complain that their child still bed-wets even at an older age. 

Bedwetting or nocturnal enuresis refers to the unintentional passage of urine during sleep.  Enuresis is the medical term for wetting whether in the clothing during the day or in bed at night.  Enuresis is also called urinary incontinence.  Acquiring urinary continence is part of the transition from infancy to childhood.  Urinary incontinence is inconvenient but parents tolerate it until a child falls behind peers.

Enuresis is defined as voiding in bed or on clothes that occurs at least twice a week for at least three consecutive months in a child who is at least five years old.  It is at this age that the anticipated 24-hour-per day bladder control is expected. Children who are intellectually disabled should reach a mental age of four years before they are considered enuretic.  Urinary continence is reached earlier in girls than in boys.   The diagnosis of enuresis is reserved for girls older than five years of age and boys older than six years of age.

There are two types of enuresis based on the time of occurrence of the inappropriate voiding patterns.  The types are:

  1. Diurnal – wetting during the daytime
  2. Nocturnal – passage of urine during the night

Enuresis is described as either primary or secondary.

  1. Primary – observed in children who never had a period of  sustained dryness
  2. Secondary – occurs in children who have been dry in the past for a period of at least six months, with nocturnal enuresis and three months with diurnal enuresis

Classification of nocturnal enuresis:

  1. Monosymptomatic   –  no daytime symptoms to suggest lower urinary tract infection in patients are present
  2. Polysymptomatic   –   associated with symptoms such as urgency, frequency, dribbling, or daytime enuresis

These are the following causes of primary enuresis:

  1. Faulty toilet training

This may perpetuate both diurnal and nocturnal enuresis.  Parental expectations are believed to play a role in the toilet training experience.  Parents who allow children to sleep in diapers may be delaying the achievement of night dryness.  However, it is unlikely that the use of diapers causes nocturnal enuresis.  Poor toilet habits, particularly infrequent voiding or constipation may be associated with urinary tract infections.

.                     2. Maturational delay

The development of the inhibitory reflex of urination may be delayed in some children which may contribute to bedwetting until the age of five years.  This is similar to the range with which children achieve other developmental milestones.  Beyond this age maturational is not a common cause for enuresis.

       3. Small bladder capacity

Studies show that some children with enuresis have smaller bladder capacities.  This is associated with diurnal frequency or incontinence.

       4. Sleep disorder/impaired arousal

Children who bed-wet have diminished arousal during sleep and do not wake even if the bladder is full.

       5. Allergens

There is no evidence to confirm that exposure to certain food additives or sugar contributes to enuresis.  However, drinking beverages with caffeine may increase the incidence of nocturnal enuresis.

       6. Nocturnal polyuria/relative vasopressin deficiency

The diurnal release of vasopressin is disturbed in enuretic children

       7. Dysfunctional bladder contraction

Children with “uninhibited bladder” have not learned to inhibit bladder contraction.  They may assume a certain posture called “Vincent curtsy, in an effort to prevent passing out urine.  Some children exhibit discoordinated, incomplete voiding and the urine comes out of the urethra in a staccato stream.

The causes of secondary enuresis are:

        1. Urinary tract infection

The resulting bladder irritation can cause abdominal pain, painful urination, a stronger urge to urinate, and frequent urination.  In children, urinary tract infection may indicate an anatomic abnormality

        2. Diabetes Mellitus

Having to urinate frequently is a common symptom of diabetes.  People with type 1 diabetes have a high level of sugar (glucose) in their blood.  The excessive glucose levels in the blood cause the body to increase urine output. 

        3. Genitourinary anomalies

An abnormality in the organs, muscles or nerves involved in urination can cause incontinence or other urinary problems that could manifest as bedwetting.

        4. Neurological problems

Abnormalities in the nervous system or injury or disease of the nervous system can affect the delicate neurological balance that controls urination.

        5. Emotional stress

Stressors that can cause bedwetting – parental conflict in the home, starting school, the advent of a new baby, moving to a new home, physical and sexual abuse

        6. Sleep patterns

Obstructive sleep apnea characterized by excessively loud snoring and/or choking while asleep can be associated with enuresis

       7.  Pinworm infection

This can bring about intense itching of the anal and genital area.

       8.  Excessive fluid intake

Dr. John Mersch suggests the following home remedies for bedwetting:

  • Reduce evening fluid intake. The child should try not to take excessive fluids, chocolate, caffeine, carbonated drinks, or citrus after 3:00 pm. Routine fluids with dinner are appropriate.
  • The child should urinate in the toilet before bedtime.
  • Set a goal for the child of getting up at night to use the toilet. Instead of focusing on making it through the night dry, help the child understand that it is more important to wake up every night to use the toilet.
  • A system of sticker charts and rewards works for some kids.  The child gets a sticker on the chart for every night that he or she remains dry.  Collecting a certain number of stickers earns a reward.  This motivational approach works a lot for younger children resulting in significant improvement in dry nights with a low relapse rate.
  • Make sure that the child has safe and easy access to the toilet.  Clear the path from his or her bed to the toilet.  Install night lights. If needed, provide a portable toilet.
  • Some believe that you should avoid using diapers or pull-ups at home because they can interfere with the child’s motivation to wake up and use the toilet.
  • Parental attitude is vital in motivating a child who bedwets. 
  • Focus on the problem: bedwetting. Avoid blaming or punishing the child. The child cannot control the bedwetting so blaming and punishing just add frustration.
  • Be patient and supportive.  Reassurance and encouragement help.
  • Enforce a no teasing rule in the family.  Bedwetting should not be discussed in front of other family members.
  • Help the child understand that the responsibility for being dry is his or hers and not that of the parents.  Reassure the child that you want to help him or her overcome the problem. 
  • The child should be included in the clean-up process.

Self-awakening programs are designed for children who are capable of getting up at night to use the toilet.  Parent-awakening programs can be used if self-awakening programs fail. 

Bedwetting alarms have become the mainstay of the treatment.  For the alarm to be effective, the child and parents need to be highly motivated.

Consultation with your primary care physician or pediatrician can help with problems of bedwetting.

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