Bed wetting (Enuresis)

Bed wetting (Enuresis)

In simple words habit of passing urine unknowingly during sleep called bed wetting beyond certain age is known as enuresis in medical language. 

Though this phenomena is normal finding up to certain age, most of the children are dry during day and night by age 3-4 years. Remaining most gain bladder control by age 7 years. 

Is your child still have habit of bed wetting? Are searching for more information on it. So here we are. We will discuss here the causes and the management of bed wetting. This is very common problem in daily OPD and can be managed successfully.  

What are causes of bed wetting?

• Anxiety : Improper toilet training in children leads to anxiety in their minds this children feel difficulty in controlling urine. The problem of enuresis continues till this anxiety is mitigated with support from family members and parents.
• Low confidence : The children which are scolded and laughed upon for their bed wetting habit have low confidence to hold the urine and stay dry by night.
• Constipation : Children with constipation generally have bed wetting habits. As toilet training goes bladder and bowel hand in hand pain while passing stool and difficulty in passing stony hard stool increases anxiety in children’s mind and making it difficult to control urine. Additionally constipation may lead to urinary tract infection worsening the problem of bed wetting.
• Genetic : Some families have history of members who got bladder control late. This may get inherited in children so that they get bladder control at latter age.
• Trauma : Any trauma to spine or brain may lead to loss of bladder control mechanism and lead to involuntary bed wetting.
• Unknown : Most cases of primary nocturnal enuresis may have causes that are yet not known.
• Urinary tract infection : Urinary tract infection is among most common primary or secondary enuresis. 

There are two types of bed wetting grossly:

• Primary enuresis : Primary enuresis is condition in which child has never been achieved dry by night state. Most likely primary enuresis children have structurally normal components needed for bladder control.
• Secondary enuresis : Secondary enuresis is condition in which child had achieved dry by night state before but again started bed wetting. The underlying cause is to be found out for the further treatment. These children may have other problem like urgency, frequency, incontinence, constipation, anxiety, sleep disorders, or urinary tract infection.

Depending on associated symptoms bed wetting ( Enuresis ) is classified as 

• Mono-symptomatic : Mono-symptomatic enuresis patients do not have other problem like urgency, frequency and incontinence. 
• Non Mono- symptomatic : They may have others associated symptoms. This may be primary or secondary enuresis.

Depending on time of day bed wetting is classified as Nocturnal or day time. The most common and fortunately conservatively manageable condition is primary nocturnal enuresis. So we will first see the details of primary nocturnal enuresis..  

Primary nocturnal enuresis

As its name implies this is night time bed wetting in children beyond certain age which have never achieved nocturnal enuresis. It is a common condition found in children and sometimes even in teens. Most of the children are dry by night and day at age 3-5 years. 99 percent are dry by night till age 7 years.  These children generally are mono-symptomatic that is generally they do not have day time frequency, urgency and incontinence. They can well control the bladder during day time. But during night time they have problem of bed wetting.  Some rare teens are also affected by the problem. They have other problems like structural abnormality, emotional problems and sleep disorders like obstructive sleep apnea. Fortunately large proportion of patients do not have these problems. Sometimes the efforts of treatment of condition seem futile but it is necessary to keep patience.  At what age we should expect child to achieve bladder control and stay dry by night?  

• 2-2.5 years old children most are dry by day and many are dry by night too.
• 3-4 years most of the children are dry by night.
• By 7 years most children are dry by night and day almost 99 percent.

When to start treatment of bed wetting?

• Generally treatment is optimally started at age 6-7 years or afterwards.

What treatment is given for primary nocturnal enuresis?

• Child should be given emotional support especially from the parent.
• Child should be counselled regarding the treatable condition and the family members should achieved bladder control late should tell their history and should provide support to children.
• Child should feel confident that he can achieve the goal that is staying dry by night.
• Child should be taken to toilet before sleeping.
• Carbonated soft drinks, coffee and tea should not be given to child.
• Children are advised not to hold urine during day time and use toilet whenever they want to use it.
• A not should be sent to schoolteacher that child should not be restricted from going to toilet.
• Adequate and liberal amount of water intake should be given during day time.
• Water intake should be minimum in evening and after dinner.
• Any constipation if present should be treated with fibrous diet.

Conditional alarm system for bed wetting :

This is good and non pharmacological method of treating bed wetting.

It teaches children to wake up when moisture is detected in pants.

So by this way children get their brain trained that when they want to urinate they need to wake up.

The Success is around 60 percent when used consistently for 4 months.

The moisture sensor is kept in pants and the alarm near shoulder.

Alarm rings when the moisture is detected in pants.

Drawbacks : Many children do not wake up to alarm.

Instead it way disturb sleep of other family members.

Family members have to help children to become fully awake.

For may people in country like India cost is issue, may not be affordable to every one.

Recurrence : Bed wetting may recur if the use of alarm is stopped.

Pharmacological (Drugs) for bed wetting?

No drug provides definitive treatment for this condition.

Drug only helps to control the urine production in night or increase bladder capacity and inhibit reflex activity of the bladder.

Imipramine : This is tri-cyclic antidepressant. It is found to be effective for primary nocturnal enuresis. It shows its effect mainly by inhibiting reflex activity of bladder, and lightening the sleep and also somewhat decreases anxiety.

It may induce the abnormality of heart rhythm, and death in case of large doses given accidentally.

It should be avoided in children with family history of sudden death due to any cardiac disease.

Difficult to initiate urine is embarrassing side effect in some children.

Some children may feel sleepiness which goes after some days of use.

Some children may experience emotional changes and behavioral changes.

Desmopressin : It is a hormone artificially made which reduce formation of urine.

Given 2 hours before sleep.

Child is suggested not to drink more than 100 ml water after dinner.

If water or drinks taken after taking medicine it can cause dangerous fluid overload and hyponatremia and death.(rare)

Given with caution with at least every 15 days follow up.

Oral preparation is better tolerated will least side effects. Intra-nasal preparation should not be used.

Effective for 25-65 percent patients.
The drug therapy is to be given only if the non pharmacological therapy fails. The alarm conditioning is labelled as failed if no effect in 4 months. The drug therapy should at least be given for 4 months.  The combination of both pharmacological and non pharmacological therapy is found to be better than either of two alone.  The crux of the story is either or combination of treatment is given for months is effective in 80-85 percent children Other class of drugs like oxybutinin and flavoxate can be used in patients with symptoms of urgency, frequency and incontinence. Antibiotics may be needed to treat infection if present. 

What investigation are needed?

• The investigations are needed to confirm the clinical findings.
• Urine routine microscopy may be needed to rule out infection of urinary tract.
• If structural anomaly of trauma is suspected MRI spine or brain may be investigation of choice.
• If conditions like renal tubular acidosis is suspected detailed blood and urine analysis is needed.
• Other studies like uroflowmetry, USG bladder may be needed as per indication by clinical presentation.
• ECG is needed to rule out heart rhythm abnormality if imipramine is considered for treatment.
• Sleep studies are needed if Obstructive sleep apnea or other sleep disorders is suspected.
• X ray Skull may be needed if hypertrophy of nasal adenoids is suspected.

Disclaimer : These are just general guidelines about bed wetting. Each child is different. The treatment should be started only after assessment by a pediatrician. You can visit us for appointments here.  

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