Bedwetting is a common condition seen in children aged 5 years and above, affecting about 15% of children. Bedwetting refers to the occurrence of intermittent urinary incontinence (loss of bladder control) during sleep at least once a month for a minimum period of 3 months in a healthy child beyond 5 years of age. Frequent bedwetting is defined as more than 4 times per week and infrequent bedwetting can be as less than 4 times per week. Most children seeking treatment in Singapore are five years or older, with the majority between 7 and 12 years old. This group of children would also have had frequent bedwetting of at least twice per week, with the majority experiencing bedwetting almost every night.
The various risk factors for bedwetting include:
- Hereditary cause – Bedwetting often runs in the family. Up to 75% of affected children have first degree relatives who had experienced bedwetting.
- Decreased sleep arousal and maturation delay of the central nervous system. Bedwetters are known to be deep sleepers. Bedwetting tends to improve with time and it will ultimately stop for most children.
- Reduced functional bladder capacity during sleep.
- Lack of the production of a naturally occurring body hormone called Anti-Diuretic Hormone (ADH) during sleep. This hormone is important for reducing urine production at night.
The vast majority of children who bedwet are healthy with no underlying diseases. Only rarely is bedwetting associated with other diseases.
When this occurs, it is almost always associated with symptoms like wetting in the day, pain on passing urine, fever, excessive thirst, large urine volume or growth failure.
Bedwetting should be treated especially if the child is already at school going age and the wetting is frequent. Without treatment, bedwetting typically resolves spontaneously at a rate of 15% per year with persistence at higher ages. Studies have shown that constant bedwetting can adversely affect the psychosocial development of the child, causing low self-esteem and poor social adjustment. It can also cause resentment and anxiety in parents and other family members and become a source of embarrassment and deters the child from healthy outdoor activities like overnight camping and travelling.
With treatment, most children will stop bedwetting or improve significantly. Although bedwetting can resolve spontaneously, if left alone, this may take several years and a small percentage of them (1-3%) will continue bedwetting beyond puberty. The choice of treatment depends on the child’s age and motivation, the frequency and severity of bedwetting and the caregiver’s ability to cope.
A child should be offered active treatment if he/she is 6 years and above, and the condition has affected his/her normal social and emotional development or schoolwork.
1. Urotherapy
This involves education on normal bladder function and urinating habits, fluid intake, avoidance of constipation as well as support for the child and caregivers. Co-existing conditions such as constipation should be treated at the same time.
2. Enuresis (bedwetting) alarm
The bedwetting alarm is currently the most effective treatment available and is considered first line therapy for bedwetting and is usually combined with motivational therapy (positive reinforcement). The bedwetting alarm includes a moisture sensor, placed under the child’s underwear or as a pad beneath the child, which is then connected via wire or wirelessly to an alarm that delivers a loud, sound stimulus when it detects wetness. In this way, the device serves as a conditioning device using a sound to link the stimulus of a full bladder beginning to empty the urine with the desired behaviour of stopping urination and waking. Thus, it takes time to train the bladder. Results are often seen only after weeks of therapy. The success rate is 50-80% but it requires high motivation and patience on the part of the child and their parents, as well as constant support from therapists.
3. Medications
A group of children with bedwetting can produce a great amount of diluted urine during sleep. To reduce this excessive urine production, a synthetic anti-diuretic hormone (ADH) called desmopressin is used at bedtime to help concentrate the urine. Up to 70% of bedwetters can respond to desmopressin treatment. An initial trial of treatment over two weeks is necessary to assess the response. If there is satisfactory response, treatment is continued for at least 3 months, after which treatment needs to be reviewed. Some children need a longer period of treatment. With careful monitoring, there are rarely, if any, significant side effects. However, as desmopressin reduces the removal of water from the body, it can potentially cause water retention if a child continues drinking excessively after taking the medication. Side effects occur occasionally and can include headache, loss of appetite, abdominal cramps and rarely, fits. An important precaution for those children using desmopressin is to restrict fluid intake within 2 hours of taking desmopressin.
Seek help and treatment from your doctor if your child has bedwetting.
References:
- Austin PF, Stuart Bauer SB, Bower W, Chase, J, Franco I, Hoebeke P, Rittig S, Vande Walle J, von Gontard A, Wright A, Yang SS, Neveus T. The Standardization of Terminology of Lower Urinary Tract Function in Children and Adolescents: Update Report from the Standardization Committee of the International Children’s Continence Society. Neurourol Urodyn 2016; 35: 471-81
- Neveus, T. Pathogenesis of enuresis: Towards a new understanding. Int J Urol 2017; 24(3): 174-82
- Neveus T, Fonseca E, Franco I, Kawauchi A, Kovacevic L, Nieuwhof-Leppink A, Raes A, Tekgül S, Yang SS, Rittig S. Management and treatment of nocturnal enuresis – an updated standardization document from the International Children’s Continence Society. J Pediatr Urol 2020; 16(1):10-19
Contributed by:
Associate Professor Ng Yong Hong
Head and Senior Consultant, Nephrology Service, Department of Paediatrics
KK Women’s and Children’s Hospital, Singapore