bedwetting

Bedwetting, or enuresis, is a very common problem for youngsters and their parents. It tends to be a familial problem, more likely on the male side (father to son).

There are a couple of schools of thought as to why children wet the bed.

Urologists (urinary system specialists) tend to blame things like bladder capacity - they like to measure stuff like that. Studies have shown smaller average bladder capacity in bedwetters versus those dry at night, but that might be because bedwetters never hold a full night's urine to stretch their bladders. Certainly bladder stretching exercises (hold it as long as you can) may be helpful combined with other approaches.
I'm in the sleep disorder camp. We see bedwetting as a somewhat inherited disorder of too sound sleeping. Any parent of a bad bedwetter will tend to agree - a cannon could go off next to some of these kids and they wouldn't wake up. Very young children sleep the soundest; as any person ages, his sleep becomes less deep. This explains why the condition gets better with time. Once children reach about age 6, the incidence of spontaneous cure is about 15% per year (a pretty depressing number).
The one thing everyone agrees on is that bedwetting is not an emotional disturbance or willful misbehavior. Behavioral modification techniques do tend to help, though, usually in conjuction with other approaches.
Incidence in the population per article in Sept.96 Pediatrics:
- age 5 - 33%
- age 8 - 17%
- age 11 - 7%
- age 17 - 0.7%

The treatment or management of enuresis falls into several categories:

Wait it out. Eventually, the problem does almost always resolve. However, as they say, eventually can be a long time.
Behavior modification. This approach relies on a sort of subconcious programming by suggestion before bedtime. Techniques involve stories, record keeping with star charts and so forth, and lots of encouragement. It is sometimes successful; I am generally unimpressed with the results, but if they work for a given child, that is great.
Drug therapy. These drugs either affect the valve that lets urine out of the bladder (urinary sphincter), or reduce the production of urine at night. The former group includes Ditropan® and Tofranil®; because Tofranil® (imipramine) is extraordinarily dangerous in overdose, many doctors are reluctant to use it in any household with small children; an EKG (heart tracing) should ordinarily be done before starting the drug to rule out any silent heart rhythm problems that could be worsened by the drug.
Having said that, it is quite cheap and in actual use over many years has had very few adverse events. I do use it myself for some cases.
The second category of medication is DDAVP, or synthetic antidiuretic hormone. This is used as a nasal spray or now an oral preparation at bedtime and tells the kidneys to drastically reduce the amount of urine produced. It is dreadfully expensive - $100 a month or so for treatment. Neither category of drug therapy has very good long term statistical success; relapse is fairly common.
Bladder capacity exercises. If nothing else, it does increase the child's daytime awareness of the urge to void and maybe helps at night.
Alarm devices. These are now the preferred method of treatment but are of course not always successful - nothing is. Modern bedwetting alarms are generally designed with a sensor probe and a very loud buzzer. The probe goes in the pants and the buzzer goes by the ear. At the first drop of wetness, the buzzer goes off, wakes the child, who gets up and goes to the bathroom. Over time, the child's brain begins to associate the urge to void at night with that obnoxious buzzer, and starts to awaken before it goes off. At that point, he's dry. Relapses are common but usually easy to retrain quickly with a week or two back on the buzzer. The problem is that many times the child may sleep so soundly that he sleeps through the buzzer, which awakens everybody ELSE in the house (that's why I'm in the too-sound-sleeper school of thought). I tell those parents to wait six months or so and try it again when the child hopefully doesn't sleep quite so soundly. There are several alarms around; most pediatricians will have brochures for ordering them. If you wish to use an alarm, it is helpful to have some good instructions for managing the nighttime alarms. I have reprinted Dr. Barton Schmidt's directions here for you in a printable Adobe Acrobat® file - click here.

It is also well to keep in the back of your mind that bedwetting is sometimes a symptom of obstructive sleep apnea, a potentially serious condition. Suspect this in any child with loud snoring at night, the child who "stops breathing" temporarily in the night, one who has a weight problem, or has any sort of developmental or muscular problems.

A sudden onset of significant bedwetting in a previously dry school age child could also mean diabetes or urinary tract infection as well. Notify your doctor if your child's bedwetting seems out of the ordinary.

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