What is Bedwetting?

Enuresis is the medical term used for bedwetting also referred to as involuntary urination. Bedwetting is characterised by the complete emptying of the bladder during sleep without any symptoms of bladder dysfunction in children age 5 years or more with a severity of at least three times per week in the absence of congenital or acquired defects of the central nervous system. Bedwetting happens more in boys (almost up to three times more so) than in girls and happens more often in the first-born child.

Epidemiology: extent of bedwetting is widespread, it has been argued nocturnal enuresis is the most prevalent of all childhood problems.

Some Bedwetting History

The first mention of bedwetting in history was on a medial scroll of papyrus dated “1550BC” in which the recommended solution for bedwetting was “juniper berries, cypress and beer”. (This is not recommended for your child.) Enuresis is derived from a Greek word that means “to make water” and is the medical term for bedwetting.

Bedwetting Facts

  • 16.6% of 5-year olds wet the bed
  • About 6.6% of 7-year olds wet the bed
  • 97% of bedwetting kids are dry by the time they are 12
  • 98% of children are dry by the age of 15
  • Bedwetting is far more common in boys than girls
  • In a survey conducted, many parents thought the reason their children were wetting the bed was because of laziness, this is incorrect.
  • Bedwetting is often inherited, if one parent suffered from bedwetting (as a child) there is an approximate 43% chance that their child will wet the bed, however if both parents wet the bed as children, there is an approximate 77% chance that their child will wet the bed.
  • In some studies food sensitivities have been found as one of the causes of bedwetting, some foods that may cause bedwetting are carbonated fizzy drinks, citrus juices and artificially coloured lollies.

Famous Bed Wetters

Franklin D. Roosevelt

Franklin D. Roosevelt was president of the United States from 1933-1945, longer than any other U.S. president.  He led the United States out of the Great Depression of the 1930’s and through World War II.

He had to wear diapers because of polio, which he was afflicted with as a young man.   In spite of his disability he went on to become one of the greatest men in history.

Source:  Tri-State Incontinence support group

Suzanne Somers

Suzanne Somers starred for many years in “Three’s Company” and other popular TV shows as well as several movies.  She grew up in the shadow of an abusive father, Frank Mahoney, a physical labourer.  Her childhood was a difficult one. Born in 1946, she spent her early years wetting her bed almost nightly because of the anxiety brought on by her father’s drinking binges and mood swings.  She wet almost every night until she was 14 years old, as did her brother Danny.

Then she finally tried a wetness alarm.  Here is an exert from her autobiography, Keeping Secrets: “I was invited to a couple of slumber parties. I was dying to go, but what if I wet the bed at one of those fancy houses? The idea of wetting my bed at a friend’s house horrified me. My mother got me a bedwet alarm. What if I wet the bed when I was married? I had to try this, crazy as it sounded. The crazy screen/alarm contraption worked! I stopped wetting the bed at last.”

Sources:   Keeping Secrets Suzanne Somers – Book Review

Michael Landon

One   of   the   most   outspoken   celebrities    about bedwetting, the late Michael Landon, who starred in hit shows like Little House on the Prairie and Bonanza, wrote about his childhood and how he wet the bed until he was 14 years old in his autobiography.

Michael Landon was born Eugene Orowitz, son of a former dancer and a movie theatre district manager. His mother Peggy lavished attention on his older sister Evelyn, and the few times his father was home he showed little open affection toward him.

Eugene (Michael) had a   bed-wetting problem until age 14. His mother would display his un-washed wet sheets on her clothesline for the whole neighbourhood to see.  Before he went to school she tied parts of the sheets to him.  After high school Eugene left home, eventually entered acting, and changed his name to Michael Landon.  He landed the lead part in the low budget film, “I Was A Teenage Werewolf”, which to his surprise, became a smash hit.

He is most remembered for his heart-warming roles as Little Joe in “Bonanza”, and Charles Engles in “Little House on the Prairie.” In 1976 Michael Landon directed a movie, “The Loneliest Runner”, starring Lance Kerwin.    Lance plays   the “child version” of Landon.    Michael Landon was an Olympic hopeful pondering on his childhood through the movie.

In the movie Lance is a 13-year old bedwetter, and his mother hangs his un-washed wet sheets outside his bedroom window in a cruel (boneheaded) effort to get him to stop the bedwetting. This is how he becomes such an excellent runner, having to run home for nearly a year to get the sheets out of his window, (lest his friends or best girl, played by Melissa Sue Anderson, see this embarrassment).  He eventually becomes a runner in the Olympic-games, and he wins a gold medal!

Source:  Michael Landon Biography

Anatomy

The normal urinary bladder

The bladder is a distensible sack made of muscle. This muscle differs from the muscles in, for instance, our arms and legs, in that it is not directly controlled by the brain but indirectly via reflexes. There is also a circular sphincter muscle around the urethra – where the urine leaves the bladder – a muscle which is partly under direct brain control and is slightly contracted most of the time in order to keep the urine in the bladder.

If all is well and you have reached the age of five or six, this is how it all works:

  1. As the bladder is filled with urine, the relaxed bladder muscle is distended and the desire to go to the toilet is gradually increasing – but there is no sense of panic.
  2. You find a toilet and prepare to pee. The bladder muscle is still relaxed!
  3. The sphincter muscle is now ordered to relax.
  4. This, in turn, starts a reflex via the spinal cord that makes the bladder muscle contract.
  5. The sphincter is relaxed as long as the bladder muscle contracts and the bladder muscle contracts until the bladder is empty.

The Prevalence of Bedwetting

As children feel uncomfortable acknowledging this problem, the reported incidences may actually be higher than what have been recorded. Statistics show that children between the age of 5 – 9 years are most affected by enuresis, with the largest proportion of bedwetters being boys. It has also been noted that as children grow older the prevalence of bedwetting decreases

Did you know that in a class of 30 children aged:

  • 5 years – 5 wet the bed
  • 7 years – 2 wet the bed
  • 12 years – 1 wets the bed
  • 15 years – 1 child in every 2 classes wets the bed

Genetic factors

Bedwetting often is often genetic, so if you or your partner wet the bed as a child there is a good chance your child has inherited this trait. If both parents were enuretics, the risk for the child being a bedwetter is 77%. If only 1 parent was an enuretic the risk for the child being a bedwetter is 45%.

Causes of Bedwetting

The terminology describing bedwetting can be confusing as bedwetting is described as enuresis, nocturnal enuresis as well as primary and secondary enuresis. In general, bedwetting is referred to as enuresis.

There are different types of bedwetting that may occur, including the following:

  • Diurnal enuresis – wetting during the day.
  • Nocturnal enuresis – wetting during the night.
  • Primary enuresis – occurs when your child has never been toilet trained at night.
  • Secondary enuresis – occurs when your child did have a period of dryness, but then returned to having accidents at night.

Primary enuresis

Primary enuresis is classified according to the Butler model and has the following three causes:

  • Nocturnal detrusor overactivity: an over active bladder causing the bladder to empty spontaneously during sleep. Normally a bladder fills and when it is full, the brain activates the bladder and the bladder empties. With an over active bladder, the bladder contracts during the filling phase, causing the bladder to empty spontaneously. When this occurs during sleep, the child empties his bladder unconsciously.
  • Lack of vasopressin causing polyuria: Lack of vasopressin causing an overproduction of urine at night. The brain produces a hormone at night called vasopressin. This hormone stimulates the kidneys to produce less urine at night than during the day. This in turn allows us to have a good night’s sleep, as we don’t produce more urine than our bladder can accommodate. When we don’t produce enough vasopressin at night, the kidneys make just as much urine during the night as during the day. The bladder then becomes over full and has to empty, causing the child to empty his/her bladder in bed.
  • Lack of arousal from sleep: Lack of arousal from sleep. Children with a bedwetting problem don’t wake up with the sensation of a full bladder. The centre in the brain that wakes a child up with the sensation of a full bladder isn’t functioning correctly. Thus, an under-development of the body’s alarms that signal a full or emptying bladder.

Secondary enuresis

Secondary enuresis has a physical or emotional cause for the enuresis, or the child has started wetting his/her bed again, after being dry for more than six months.

Secondary causes include:

  • Urinary tract infections,
  • Diabetes
  • Spinal cord defects
  • Rare cases emotional trauma

It is now thought that the emotional distress caused by the bedwetting is more likely to cause the behavioural problems than the other way around.

What can be done about it?

Bladder problems can often be treated quite easily, it’s all about helping the child take command over his/her bladder.

These are some basic strategies:

  1. Go to the toilet regularly, every second hour or about six times per day (when getting up from bed, mid-morning, lunch, mid-afternoon, late afternoon and at bedtime).
  2. Don’t rush it when peeing! Give the bladder time to empty itself completely. Sit with good support for both thighs and feet.
  3. Don’t drink too little (mostly water!). It must be appropriate for your child’s age.
  4. Boys may pee standing or sitting, as long as they don’t rush it and don’t leave drops!
  5. Watch out for signs of constipation.
  6. Explain to the child how the bladder functions. This will increase his/her cooperation.

Treatment

Many families have tried to solve the problem by not allowing the child to drink in the evening or by waking him/her during the night. These strategies are usually not effective. It’s important to treat each condition separately. Any child should be assessed by doctor. It has to be ascertained if the child has primary or secondary enuresis.

Once the child has been thoroughly examined by a doctor and the cause has been determined the child can be treated effectively.

Treatment for Primary Enuresis

  • Treatment for Over Active Bladder
    • Medication
    • Bladder retraining
    • Diet & Fluid modifications
    • Behavioural modification
    • Biofeedback for pelvic floor rehabilitation
  • Treatment for Lack of Vasopressin
    • Medication – Desmopressin
    • Diet & Fluid Modifications
  • Treatment for Lack of Arousal form Sleep
    • Alarm treatment for bedwetting

To which children is the alarm suitable?

The treatment can be given to bedwetting children who are at least 6-7 years old, who pee in their beds most nights and who are bothered by their bedwetting and motivated for treatment.

Treatment for Secondary Enuresis

When secondary causes of enuresis are treated and the underlying condition for example a bladder infection is cured, the bedwetting can spontaneously clear up.

“Day” Wetting

Most children have gained daytime bladder control by the age of four.

If a child regularly wets during the day after this age professional advice is necessary. Loss of bladder control during the day can be called daytime incontinence, while loss of bladder control during sleep is called nocturnal enuresis or bedwetting. Children can have both day and night wetting.

Why do children wet during the day?

Most wetting occurs because the bladder is not working normally.

Common problems are:

  • Overactive bladder – this occurs when the bladder has problems storing urine. The child has urgency (bursting) and may leak urine on the way to the toilet. They may also go to the toilet more than eight times per day.
  • Under-active bladder – this occurs when the child goes to the toilet infrequently (less than four time a day) and sometime urine escapes without any warning as the bladder overfills. Urinary tract infection is common.
  • Leakage – this can occur if the child is in the habit of putting off going to the toilet and wets when the bladder is overfilled.
  • Incomplete emptying of the bladder – some children have learned to empty their bladder incompletely and this can also lead to wetting.

Structural problems are rare. However, a medical specialist should manage any child identified as having an anatomical or neurological cause for their incontinence.

Day wetting is NOT caused by:

  • laziness
  • naughtiness, or
  • attention seeking.

Overactive Bladder

The most common bladder disturbance in childhood is bladder over-activity, where the bladder muscle tends to contract without notice, and perhaps even without being more than half-full. The result is either that the child senses a sudden, unexpected and strong desire to pee and needs to contract the sphincter forcefully to stay dry, or else a small or large amount of urine is without warning voided into the clothes.

The parents often think that the child “doesn’t notice” when it’s time to go to the toilet, but the truth is that it’s the bladder that doesn’t tell the child that it is about to contract. Other children get the habit of postponing bladder emptying as long as possible, using various manoeuvres – squatting with the heel pressed to the crotch, standing on tip-toe with legs crossed etc.

Many of these children also suffer from bladder over-activity. A well-known cause of bladder over-activity is an urinary tract infection, when harmful bacteria irritate the bladder, but the bladder is more often overactive without the help of bacteria. What many people don’t know is that constipation may cause bladder over-activity, since the distended rectum may compress the bladder from behind.

Another common problem is that the bladder may not completely empty. This is most common in those children who contract the sphincter while they pee or those who habitually wait too long before going to the toilet and thus over-extend their bladders. And if the bladder is not properly emptied there is a clear risk for urinary tract infections. Some children may have both bladder over-activity and emptying difficulties, and constipation may cause both disturbances.

FAQ

Bedwetting, or enuresis according to scientific terminology, is very common. It afflicts 5-10% of children below the age of ten years, and a few per cent of older children and teenagers as well. It is equally common in all cultures and among all social groups. Boys are somewhat more often affected than girls.

The old ideas about enuresis as a psychiatric disorder are false. Usually when a child wets the bed, neither the parents nor the child him/herself is to blame. Modern research has shown that bedwetting has three major causes:

  1. almost all bedwetting children are difficult to arouse from sleep at night,
  2. many bedwetting children have kidneys that produce too much urine during the night, and
  3. the urinary bladder of many bedwetting children is too “irritable” and contracts too easily. Furthermore, enuresis is often inherited within the family.

The body is not harmed by bedwetting. Sleeping in wet sheets does not, for instance, cause urinary tract infections. But many bedwetting children suffer from low self-esteem, which may be socially handicapping.

Yes, the problem will usually go away by itself, but it may take many years. Thus, for a bedwetting child six years old or more, who is bothered by his/her predicament, active treatment should definitively be started.

  • Waking the child and taking him/her to toilet during the night, will cure bedwetting.  This is counterproductive, as you are teaching the bladder, that is should empty at night, thus aggravating the condition
  • Stressful events cause bedwetting. Stressful events are often blamed on enuresis. A study done in Turkey showed that death and divorce had no effect on the prevalence of enuresis and that the prevalence of recent physical or psychological trauma was no different between enuretic and non-enuretic children.
  • Fluid restriction during the day will prevent bedwetting. When fluid is restricted during the day, the production of   vasopressin is stimulated, and this can cause a deficiency in the excretion of vasopressin at night. The child then wet at night. So always encourage fluid intake during the day.

  • Bedwetting often resolves spontaneously. Although this is true, it might take years, causing great distress to the child. A Study asking children what was the worst thing that could happened to them listed the death of a parent as the worst follow by bedwetting. This demonstrates the trauma that bedwetting can cause children.
  • Constipation is also often the cause for failed treatment of enuresis. It is important to always treat the constipation. Some of the medication used to treat bedwetting can also cause constipation. Always let your doctors know if your child is constipated.

Myth – Bedwetting is a psychological problem.
Fact – Bedwetting is rarely caused by psychological problems. Rather, bedwetting occurs because of a number of medical reasons and can be successfully treated.

Myth – There is nothing that can be done about bedwetting.
Fact – Bedwetting is a treatable condition. If your child is over 6 years old, still wets the bed, but wants to be dry, you should seek medical advice from your doctor.

Hints & Tips

Why don’t you try doing some of these activities that will make your child feel support that he or she needs while faced with bedwetting?

Let your child have a say!

Any issues relating to bedwetting are going to take time, patience and commitment to resolve, both by yourself and your child. If your child is not bothered by the bedwetting, trying to force the issue will almost guarantee failure. Fortunately, this is highly unusual as most children want to be dry at night.   It is hard to underestimate the embarrassment and distress bedwetting can cause to a child.

However, trouble really begins when the wet bed becomes the focus of anger or a battle of wills. There are significant extra costs and workload – including lack of sleep – for parents who have a child who bed wets.

It’s normal for parents to sometimes feel tense, frustrated and at a loss. Nonetheless, it’s important to stand back a little and look at the situation coolly.

A quiet chat:

Talk to your child about what they think and feel. You may uncover fears which are stopping them going to the toilet during the night. It could be the way their bedroom is laid out, fear of the dark, or something in the toilet or home causing the problem.

It is also worth asking the child if they have any ideas for dealing with the problem.  You are not going to be able to impose solutions on your child because their co-operation is essential for success. Therefore, reaching an agreement to proceed with getting help and treatment is very important.

Working together is the first step towards treatment

  • Empathy for the child. Showing support and understanding with what your child is going through are some means that parents may ease a child’s condition. Be sensitive of how your child feels about the condition and act respectfully like how you would want your elders do to your when you were in your childhood and experiencing the same.
  • Bedwetting is caused by various factors over which the child has no control. So be patient and never punish or scold your child.
  • Teach your child to be disciplined. Good habits such as limited fluid intake during night-time especially before bedtime may decrease the chances of your child wetting the bed. Likewise teach your child to head the comfort room first before the bed. You may also try encouraging him to be sensitive about his bladder when it is already full and that it will be nicer if he can go use the toilet.
  • Reassure the child. Your child can feel helpless and become easily discouraged while trying to become dry. Be understanding and supportive.
  • Joining your child at clean-up. Teach your child to help you wash his or her wet clothes. When he feels responsible about the things affected by his bedwetting, he will learn to control his bladder and would be motivated to overcome his situation.
  • If your child still wets the bed after the age of 6 years and is unhappy and uncomfortable about it, you should discuss it with your doctor.
  • Show appreciation as a reward. When you notice that your child’s bedwetting frequency is lessening, praise. When he feels his actions are appreciated, he will be encouraged and be more confident to do the same action next time. Knowing what to do and how to support your child at this experience will help things eventually become better.

Tips for sleepovers and camping trips

  • Sleepovers and school camping trips are an important part of a child’s life it can be a very exciting time. However, for children who continue to wet the bed sleepovers can be a cause of distress and worry. Some children may avoid sleepovers. The good news is that many children manage to stay dry on camping trips and sleepovers and have a great time despite all the worry.
    When sleepover? You need to allow enough time to prepare for camping trips or sleepover and trial different strategies in the familiarity of your own home. We encourage seeking professional help.
  • How old is your child and how much responsibility can they take on their own? Some children may be able to clean up discreetly if bedwetting occurs, but you may also need to tell the adult who is supervising your child about the bedwetting so they are prepared to assist your child.
  • Is your child going to require protection for themselves and / or the bed?  If so, your child will need to learn ways of using products such as bed pads which can be discreetly placed in sleeping bags. You will also need to teach your child how to discreetly dispose of products, for example by setting an alarm clock earlier than others so they can get up and dispose of products in a suitable rubbish bin.
  • Does your child get up to the toilet during the night? Ensure your child is orientated to their new surroundings and that they are aware that they should go to the toilet before bed and again just before sleep. During camps and sleepovers children tend to talk for sometime after retiring and the bladder will be re-filling. Ensure a night light or torch is available to find the toilet.

What to pack:

  • Wipes for your child to maintain their hygiene after bedwetting. This will reduce body smells.
  • Plastic bags to dispose of the washable or disposable products.
  • Ensure enough products for the duration of the sleepover.
  • Medication if required.
  • Extra clothing and underwear.

Tips for supervising someone else’s child with a bedwetting problem

If you are aware that a child has a bedwetting problem, it’s important to let them know that you are available to assist them. You should ask them how you can access them during the night, but do not dwell on the issue.

You should know how to help the child with using and disposing of products and their toilet modifications if required.

It is very important to remember how sensitive this issue is to children. Be careful to always respect their privacy. Never discuss the bedwetting with other people or your own children unless you have been given permission to do so by the parent and the child.