Bedwetting and children
by Dr Kanahes Yoganathan
Every night, across the globe, many children experience
a common condition called Bedwetting or Nocturnal Enuresis. In many cases, parents
manage this problem by hushing it up or ignoring it, in the hope that their children
will outgrow it soon. Others choose to blame their children, as they believe this
to be an act of defiance or a sign of weakness.
According to experts, bedwetting should not be ignored, but be treated, as, if left
untreated, may lead to some serious emotional problems for the affected child. Moreover,
there are some easy and effective ways that parents can use, to overcome this problem.
To enlighten you on the subject of Nocturnal Enuresis is Dr Kanahes Yoganathan,
a Consultant Paediatric Nephrologist with the Faculty of Medicine at University
Kebangsaan Malaysia.
Dr Kanahes graduated from the University of Liverpool in1984. Since then, she has
worked in Paediatrics for three years in UK, followed by another four years with
the Ministry of Health in Malaysia. She then obtained her MRCP and later joined
the University Kebangsaan Malaysia as a lecturer. Her main interests are in general
Paediatrics and Nephrology. She has recently completed a study on the Prevalence
of Enuresis, which is awaiting publication. She runs a nephrology clinic once a
week and is embarking on an enuresis clinic.
Q1) What is bedwetting?
A) Bedwetting or Nocturnal Enuresis, is the involuntary voiding of urine
beyond the age of expected control in the absence of a congenital or acquired abnormality
of the nervous system or urinary tract. This age is commonly accepted to be 5 years
as most children become dry by day, by age 2 years and dry by night, by 4 years
of age. Enuresis can be classified as Primary or Secondary. Primary enuresis is
wetting in a child aged 5 years or more who has never been dry before whilst secondary
wetting is the onset of wetting after a continuous period of dry nights for at least
6-12 months.
Q2) What are the causes of bedwetting? Does it run in families?
A) There are a few causative factors of bedwetting and they are:
a. genetic/familial; this means that the bedwetting occurs in other family members
and may be inherited
b. sleep disorders, ie deep sleep or difficulty in arousal; the evidence for this
is that many parents actually complain that the child is difficult to awaken and
physiological sleep studies do collaborate this evidence. Also sleep studies have
shown that it may not be the deep sleep that causes the problem but a faulty 'arousal'
from sleep mechanism that may be the issue.
c. reduced bladder capacity; This means that the size of the bladder is significantly
small and is therefore unable to store large volumes of urine necessitating frequent
voiding.
d. hormonal, ie anti-diuretic hormone; Anti-diuretic hormone is a hormone present
in our brain that codes the kidney to produce less urine. This hormone level normally
rises in the night or during sleep (normal circadian rhythm) and in children with
enuresis there has been shown to be a faulty rhythm, resulting in an inadequate
rise in the ADH levels during sleep, hence the volume of urine produced during sleep
in this child will be as much as that which is produced in the day. Hence if the
child is able to wake and pass urine he/she may complain that he needs to wake up
often to micturate but in a child who fails to wake up, bedwetting is the result.
e. maturational delay. This simply means that there is a variation in the time taken
to achieve what is assumed is a developmental process. Much like the time taken
to achieve walking or to say the first word or to develop the first tooth. As we
know there is a wide variation in the time to achieve these parameters. There may
be a similar delay in the development of dryness at night. Often, these children
may also show minor developmental delays in acquisition of speech or visual-spatial
concepts but eventually will achieve all these parameters.
Many studies show a high positive family history of bedwetting. The risk of bedwetting
is 15% if family history is negative but this increases to 45% if one parent was
a bedwetter and increases to 75% if both parents have been bedwetters. There studies
which indicate children with enuresis have low self-esteem and that this improves
with the treatment of the enuresis.
Q3) What are the symptoms?
A) There are no other symptoms in a child with nocturnal enuresis. If other
symptoms occur (eg: frequency of passing urine, pain or discomfort on passing urine,
inability to control one's urine or incontinence) then an underlying organic (usually
bladder or neurological) problem exists. In other words, the presence of other symptoms
almost exclusively rules out the diagnosis of primary nocturnal enuresis in a child.
Q4) What is the prevalence of bedwetting among children?
A) The prevalence rates vary tremendously. Rates of 2.5% to 23% have been
reported. Possible reasons for this variation are the different methods of study
and definitions used to identify children with wetting. Majority of studies are
from Western countries though the Taiwanese and the Koreans also have reported primary
enuresis in 8% and 9% of their children respectively. I recently completed a study
in Kuala Lumpur on children aged between 7 and 12 years and the prevalence was 6.2%.
Q5) Does bedwetting occur equally in both boys and girls?
A) Bedwetting is more common in boys in the early years, with a ratio of
Male : Female of 1.4 : 1.0, but the prevalence evens out in the later years.
Q6) Do children eventually grow out of it? Can it be cured?
A) Most children eventually grow out of it but about 1% of adults are still
bedwetting.
Q7) What is the psychological impact of enuresis on children,
if any? If it's untreated, will it lead to poor self-esteem, and other psychological
disorders?
A) Many reports of low self-esteem and behavioral problems in bedwetters
have been published. Children often get depressed about their problem and shy away
from social activities.
Q8) What should parents of such children do to help them to overcome
this?
A) Firstly, parents need to be aware of the possible effect on the child's
self-esteem and morale. Thus, they should try not to punish or embarrass the child.
This is often a sad but true consequence in families of bedwetters.
Parents should try to be sympathetic and help their child to understand the problem
and help them overcome it. Some measures are:
a. reducing oral intake of fluids at least one hour before bedtime.
b. ensure child empties the bladder before going to bed.
c. wake the child at least once in the night (lifting)to empty the bladder again.
d. positive reward system of reinforcement of a dry night.
Q9) Who and where should parents of such children approach for
help or more information?
A) The General practitioner or their paediatrician should be able to offer
some help.
Q10) What are the modes of treatment for nocturnal enuresis?
A) There are four modes of treatment for nocturnal enuresis and they are:
1. Positive reinforcement or star charts. The child is encouraged to keep a diary
and gets a star for every dry night achieved. After a pre-arranged number of dry
nights has been achieved, the child receives a reward. Once the system is established,
the rewards are harder to earn, i.e. the child needs to achieve longer periods of
dry nights.
2. Alarm systems. These are made in the form of a pad and bell/alarm. The pad may
be worn around the body or placed on the matress beneath the buttock and detects
moisture (urine) from the child. It then triggers the bell or alarm to wake the
child.
3. Drug therapy. There are mainly two groups of drugs useful in bedwettings. These
are the tricyclic antidepressants and the anti-diuretic hormone analogue, DDAVP.
Q11) What's your opinion of alternative treatment methods such
as hypnosis, massage, etc... that are used to treat nocturnal enuresis?
A) There is little evidence that alternative treatments such as hypnosis
works and I have had no experience in this.
Q12) Can nocturnal enuresis be prevented and if so, how?
A) There is no clear evidence for prevention. It's possible that early toilet
training may reduce the prevalence, but this needs further study.
Q13) Will adults who had a history of nocturnal enuresis during
childhood be more prone to urine incontinence later in life?
A) As far as the evidence available, there is no link between childhood enuresis
and incontinence in later adulthood in the true monosymptomatic primary enuresis
children. However this does occur in those who have enuresis as a symptom of a more
complex bladder dysfunction.(see answer to Q3).