Dr. M.J. Bazos, MD
Patient Handout
ENURESIS
About Your
Diagnosis
Enuresis, commonly called
“bed-wetting,” is defined as the intentional or involuntary passage
of urine into bed or clothes by children aged 4 years or older who do not have
any physical abnormality. Acquiring the ability to hold one’s urine is the
final stage of a very consistent developmental process. Usually the beginning of
this process is bowel control during sleep, followed by bowel control during
waking hours. Control of the bladder during the day occurs next, followed by
nighttime control of the bladder. Most children are able to control their
bladder at night by the age of 3 years. However, as children get older, the
likelihood that they will stop bed-wetting becomes much
less.
Living With Your
Diagnosis
Bed-wetting is as common in
boys as it is in girls until the age of 5 years, but by age 11 years of age,
boys outnumber girls by two to one. In fact, not until 8 years of age are boys
able to hold their urine at night as well as girls do by 5 years of age. This
appears to be because boys mature at a slower rate than girls do. Interestingly,
however, daytime wetting occurs more commonly in girls than in boys and has a
much higher incidence of associated
emotional
problems. In evaluating enuresis,
it is important first to consider medical factors that might be causing the
condition. This would include an investigation of any abnormalities in the
urinary tract (e.g., a bladder that is unable to carry a full amount of urine),
any abnormalities in hormone secretion, some abnormal sleep patterns, the fact
that it may run in the individual’s family, and also, any overall delays
in the development of the child. There also seems to be a relationship between
children who get frequent urinary tract infections (UTIs) and enuresis. However,
it is now believed that the (UTIs) found in these individuals are probably more
a result of the bed-wetting than the cause of it. Although the size of the
bladder and the level of sleep of the patient may or may not be related to
enuresis, it does seem that enuresis may be inherited. About 70% of children who
have nighttime bed-wetting have a relative who has or has had this condition.
Also, stress may play a role in those patients who have enuresis after a period
of being dry at night. In particular, the birth of a younger sibling, frequent
early hospitalizations, and head injury can lead to secondary enuresis. In many
instances, families have attempted to treat the nighttime bed-wetting at home.
These treatment attempts have included fluid restriction, especially after
dinner, night lifting, and a system of rewards and punishments. Although
rewarding children may be somewhat beneficial in treating enuresis, usually
punishing them for enuresis merely makes the condition worse. It may also lead
to even more self-esteem problems for the children. The evaluation of the
patient should include both a physical examination and a mental status
examination, as well as any x-ray studies, urinalysis, and blood tests that are
needed to be sure that a physical cause is not responsible for the
enuresis.
Treatment
Most
studies suggest that the majority of children with enuresis never come to the
attention of health care professionals. It seems that most families consider
bed-wetting part of normal childhood development. Initially, after obtaining a
good history, treatment is aimed at reassuring the child that enuresis can be
treated, and that a number of children have enuresis. About 10% of patients who
undergo this first evaluation visit will improve without further treatment.
Other therapies involve waking the child and fluid restriction. A number of
medications have been used to treat enuresis. These have included hormonal drugs
and antidepressants, especially the antidepressant imipramine (Tofranil).
Imipramine has been shown to be very effective in treating bedtime enuresis, and
it definitely reduces the frequency of bed-wetting in about 85% of bed-wetters
and eliminates it entirely in about 30%. However, there are many side effects
from imipramine treatment of enuresis, including dry mouth, constipation,
headache, and dizziness. There is also some concern about whether drugs like
imipramine cause arrhythmias that may contribute to sudden infant death
syndrome. Stimulant drugs such as dextroamphetamine have also been used, as well
as other drugs that reduce the frequency of urinating. There are also
psychosocial treatments for enuresis, one of which is the night alarm. This
system initially used two electrodes that were separated by some bedding
connected to the alarm. When the child wet the bed, the urine completed the
electrical circuit, sounding the alarm and awakening
the
child. Since the initial alarm system, other
devices have been used. A vibrating pad beneath the pillow can be used instead
of a bell or a buzzer, or the electrodes can be made into a single unit. They
can be miniaturized so it can be attached to nighttime or daytime clothing. With
such treatment, full elimination of enuresis can be expected in about 80% of the
cases. If the alarm system is used, it is important to be patient because it
usually is not until the second month after the alarm has been used that
enuresis begins to decrease. Relapse after successful treatment of any kind
usually takes place within 6 months after the treatment is stopped, and it seems
that about one third of all children relapse. Unlike nighttime bed-wetting,
daytime enuresis is much more likely to be associated with urinary tract
problems including urinary tract infection, and also with other psychiatric
disorders. It seems that nighttime bed-wetting can often be kept a secret,
whereas daytime enuresis is almost impossible to hide from other individuals.
The most appropriate intervention for daytime enuresis may be regular trips to
the bathroom before the enuresis occurs. This may require some help from the
teacher, who might remind the student about going to the bathroom. Often,
students with enuresis are ashamed to ask to go to the bathroom for fear of
calling attention to themselves. As mentioned earlier, there are also portable
systems that can be worn on the body during the day, or a sensor in the
underwear that can serve as an alarm to the patient. A simpler intervention is
to buy the child a digital watch with a countdown alarm timer. Unlike nighttime
bedwetting, the use of anti-depressants such as Tofranil or imipramine are not
effective for daytime enuresis. Daytime wetters may respond to the use of drugs
that actually slow down the function of the bladder. It is, of course, important
to appreciate the tremendous psychosocial distress that daytime enuresis can
cause. The child will need reassurance, and the parents and family will have to
exercise patience to avoid long-term effects on the child’s
self-confidence.
The
DOs
• If your child has enuresis,
you should avoid excessive criticism of
him/her.
• Your child should avoid
liquids in the evening, and urinate at specified times (e.g., after dinner,
before leaving house, before
bedtime).
• Give your child positive
reinforcement for “dry”
nights.
The
DON’Ts
• Don’t
“baby” or smother your child (infantilization) because this will
only increase dependency.
When to
Call Your Doctor
• If daytime
wetting occurs in a child who initially only wet the bed at
night.
• If urine produced is foul
smelling, blood tinged, or associated with
pain.
• You should also call your
doctor if the bedwetting stops. He likes to hear good news
too!