Helena Baker, RGN.
Freelance Nurse Consultant, Chelmsford, EssexBedwetting is the most prevalent of chronic childhood disorders (Hicks and Clark, 1999), and families who are affected may feel isolated and stigmatised. This article discusses the nature of bedwetting - including definitions and epidemiology - treatment strategies and the role of the health visitor and practice nurse in managing this problem.
Bedwetting is the most prevalent of chronic childhood disorders (Hicks and Clark, 1999), and families who are affected may feel isolated and stigmatised. This article discusses the nature of bedwetting - including definitions and epidemiology - treatment strategies and the role of the health visitor and practice nurse in managing this problem.
Definitions and prevalence
Bedwetting, or enuresis, is defined as the involuntary discharge of urine by day or night or both in a child aged five years or older, in the absence of congenital or acquired defects of the nervous system or urinary tract (Forsythe and Butler, 1989). Enuresis may occur during the day, when it is defined as daytime wetting, or at night, when it is termed nocturnal enuresis. This article focuses on nocturnal enuresis, which can be split into two categories:
Primary nocturnal enuresis (PNE) - PNE is the most common form of the condition. The child has not achieved dryness at night for a consistent period. Dryness during the day is normally achieved through potty training.
Secondary nocturnal enuresis (SNE) - In SNE, the child has achieved dryness at night through potty training and has remained dry for a significant length of time (at least six to 12 months) and then started wetting again.
Nocturnal enuresis affects at least 500,000 children between the ages of five and 11 in the UK each year. The prevalence of the condition among the entire child population is broken down in Box 1.
Causes of bedwetting
The actual causes of bedwetting are largely unknown, outside pathological reasons such as urinary tract infections (UTIs) or physical factors such as hypospadias, malfunctioning urethral valves or spinal defects. Recognising when the bladder is full is a skill that has to be learned, in much the same way as walking and talking, and children achieve these skills at different times and at different speeds.
It is only once the bladder is full and contracts, sending messages to the brain indicating the need to void, that the individual has control over the process. Postponement of voiding involves tensing the muscles in the pelvic floor to keep the sphincter muscle closed and then relaxing the same muscles in the right place and at the right time. As Dr Richard Butler from the Enuresis Resource and Information Centre describes: 'Staying dry depends on the ability to recognise and react to the signals (from the bladder muscles) either by increased holding on or by using the toilet' (Hicks and Clark, 1999).
Genetics - Research has revealed a strong genetic link in cases of enuresis (vonGontard, 1999). The associated genes have been isolated to 8q, 12q and 13q on the human genome. These sites all appear to be involved in gaining bladder control. While there is no cure at present, this knowledge may at least help us to understand why the problem seems to run in families. Indeed, Dr Godfrey Clark, who has undertaken research in the field, suggests that if one parent wet the bed as a child, then their children have a 45% chance of doing so. If enuresis was a problem for both parents, this figure rises to 80-90%. There is also some evidence of a genetic cause in cases of daytime wetting and urgency. However, research in this area is still in the early stages.
Stress - Other possible causes of enuresis include stressful life events such as moving house, parental divorce or bullying at school or at home. Stress before the age of four can contribute to primary nocturnal enuresis, while stress after bladder control has been achieved at night can contribute to secondary nocturnal enuresis. In addition, stress related to the wetting itself can make the situation significantly worse. Couchells et al (1981) found that mothers of children with enuresis applied more rule-orientated child-rearing practices than those with a non-enuretic child.
Constipation - Constipation is another common cause, with a loaded rectum and sigmoid colon putting additional pressure on the bladder. In addition, constipation is often associated with poor fluid intake and diet, both of which also affect the condition.
Hormonal problems - In some children, the hormone arginine vasopressin, secreted from the posterior pituitary gland overnight to concentrate urine and reduce its volume, can be under-produced. Vasopressin stimulates the reabsorption of water through the kidneys during sleep, producing small amounts of very concentrated urine each morning. Some children with enuresis continue to produce large amounts of urine overnight and may be under-secreting vasopressin (Rittig, 1997).
Effects of bedwetting on parent and child
Regardless of the cause, nocturnal enuresis is frustrating and upsetting for everyone involved. The child will be embarrassed, and evidence suggests that self-esteem in children with nocturnal enuresis is significantly lower than in children who do not wet the bed (Wagner et al, 1982; Butler et al, 1994).
Being woken up in the middle of the night to change sheets, the extra washing, cleaning, coping with holidays and nights away from home also place a tremendous burden on parents, both physically, psychologically and financially.
Solutions to the problem
For years, the standard response from any medical professional when confronted with the bedwetting child was to state: 'They'll grow out of it.' Fortunately, a more practical approach is taken these days, and children are finally getting the help they need.
On the whole, solutions are based on sound common sense and evidence-based practice. First and foremost, any bedwetting child should have a medical examination to rule out any physical abnormality, and a urine dipstick to check for UTI or diabetes. While these causes are reasonably uncommon, it is essential to rule them out.
Practical issues - Once any physical cause has been eliminated, the child's home environment should be discussed. This may involve considering practical issues that affect getting to the toilet at night. Many children are afraid of the dark and do not want to get out of bed alone.
Downstairs bathrooms and houses that are cold at night also tend to exacerbate the problem. It may be worth suggesting making a potty available in the bedroom in such circumstances. Nightlights, child toilet seats (so that they do not fear falling down the toilet) and child gates across the top of the stairs (so that they do not fear falling down the stairs in the dark) may help to relieve the problem.
Fluid intake - Another common problem is that some children do not drink enough water during the day and so tend to make up for it in the evening. They then go to bed with a full bladder. A child's fluid intake should not be restricted - they rarely get as much as they should - but encourage the parents to try to ensure they drink throughout the day, rather than in the evening.
Reducing their intake of fizzy drinks, along with caffeine-containing drinks, such as tea, coffee and cola, also seems to help. Once these simple, practical measures have been taken, there are a number of other possible measures that are worth trying.
Rewards and star charts - I and others have used this system for many years, with varying degrees of success. This may be because often the programme rewards only dry nights, which are likely to be rare in the early stages. A child who rarely achieves a reward target will become demotivated. To make sure the programme is a success, advise parents to keep the reward small and make it something the child values.
If they promise a bike when the child becomes dry, the reward programme will fail, because the child will view it as completely unachievable. Instead, advise them to use stars on a chart or a five pence piece in a pot. It is important for the parent to agree certain goals and acceptable behaviours with the child, such as disposing of wet sheets and clothes in an agreed manner, or helping change the sheets when wet.
The child should be rewarded for complying with this agreed behaviour. Rewarding the action rather than the overall outcome is far more likely to be successful than only rewarding dry nights.
Waking - Many parents lift the child and put them on the toilet just before they themselves go to bed. If the child is still asleep, he or she is unlikely to have any memory of the activity the following morning. Further, because the child is still asleep, the habit of urinating during sleep is reinforced. If the parents do wish to continue to lift the child, they need to wake the child properly, so that he or she can walk to the toilet and urinate with full awareness of the action. At this point, the child should then be rewarded with a star, for example, and praised for using the toilet. Once back in bed, the child should be encouraged to check that the sheets are dry. The child should then go back to sleep, having received lots of encouragement to keep the sheets dry until morning.
Medical professionals have mixed views about waking programmes. However, my experience has been that they work quite well, provided the child is fully aware and receives the reward immediately.
Disposable pants - While not suitable for long-term use, absorbent pants can occasionally be worn under pyjamas or nightdresses. They are particularly helpful if the child is going on a school trip or to stay with a friend or if the family is planning a night away from home, as they look like normal underwear. They are available from most supermarkets and pharmacies.
Desmopressin (DDAVP) - DDAVP is a synthetic version of the hormone vasopressin and is used to reduce the amount of urine produced overnight. This treatment works very well, particularly in children who wet many times each night or who seem to produce large quantities of urine overnight.
The treatment is available as a nasal spray or tablet on prescription and should be given for three to six months, gradually reducing the dose until the child is consistently dry.
Provided the child is kept on the drug for at least three to six months and the dose is withdrawn slowly, enuresis is cured in around 75% of cases with a very low relapse rate. Children can start using DDAVP from five years of age.
Relapse may be caused by using the drug for the short term only or failing to reduce the dose slowly. The drug should be taken just before the child goes to bed. After taking it, only enough fluid to satisfy thirst should be offered to the child, as the drug alters the way fluid is retained in the body. However, it is important to emphasise to the parent that fluid intake is not restricted before the drug is taken, since this will inevitably lead to dehydration.
Alarms - The enuresis alarm is a conditioning therapy, and should not be used in children under the age of seven years. Alarms use a sensor either worn in the pants or placed under the bottom sheet. If the child urinates while sleeping, the urine hits the sensor and a buzzer goes off.
This wakes up the child, who should then go to the toilet to finish urinating. Gradually, over a period of four to six months, the child will learn to wake, not to the sound of the buzzer, but to the sensation of urine in the bladder. Like DDAVP, this method succeeds in 75% of cases, with a very low relapse rate.
Both systems should ideally be managed in a specialist enuresis clinic, by staff who are experienced in their use. School nurses usually run the clinics with community medical officers and most trusts run at least one clinic.
The problem of bedwetting is often overlooked or ignored, yet it can cause the child great and unnecessary embarrassment. There is often a solution, and the practice nurse or health visitor is often the first health professional the family will speak to for advice on the matter.
Offering simple, practical advice and then referring the child to a clinic or specialist practitioner will provide huge reassurance to families that have usually been struggling with the problem for years.
The author would like to thank the Enuresis Resource Information Centre for assistance in the preparation of this article.
Bedwetting Education Service Tel: 0800 085 8189 (Mon-Fri 9am-5pm).
Continence Foundation Helpline Tel: 020-7831 9831 (Mon-Fri 9.30am-4.30pm). Practical advice for bedwetters and families.
Incontact Tel: 020-7700 7035. Confidential advice from specialist nurses.
PromoCon 2001 Tel: 0161-834 2001. Advice for people with bladder or bowel problems.
Enuresis Resource Information Centre (ERIC). Tel: 0117-960 3060. Information on bedwetting protection.
Butler, R.J., Redfern, E.J., Holland, P. (1994)Children's notions about enuresis and the implications for treatment. Scandinavian Journal of Urology Nephrology 163: (Suppl) 39-47.
Couchells, S.M., Johnson, S.B., Carter, R., Walder, D. (1981)Behavioural and environmental characteristics of treated and untreated enuretic children and matched nonenuretic controls. Journal of Pediatric Psychology 99: 5, 812-816.
Forsythe, W.I., Butler, R.J. (1989)Fifty years of enuresis alarms: a review of the literature. Archives of Disease in Childhood 64: 6, 879-885.
Hicks, M.R., Clark, G. (1999)Top 100 nocturnal enuresis. GP Medicine August: 30-31.
Pierce, C.M. (1980)Enuresis. In: Kaplan, H.I., Friedman, A.M., Sadock, B.J. (Eds.). Comprehensive Textbook of Psychiatry (3rd Ed). Baltimore: Williams & Wilkins.
Rittig, S. (1997)Dirunal variation in plasma levels of antidiuretic hormone and urinary output in patients with enuresis and control subjects. Nephrology and Urodynamics 6: 260-261.
Rutter, M., Yule,W., Graham, P. (1973)Enuresis and behavioural deviance: some epidemiological considerations. In: Kolvin, I., MacKeith, R.C., Meadows, S.R. (eds) Bladder Control and Enuresis. Cambridge: Cambridge University Press.
vonGontard, A., Eiberg, H., Hollman, E., Rittig, S., Lehmkuhl, G. (1999)Molecular genetics of nocturnal enuresis: linkage to a locus on chromosome 22. Scandinavian Journal of Urology and Nephrology 202: 76-80.
Wagner, W.G., Johnson, S.B., Walker, D. et al (1982)A controlled comparison of two treatment methods for nocturnal enuresis. Journal of Pediatrics 101: 302-307.