Nocturnal Enuresis in Children

All children start life being incontinent of urine both by day and night and, as neurological maturation occurs, voluntary control of the bladder is gained first by day and then by night. Very few never gain control of the bladder unless there is obvious neurological disease, including gross mental handicap. In most cases, nocturnal enuresis in children should be seen not as a disease but as a variation of the normal rate of neurological maturation.


Three factors are commonly involved: a disorder of sleep arousal, a low nocturnal bladder capacity and nocturnal polyuria. Constipation may be an additional aggravating condition.


  • Primary nocturnal enuresis: This is the recurrent involuntary passage of urine during sleep by a child aged 5 years or older, who has never achieved consistent night-time dryness. Some children have enuresis only at night and others also have daytime symptoms (urgency, frequency or daytime wetting).
  • Secondary nocturnal enuresis: This is the involuntary passage of urine during sleep by a child who has previously been dry for at least 6 months.


Primary enuresis most often represents developmental delay which resolves in time. In secondary enuresis the patient regresses after a period of incontinence which requires the exclusion of underlying pathology, e.g. a urinary infection.


There are a number of factors that predispose to persistent nocturnal enuresis:


  • Genetic predisposition: It is said that the risk of nocturnal enuresis is 15% if neither parent was affected, 40% if one parent was affected and 75% if both had the condition.
  • 23% of nocturnal enuresis is associated with encorpresis and daytime incontinence.
  • Enuresis is to be expected as a manifestation of developmental delay, in those with global developmental delay, with or without an associated syndrome such as Down’s syndrome Even without gross developmental delay, there is more likely to be persistent bed-wetting in children with delayed developmental milestones, premature delivery or behavioral disorders such as hyperactivity or inattention deficits.
  • There may be neurological problems such as spina bifida or cerebral palsy.
  • Constipation can cause bladder problems.
  • Other risk factors include disturbed sleep, mother aged less than 20 at time of birth, and mother smokes at least 10 cigarettes a day at home and not being first born.
  • Airways obstruction with snoring increases risk.
  • Drinks containing methylxanthines (e.g. caffeine and theophylline found in 'high-energy' drinks) can aggravate the situation by their diuretic action. These include tea, coffee, cola and chocolate.
  • Stresses in the child's life such as an admission to hospital with separation from the mother, or bullying, are more likely to cause secondary enuresis. The older the child, the more likely it is that psychological problems are the result of enuresis and not the cause.


Bed-wetting affects children:


Bed-wetting is not physically painful, but such children might suffer from emotional problems. This is largely due to the stigma associated with bed-wetting. Some children may become victims of punishments meted out to them for their bed-wetting. Others may be belittled by their uninformed parents or taunted by their siblings. Punishing or teasing your children will only harm their self esteem and make it more difficult for them to stop.

Bed-wetting also prevents children from attending certain social activities like sleepovers and overnight trips. Children who are unable to join in these gatherings may find themselves missing out on spending quality time with their peers for no fault of theirs.


Parents do remember:


The first thing to remember is that bed-wetting is an involuntary response. A child does not deliberately wet the bed. He just cannot control the flow of urine while he is asleep. Almost all children wet their bed till their bodies learn to control their bladder. Thus, bedwetting until the age of five or six is perceived to be a common occurrence and is usually not considered a problem.


Steps parents can take:


There are some steps parents can take to minimise a child's chances of bed-wetting. The simplest way is to limit a child's fluid intake a few hours before bedtime. Also, encourage your child to visit the toilet before he goes to sleep.


If necessary, wake him up once during the night so that he can empty his bladder. Bed-wetting may increase with a drop in temperature, so make sure your child is dressed in warm clothing. If you wish, make your child wear diapers to reduce his embarrassment and prevent him from making a mess.


Behavioral modification:


  • Star charts: The aim is to reinforce success rather than to punish failure. Remember that the child does not choose to wet the bed at night. The star chart requires a calendar and some sticky stars. Every time that the child has a dry night, a star is placed on that date. If it is not a dry night, that date is ignored. The star is a reward. There is no punishment. Perhaps a run of success, such as 7 consecutive stars, may merit a treat. For this to be viable, the child must have a significant number of dry nights already.
  • Enuresis alarms: Alarms are the treatment of choice for the long-term management of nocturnal enuresis. Most providers of buzzers and pads insist that the child should be at least 7 years old and have been checked for UTI. The device should be used for 3-5 months. The aim is to wake the child as they start to urinate, so that they will stop, go to the toilet and learn to recognize the nocturnal sensation of a full bladder.


A common cause of nocturnal enuresis is that the child sleeps so deeply that he does not respond to the sensation of a full bladder. 65% of children become dry with treatment although, after 6 months, 50% tend to relapse. 'Over-learning' (increasing fluid intake beyond that normally expected, to train the bladder) may help reduce this.


When to consult your healthcare provider:


  • In severe cases of bed-wetting.
  • If the child is more than 6 years old.
  • If the child was previously dry but recently is suffering from enuresis.
  • Any child with daytime symptoms.
  • Failure of an enuresis alarm may be an indication for referral to confirm the diagnosis and obtain specialist advice regarding management.


What will the doctor do?


  • Your healthcare provider will take a detailed history, do a complete physical examination and order some investigations to determine the underlying cause.
  • If no underlying cause is detected then he may prescribe a hormonal supplement to compensate for the low levels of ADH. He may also recommend exercises to strengthen the bladder.


Bed-wetting is not a disease. It is simply an unfortunate condition that affects children not just physically, but mentally as well. However, it can be easily cured and in most cases, the best healer is time.



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