Bedwetting is common. In time, most children become dry at night without any treatment. However, an option is to use treatment which promotes dry nights sooner rather than later. Treatment is considered for children aged 5 and over.
What is bedwetting?
Bedwetting (nocturnal enuresis) means a child passes urine in the night when they are asleep. Many parents expect children aged 3 to be dry at night.
Although many children are dry at this age, it is common to need nappies at night until school age. However, even beyond this age, bedwetting is common.
About 1 in 7 children aged 5, and 1 in 20 children aged 10 wet their bed at night. Bedwetting is still considered normal in children under the age of 5 years.
A child who has never been dry at night has primary nocturnal enuresis. A child who has had a good period of dry nights, but then develops bedwetting has secondary nocturnal enuresis.
Bedwetting is twice as common in boys as it is in girls.
What causes bedwetting?
In most children there is no specific cause. Bedwetting is not your child’s fault. It occurs because the volume of urine produced at night is more than your child’s bladder can hold.
The sensation of a full bladder does not seem to be strong enough to wake up your child at night.
Some factors are thought to make bedwetting worse or more likely. They may tip the balance in some children on some nights. These include the following:
- Times of stress may start up bedwetting again after a period of dryness. For example: starting school, arrival of a new baby, illness, bullying, abuse.
- Drinks and foods that contain caffeine. These include tea, coffee, cola and chocolate. Caffeine increases the amount of urine made by the kidneys (it is a diuretic).
- Constipation. Large stools (faeces) in the back passage (rectum) may press on and irritate the back of the bladder. In particular, children who have persistent (chronic) constipation are more likely to have a bedwetting problem.
- Children with attention deficit hyperactivity disorder (ADHD) have an increased risk of having a bedwetting problem.
Other specific medical causes of bedwetting are rare. For example, a urine infection, pauses in breathing whilst asleep (sleep apnoea) due to an obstructed airway, diabetes and rare disorders of the bladder may cause bedwetting.
A specific medical cause is more likely if daytime wetting occurs in addition to bedwetting. A doctor can usually rule out these causes by examining the child and testing a urine sample.
Occasionally, more tests are done in children who have daytime wetting to check for rare bladder problems.
Enuresis and psychiatry/psychology
Bedwetting is not believed to be due to a learning disability or psychological issue. It can, however, become a source of problems if the stresses and pressures from the enuresis severely affect the child or his/her family.
Children who have enuresis can develop fear of discovery by their friends and may suffer from teasing from siblings. They can become withdrawn and anxious.
Family members, especially parents and guardians, are asked to be supportive and understanding. Remember that the child in nearly all of these cases cannot directly control what is happening.
Although it may take longer than usual, children who are developmentally delayed can achieve control of their urination as long as their basic neurological function is normal.
Social stress such as a new sibling, sleeping alone, starting a new school, a family crisis, an accident or trauma can probably cause enuresis in children who are genetically predisposed to the condition, but the mechanism and the causes behind the wetting in these children is largely similar to that of other bedwetting children, and the treatment is also similar.
Enuresis and daytime incontinence
Daytime incontinence and enuresis can occur together in some children. In those children, both the day and nighttime wetting need to be addressed.
Sometimes solving the daytime incontinence problem is emphasized first because the child can participate in daily activities more readily. During the day, the child is awake, alert and can assist in helping to stay dry. At night, the child is asleep and is unable to help directly in this response.
The usual cause for daytime incontinence – or for combined day and night wetting – is that the bladder is “overactive”. This means that it tends to contract and tries to empty without warning and without being full. This is not the child’s fault but it can be aggravated by bad toileting habits or by constipation .
Constipation in children often occurs with symptoms of abdominal pain or fecal soiling rather than with the usual complaint of having “hard stools.”
In the latter case, the mechanism is probably that the stool -filled rectum compresses the bladder from behind and makes it irritable and prone to premature contractions.
Thus, when there is day and night wetting it is often important to assess the toilet habits – both for urine and stool – of the child.
The toileting habits of normal children are different from those of adults. Many adults urinate three to four times each day and it is not unusual for them to wait eight hours between urinations.
Children cannot be evaluated with these same standards. Studies have shown that children normally urinate, or should urinate, more frequently. Many children will also exhibit “avoidance maneuvers.”
These are repetitive actions that the child performs to suppress an urge to urinate. Leg crossing and squeezing, squirming and heel sitting are all common examples. When these maneuvers are observed it strongly suggests that the child is trying to suppress an urge to urinate.
Sometimes these actions become habitual and the child may do them without realizing it.
The following are some general tips that may help
If you decide ‘now is the time’ then stop using nappies. Some older children are still put in nappies at night when trying to be dry. This gives them little motivation or need to be dry.
The risk without nappies is wet beds for a while. However, in younger children, if a trial period without nappies does not work out, then go back to nappies for a while and try again at a later date.
Patience, reassurance and love
As mentioned above, if trying without nappies fails at age 3, it may be wise to give up for a while and then try again a few months later. Treatments are not normally needed or advised for children under the age of 5 years. Keep trying every few months until successful.
Even if your child is bedwetting when he or she starts school, there is a high chance that it will stop soon. There is a great variation in when children become naturally dry at night.
Do not punish children for bedwetting. It is not their fault. Rather, they should be praised and made a fuss of if you notice any improvement.
Try to be sensitive to any family or school disruption that might be stressful to your child. If bedwetting appears after a period of dryness, it may reflect a hidden stress or fear (such as bullying at school, etc).
Explaining to children
It needs your child’s co-operation to be dry at night. As soon as your child is old enough to understand, a simple explanation on the following lines can be helpful.
‘The body makes wee (water) all the time and stores it in the bladder. The bladder is like a balloon which fills up with water.
We open the bladder’s tap when the bladder gets full. The bladder fills up at night when we are asleep. However, the bladder tap should not go to sleep, and should wake us up when the bladder is full.’
When old enough (about age 5 or 6), encourage your child to help change any wet sheets. It may be quicker for parents to do it, but many children respond to being given responsibility.
It might also give extra motivation for them to get out of bed and go to the toilet to avoid the chore of changing the sheets. Try to make it a matter-of-fact routine with as little fuss as possible.
Make sure there are no hidden fears or problems about getting up at night. For example, fear of the dark or spiders, getting up from a top bunk, etc. Try leaving the bathroom light on.
Restricting drinks sounds sensible, but it does not help to cure bedwetting. The bladder has to get used to filling up and holding on to urine.
If you limit drinks all day then the bladder cannot be trained to hold on to larger amounts of urine. A sensible plan is only to give drinks to your child if he or she is thirsty in the 2-3 hours before bedtime.
Do not restrict drinks for the rest of the day. Most children should drink about 6-8 cups of fluid a day.
Also, as mentioned above, caffeine in tea, coffee, cola and chocolate may make bedwetting worse. These are therefore ideally avoided, especially in the few hours before bedtime.
It is common practice to wake children up to take them to the toilet several hours after they go to sleep. However, this lifting is of little use, and may even prolong the problem.
Your child has to get used to waking up when their bladder is full. Children often do not remember being lifted, and it usually does not help to achieve their own bladder control.
However, make sure your child goes to the toilet just before bedtime. If your child does wake in the night then you should encourage him or her to go to the toilet then.
If your child is constipated, see a doctor for advice and treatment. Treatment of constipation often cures bedwetting too.
A common worry is that staying with friends or relatives will be embarrassing. However, it is not uncommon to find that the bedwetting stops for the nights away in a strange bed.
A few days away with an understanding relative or friend may result in dry nights. This may be a very positive experience and encouraging for your child.
Use waterproof covers for mattress and duvet, and use absorbent quilted sheets. A moisturiser cream is useful to rub on the skin that is likely to become wet, to prevent chaffing and soreness.
What are the treatment options for bedwetting?
Not using any treatment is an option, as most children will eventually stop bedwetting. The older a child becomes, the more likely that bedwetting will stop.
However, treatments often work to achieve dryness sooner rather than later. Treatment options include the following:
A device called a pad and bell or a similar alarm device is a common treatment. There is a good chance of cure, particularly for children aged 7 and older (when up to 8 in 10 children are cured).
An alarm is usually needed for 3-5 months to condition the child to wake and empty their bladder when it is full. Briefly, the alarm goes off as soon as wetting starts.
This wakes the child and prompts him or her to go to the toilet. In time, the child is conditioned to wake when their bladder is full before they begin to wet.
Alarms can be borrowed from your local continence advisor. Your doctor can advise about this. See separate leaflet called Bedwetting Alarms for more details.
Desmopressin is the common medicine used for bedwetting. It works by reducing the amount of urine made at night by the kidneys. It usually works well (in about 7 in 10 cases), and straightaway.
If it works, a common plan is to take it for three months and then try without it. However, when it is stopped, the bedwetting often returns. (A permanent cure following treatment is more likely with bedwetting alarms than with desmopressin.)
Desmopressin can also be useful for short spells. For example, during holidays or for times away from home. See separate leaflet called Desmopressin for Bedwetting for more details.
Briefly, you agree a reward with your child if he or she achieves a goal. Often the goal is not a complete dry night (as most children who wet the bed have no control over their wetting).
An agreed goal could be: going to the toilet before going to bed, getting up and telling the parents they are wet, helping to remake the bed, etc.
A goal of a dry night may be appropriate in some cases when the situation is improving. A common example of a reward system is a star chart. This is simply a calendar with a space for each day.
A child places a sticky star on each day following a good night (where the goal was achieved).
For a poor night (where the goal wasn’t achieved), the day is left blank. You may agree a reward for a number of stars. The aim is to give the child motivation to become dry.