Dr. M.J. Bazos, MD Patient Handout


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.

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!