Bedwetting (nocturnal enuresis) in children

Bedwetting, or nocturnal enuresis, is the involuntary passing of urine during sleep in a child who is already old enough to control their bladder – by the generally accepted threshold, after their fifth birthday.

The condition is more common than it seems, because families rarely talk about it: roughly one in ten seven-year-olds wets the bed at night, and some teenagers do too. Effective treatment exists, and there is no reason to wait while the bedwetting undermines the child’s self-confidence. Dr Penev sees children with enuresis in Plovdiv and Karlovo – always together with their parents and without blaming the child.

What enuresis is

A dry night needs three things: the kidneys must produce less urine during sleep, the bladder must hold what is produced, and the brain must wake up if the bladder fills. In enuresis, one or more of these links has not yet matured.

In primary enuresis the child has never had dry nights for six months or more – this is the most common form. In secondary enuresis the bedwetting returns after at least half a year without wet nights, and there is more often a trigger: an infection, constipation, stress, the onset of diabetes. In monosymptomatic enuresis the only problem is at night; in non-monosymptomatic enuresis there are daytime symptoms as well, and the bladder is assessed in more detail.

Symptoms

The main symptom is a wet bed, usually in the first half of the night, in a child who is deeply asleep. Signs of an accompanying problem:

• daytime leakage, passing urine very often or very rarely, urges that cannot be held;
• burning, pain, cloudy or smelly urine, a fever – a possible urinary tract infection;
• hard, infrequent bowel movements or soiling of underwear – constipation pressing on the bladder;
• strong thirst, weight loss and large amounts of urine – a warning sign of diabetes.

When it is urgent: if your child suddenly cannot pass urine, has severe pain in the abdomen or lower back, a high temperature with vomiting, or blood in the urine, go to an emergency department or call 112 (the European emergency number) straight away instead of waiting for a planned appointment.

Causes and risk factors

Enuresis is almost never a psychological problem or laziness. The most common causes are heredity (if a parent wet the bed as a child, the risk is considerably higher); nocturnal polyuria – the kidneys produce more urine at night because the hormone vasopressin does not rise enough during sleep; a small bladder capacity or an overactive bladder; and a high threshold for waking up. Constipation, infections, breathing problems during sleep, attention deficit disorder and stress also contribute.

Diagnosis

At the paediatric urology consultation Dr Penev asks about how often the wet nights happen, the child’s habits for passing urine and drinking, bowel movements, sleep and family history. A diary kept for two or three days with the times and amounts is useful – it shows whether the problem lies in the volume of urine at night or in the capacity of the bladder.

The examination covers the abdomen, the genitals, the back and the legs, and a dipstick urine test rules out infection and sugar. If there are daytime symptoms or a suspicion of incomplete emptying, at the doctor’s discretion an ultrasound scan of the kidneys and bladder with measurement of the residual urine is added and, if needed, uroflowmetry – a painless measurement of the urine stream.

Treatment

Routine and behavioural measures

Treatment starts by explaining to the child and the parents that bedwetting is nobody’s fault and is not under conscious control. Then come simple rules: passing urine every two to three hours during the day and before bed; most fluids drunk by early afternoon, only small amounts in the evening, and no fizzy or caffeinated drinks; treating constipation, without which the other measures often do not work. Punishment has no place; a calendar that rewards effort rather than results is useful.

Bedwetting alarm

The alarm is a small sensor in the underwear or on a pad that sounds at the first drops and wakes the child; over time the brain learns to recognise the signal from a full bladder. Treatment usually takes two to three months and needs persistence from the whole family, but the result is longer-lasting and achieved without medicines.

Medication

Desmopressin is a synthetic analogue of vasopressin that reduces urine production during the night. It is taken in the evening as a tablet or as a melt that dissolves under the tongue, in children with nocturnal polyuria and normal bladder capacity; the nasal spray is not used for enuresis. The child should not drink fluids for one hour before and eight hours after taking it, and if there is vomiting, diarrhoea or a larger amount of fluid drunk that evening, the dose is skipped so that water is not retained in the body; it is stopped gradually, as the doctor advises. For an overactive bladder, medicines that relax the bladder are added, and in persistent cases the alarm and desmopressin are combined.

When to see a urologist

A consultation is appropriate when your child is five or six years old and still regularly wets the bed, when bedwetting returns after a long dry period, when there is daytime leakage, pain, infections or changes in the urine stream, and when the problem is already weighing on the child – they refuse to go to camps or to stay with friends.

Prevention

Enuresis cannot be prevented completely, but healthy habits make treatment easier: enough fluids during the day, passing urine regularly, preventing constipation with fruit, vegetables and physical activity, a steady sleep routine and a home atmosphere in which a wet bed is just a minor incident.

Bedwetting is a temporary condition with good treatment options. If your child needs help, book an appointment with Dr Penev for a calm conversation, an accurate diagnosis and a plan that suits your family.