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Name of Symptom/Sign:
Enuresis
[[Image:{{{Image}}}|190px|center|]]
ICD-10 R32, F980
ICD-O: {{{ICDO}}}
ICD-9 788.36
OMIM {{{OMIM}}}
MedlinePlus {{{MedlinePlus}}}
eMedicine {{{eMedicineSubj}}}/{{{eMedicineTopic}}}
DiseasesDB {{{DiseasesDB}}}
Main article: Urinary incontinence


Bedwetting (or nocturnal enuresis or sleepwetting) is involuntary passing of urine while asleep after the age at which bladder control would normally be anticipated.

Most children (85-90%) will consistently stay dry by age 6. By age 10, 95% of children are dry at night. Studies place adult bedwetting rates at between 0.5% to 2.3%.

A small percentage (5 to 10%) of bedwetting cases are caused by specific medical situations. Most cases, however, do not have a specific identifiable cause. [1]

Treatment ranges from behavioral-based options to medication. Much of the rationale for treatment revolves around protecting/improving the patient’s self-esteem (Ilyas & Jerkins, 1996). [2].

The type of bedwetting depends on whether or not the individual has stayed dry in the past:

  • A child that has not yet stayed dry on a regular basis is considered to have primary nocturnal enuresis (PNE)
  • A child or adult who begins wetting again after having stayed dry is consider to have secondary nocturnal enuresis

Usual developmental processEdit

Most bedwetting can be described as, "a bothersome alteration in normal development." [3] The usual development process is:

  • Infants: Void by reflex
  • One- and two-year olds: Bladder grows larger and the brain develops the ability to sense bladder fullness (McLorie & Husmann, 1987)
  • Two- and three-year olds: Develop the ability to void or inhibit voiding
  • Four- and five-year-olds: Develop an adult pattern of urinary control

In 1940Gesell established 42 months as the norm for remaining dry at night without being picked up.[1]

Frequency of bedwetting (epidemiology)Edit

Males are more likely to wet the bed than females. Males make up 60% of bed-wetters overall and make up more than 90% of those who wet nightly (Schmitt, 1997).

Doctors frequently consider bedwetting as a self-limiting problem, since most children will grow out of it.

Approximate bedwetting rates are:

  • Age 5: 20%
  • Age 6: 10 to 15%
  • Age 7: 7%
  • Age 10: 5%
  • Age 15: 1-2%
  • Age 18-64: 0.5%-1% [4]

Children 5 to 9 years old have a spontaneous cure rate of 14% per year. Adolescents 10 to 18 years old have a spontaneous cure rate of 16% per year.

As can be seen from the numbers above, 5% to 10% of bedwetting children will not outgrow the problem, leaving 0.5% to 1% of adults still dealing with bedwetting. [5] Individuals who are still enuretic at age 18 are likely to deal with bedwetting throughout their lives. Adult rates of bedwetting show little change due to spontaneous cure. [6]

Studies of bedwetting in adults have found varying rates. The most-quoted study in this area was done in the Netherlands. It found a 0.5% rate for 18-64 year olds. A Hong Kong study, however, found a much higher rate. The Hong Kong researchers found a bedwetting rate of 2.3% in 16 to 40 year olds. [7]

Medical definitions (clinical criteria): primary vs. secondary enuresisEdit

Primary enuresis is when a child has never been dry at night or would not sleep dry without being taken to the toilet by another person or has some dry nights but continues to average at least two wet nights a week with no long periods of dryness.

Secondary enuresis occurs when a patient goes through an extended period of dryness and begins to experience night-time wetting again. Secondary enuresis can be caused by emotional stress or a medical condition.

Some medical definitions list Primary Nocturnal Enuresis (PNE) as a clinical condition at between 4-5 years old. This type of classification is frequently used by insurance companies. It defines PNE as “Persistent bedwetting in the absence of any urologic, medical or neurological anomaly in a child beyond the age when over 75% of children are normally dry.” [8]

Psychologists may use a definition from the American Psychiatric Association’s DSM-IV, defining nocturnal enuresis as repeated urination into bed or clothes, occurring twice per week for at least 3 consecutive months in a child of at least 5 years of age and not due to either a drug side effect or a medical condition. Even if the case does not meet this criteria, the DSM-IV definition allows psychologists to diagnose nocturnal enuresis if the wetting causes the patient clinically significant distress. [9]

Other definitions cast themselves as more “practical” guidance, saying that bedwetting can be considered "clinical problem" if the child is unable to keep the bed dry by age seven. [10]

D'Alessandro refines this to bedwetting more than 2x/month after the age:

  • 6 years for females
  • 7 years for males. [11]

Secondary enuresis is defined as the onset of bedwetting after having been dry at night for 6 months prior to wetting the bed again. [12]

Doctors consider medical evaluation/intervention when:

  • The physician suspects a bladder abnormality
  • Lab tests show an infection or other medical condition like diabetes
  • The bedwetting is harming the child’s self-esteem or relationships with family/friends

Doctors and parents polled in a medical study reported significantly different attitudes about bedwetting. Parents felt children should stay dry by 2.75 years old, while the physicians average response was 5.13 years. [13]

Normal processes of staying dry (regulation in the organism)Edit

Children usually achieve nighttime dryness by developing one or both of two abilities. There appear to be some hereditary factors in how and when these develop.

  • One is a hormone cycle in which a minute burst of antidiuretic hormone happens daily at about sunset reducing kidney output of urine well into the night so the bladder doesn't get full until morning. This hormone cycle is not present at birth. Many children develop it between the ages of two and six years old, others between six and the end of puberty, and some not at all.
  • The other is the ability to awaken before wetting. The body normally develops the ability to wake when the bladder is full.

Causes of bedwettingEdit

Only a small percentage of bedwetting is caused by an infection, physical abnormality, or other specifically identifiable cause. Most bedwetting is caused by neurological-developmental problems involving multiple factors. [14]

  • Infection/disease
    Less than 5% of all bedwetting cases are caused by infection or disease, the most common of which is a urinary tract infection. Infections and disease are more strongly connected to secondary nocturnal enuresis and with daytime wetting.[15]
  • Genetics
    Bedwetting has a strong genetic component. Children whose parents were not enuretic have only a 15% incidence of bedwetting. When one or both parents were bedwetters, the rates jump to 44% and 77% respectively. [16] Genetic research shows that bedwetting is associated with the genes 13q and 12q (possibly 5 and 22 also). [17]
  • Physical abnormalities
    Less than 10% of enuretics have urinary tract abnormalities, such as a smaller than normal bladder. Current data does support increased bladder tone in some enuretics, which functionally would decrease bladder capacity. [18]
  • Insufficient anti-diuretic hormone (ADH) production
    A portion of bedwetting children do not produce enough of the Anti-Diuretic Hormone. Normally ADH increases at night. This increase doesn't occur in child enuretics, but does occur in adolescent enuretics. The diurnal change may not be seen until ~age 10. [19]
  • Stress
    Stress is controversial as a possible cause of bedwetting. Some sources report that, “Psychologists and other mental health professionals regularly report that children begin wetting the bed during times of conflict at home or school. Dramatic changes in home and family life also appear to lead some children to wet the bed. Moving to a new town, parent conflict or divorce, arrival of a new baby, or loss of a loved one or pet can cause insecurity that contributes to bedwetting.” [20]
    Other sources contradict this, saying, “Doctors have found no relationship to social background, life stresses, family constellation, or number of residencies.” [21]
  • Psychological
    In rare cases, bedwetting is a symptom of a more severe underlying psychological problem. Medical guidance for doctors state that this is a relatively rare occurrence. [22] [23] When Enuresis is caused by a psychological disorder, the bedwetting is considered a symptom. Enuresis does have a psychological diagnosis code (see previous), but it is not considered a psychological problem itself.[24]

Note: Studies show that bedwetting children have more behavioral problems. It is unclear if this is a result of the self-esteem issues/stresses from bedwetting or if developmental delays that may help cause bedwetting also help cause behavioral problems. [25]

  • Caffeine
    Caffeine increases urine production. [26]
  • Food allergies
    For some patients, food allergies may be part of the cause. This link is not well established, requiring further research. [27][28]
  • Sleep disorders
    Sleep issues are another controversial potential cause of bedwetting.
    • Sleep apnea stemming from upper airway obstruction has been associated with enuresis. This can be signaled by snoring and enlarged tonsils or adenoids [29]
    • Many parents report that their bedwetting children are heavy sleepers. Research in this has some contradictory results. Studies show that children wet the bed during all phases of sleep, not just the deepest (stage four). A recent study, however, showed that enuretic children were harder to wake [30] Some literature does show a possible connection between sleep disorders and ADH production. Insufficient ADH might make it more difficult to transition from light sleep to being awake. [31]
  • Constipation
    Chronic constipation can cause bedwetting. When the bowels are full, it can put pressure on the bladder. [32]
  • Attention deficit hyperactivity disorder (ADHD)
    Children with ADHD are 2.7 time more likely to have bedwetting issues. [33]
  • Improper toilet training
    This is another disputed cause of bedwetting. This theory was more widely supported in the last century and is still cited by some authors today. Some say bedwetting can be caused by toilet training that is started too early or is too forceful. Recent research has shown more mixed results and a connection to toilet training has not been proved or disproved.[34]

Psychological-social impactEdit

A review of medical literature shows doctors consistently stressing that a bedwetting child is not at fault for the situation. Many medical studies state that the psychological impacts of bedwetting are more important than the physical considerations. “It is often the child's and family member's reaction to bedwetting that determines whether it is a problem or not.” [35]

Psychological theory through the 1960s placed much greater focus on the possibility that a bedwetting child might be acting out, purposefully striking back against parents by soiling linens and bedding. More recent research and medical literature states that this is very rare.

Medical literature states and studies show that punishing or shaming a child for bedwetting will frequently make the situation worse. Doctors describe a downward cycle where a child punished for bedwetting feels shame and a loss of self-confidence. This can cause increased bedwetting incidents, leading to more punishment/shaming, “an escalating cycle of wetting accidents and shame.” [36]

In the United States, about 35% of enuretic children are punished for wetting the bed. [37] In Hong Kong, 57% of enuretic children are punished for wetting. [38]

Parents with only a grade-school level education punish bed-wetting children at twice the rate of high school- and college-educated parents. [39]

Parents and family members are frequently stressed by a child’s bedwetting. Soiled linens and clothing cause additional laundry. Wetting episodes can cause lost sleep if the child wakes and/or cries, waking the parents. A European study estimated that a family with a child who wets nightly will pay about $1,000 a year for additional laundry, extra sheets, disposable absorbent garments such as diapers, and mattress replacement. [40]

Despite these stressful effects, doctors emphasize that parents should react patiently and supportively. [41]

Bedwetting children feel effects ranging from feeling cold on waking, being teased by siblings, being punished by parents, and being afraid that friends will find out. Whether bedwetting causes low self-esteem remains a subject of debate, but several studies have found that self-esteem improved with management of the condition. [42]

Children questioned in one study ranked bedwetting as the third most stressful life event, after parental divorce and parental fighting. Adolescents in the same study ranked bedwetting as tied for second with parental fighting. [43]

TreatmentEdit

Tricyclic antidepressant prescription drugs with anti-muscarinic properties (i.e. Amitriptyline, Imipramine or Nortriptyline) may be used to treat bedwetting with much success for periods up to 3 months.

Another medication, Desmopressin, is a synthetic replacement for the missing burst of antidiuretic hormone. Desmopressin is usually used in the form of Desmopressin acetate, DDAVP. Whether used daily or occasionally, DDAVP simply replaces the hormone for that night with no cumulative effect. However, desmopressin acetate intranasal formulations (Waknine, 2007) are no longer indicated for primary treatment of PNE due to the risk of hyponatremia that may lead to seizures and death. Providers are cautioned by the FDA to restrict fluid intake from 1 hour prior to use and up to 8 hours post use of all desmopressin formulations. {see article retrieved at http://www.medscape.com/viewarticle/566977)

Some psychologists and experts recommend the use of night-time training devices such as a bedwetting alarm to help condition the child first to wake up at the sensation of moisture and then at the sensation of a full bladder. Success with alarms is increased and relapses reduced when combined in programs which may include bladder muscle exercises, dietary changes, mental imagery, stress reduction, and other supportive activities.

Diapers can reduce the embarrassment and mess of wetting incidents. Diaper sizes for enuresis cover individuals from 38 lbs (17 kg) through adult sizes. Some research, however, inidcates that extended use of diapers can interfere with learning to stay dry. [44]

Experts generally agree that parents' understanding that sleepwetting is not the child’s fault strongly increases the child's willingness to help deal with it. Although historically, physical punishment such as spanking was the normal method of incentivizing older children to stop sleep wetting, anti-spanking advocates have discouraged any corporal punishment for this purpose. Punishments including restrictions, teasing, or shaming, whether actual or threatened, are counterproductive. Encouragement of self reliance allows for the child's own natural and native development to acquire the ability to sleep dry on his or her own terms.

See alsoEdit

References & BibliographyEdit

  1. Harriman P.L. (1961). Dictionary of Psychology. London Peter Owen and Vision Press.

Key textsEdit

BooksEdit

PapersEdit

Additional materialEdit

BooksEdit

PapersEdit

External linksEdit

External linksEdit

<--- de:Enuresis es:Enuresis nocturna fr:Énurésie nl:Enureseno:Sengevæting pt:Incontinência urinária sr:Енуреза --->

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