Bedwetting in children

Bedwetting in Children (Nocturnal Enuresis)

Introduction

Bedwetting (nocturnal enuresis) is the repeated, involuntary leakage of urine during sleep in children aged 5 years and older.

• Affects about 15–20% of 5-year-olds, 5% of 10-year-olds, and 1–2% of teenagers.

• Boys are more commonly affected than girls.

• Most children outgrow it naturally, but treatment is often needed if it persists or causes distress.

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Types of Enuresis

1. Primary nocturnal enuresis

   • Child has never been consistently dry at night.

   • Usually due to delayed bladder control development.

2. Secondary nocturnal enuresis

   • Child had been dry for at least 6 months, then starts bedwetting again.

   • Often associated with stress, infection, or medical conditions.

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Causes and Risk Factors

1. Developmental and Neurological

• Delay in achieving nighttime bladder control.

• Deep sleep → child does not wake when bladder is full.

• Reduced nocturnal secretion of antidiuretic hormone (ADH) → increased nighttime urine production.

2. Urological Causes

• Overactive bladder.

• Small functional bladder capacity.

• Urinary tract infection (UTI).

• Structural abnormalities (rare, e.g., posterior urethral valves).

3. Gastrointestinal

• Chronic constipation → pressure on bladder, leading to incontinence.

4. Psychological and Social

• Stress (family conflict, new school, sibling rivalry).

• Behavioral disorders (ADHD, anxiety).

5. Genetic

• Family history: if one parent had enuresis, risk is 40%; if both, up to 70%.

6. Other Factors

• Obstructive sleep apnea (snoring, restless sleep).

• Diabetes mellitus or diabetes insipidus (polyuria, excessive thirst).

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Clinical Features

• Nighttime bedwetting: ranges from occasional to nightly.

• Child otherwise healthy, no daytime symptoms in most cases.

Associated symptoms to note:

• Daytime wetting (suggests bladder dysfunction).

• Painful urination, urgency, foul-smelling urine (UTI).

• Constipation, soiling.

• Snoring, restless sleep (sleep apnea).

• Weight loss, thirst, polyuria (diabetes).

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Diagnostic Approach

1. History

• Frequency and severity of bedwetting.

• Daytime urinary symptoms.

• Toilet training history.

• Family history of enuresis.

• Psychosocial stressors.

• Fluid intake, sleep patterns.

2. Examination

• Growth and development.

• Abdominal exam: constipation, bladder distension.

• Neurological exam: lower limb tone/reflexes.

• Genital/urinary exam.

3. Investigations (if persistent / red flags)

• Urinalysis and urine culture: rule out UTI, diabetes.

• Blood glucose: diabetes mellitus.

• Renal function tests.

• Ultrasound of kidneys/bladder if structural problem suspected.

• Sleep study if obstructive sleep apnea suspected.

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Management and Treatment

Treatment is guided by age, severity, and underlying cause. Most children improve with behavioral strategies first, then medications if needed.

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A. Reassurance and Education

• Explain to child and parents that enuresis is common and not the child’s fault.

• Most children outgrow it.

• Punishment should be avoided — it increases anxiety.

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B. Lifestyle and Behavioral Interventions

1. Fluid management

   • Encourage normal fluid intake during the day.

   • Limit fluids 1–2 hours before bedtime.

   • Avoid caffeinated or fizzy drinks.

2. Bladder training

   • Encourage regular daytime voiding every 2–3 hours.

   • Double voiding (urinate twice before bed).

3. Constipation management

   • High-fiber diet, hydration, stool softeners if needed.

   • Lactulose 10–20 mL orally once or twice daily (for constipation).

4. Reward system

   • Sticker charts for dry nights (positive reinforcement).

5. Bedwetting alarms (most effective long-term behavioral treatment)

   • Alarm device triggered by moisture, wakes child to finish voiding.

   • Requires motivation and parental support.

   • Success rate: 60–70%.

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C. Pharmacological Treatment

Used when behavioral methods fail or for temporary relief (e.g., sleepovers, camps).

1. Desmopressin (synthetic ADH)

• Reduces night urine production.

• Dose: 200–400 mcg orally at bedtime (tablet) OR 120 mcg orally at bedtime (melt under tongue).

• Fluid restriction 1 hour before and 8 hours after dose (to avoid hyponatremia).

• Good short-term results, but relapse common when stopped.

2. Anticholinergics (if overactive bladder suspected)

• Oxybutynin 2.5–5 mg orally two to three times daily.

• Useful if daytime symptoms present.

3. Tricyclic Antidepressants (rare, last resort due to side effects)

• Imipramine 10–25 mg orally at bedtime (max 50 mg).

• Risk: arrhythmias, overdose toxicity → reserved for refractory cases.

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D. Treat Underlying Conditions

• UTI:

  • Amoxicillin 250–500 mg orally three times daily × 5–7 days (depending on age and resistance pattern).

• Diabetes: insulin therapy (type 1), metformin (type 2).

• Obstructive sleep apnea: adenotonsillectomy if indicated.

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Complications

• Low self-esteem, embarrassment.

• Sleep disturbance.

• Family stress.

• Missed diagnosis of diabetes or urinary tract abnormality.

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Prognosis

• Spontaneous resolution: ~15% of children become dry each year without treatment.

• Most cases are benign, resolving by adolescence.

• Early intervention improves self-esteem and quality of life.

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Patient / Parent Education

• Bedwetting is common and treatable.

• Never punish the child — use positive reinforcement.

• Encourage a supportive, blame-free environment.

• Seek medical review if:

• Daytime wetting.

• Painful urination, fever, foul urine (possible UTI).

• Persistent symptoms beyond age 7–8.

• Associated with weight loss, excessive thirst (diabetes)