|Stop worrying. You have not missed any boats. All of the things you have
tried were reasonable. Restricting fluids before bedtime and “walking”
reduces the volume of urine that the bladder has to hold during sleep. The
reason these efforts didn’t work is that the volume of urine is not
the only factor effecting bladder control. It is not a matter of will or
desire to be trained. Many kids would give up all of their birthday presents
just to be dry. They simply cannot stop it from happening during sleep.
“It just comes out.”
It is important to understand why enuresis (the medical term for bedwetting)
is normal, and why we have to be patient and reassuring until it stops by
itself. There is nothing wrong with using disposable pull-ups to avoid the
smell, discomfort and excess laundry.
There are three factors that predispose to bedwetting:
1. The child is a deep sleeper who does not wake up even
if there is noise or disturbance.
2. The child has a small capacity bladder.
3. The child produces large amounts of dilute urine during
the night. This is caused by the lack of a hormone produced by the brainstem
that tells the kidneys to concentrate urine during the overnight fast.
Many bedwetters have all three problems. Maturity is the cure for each one.
One out of five healthy children still are “wet” every night
at the age of five. Every year after that, about one out of five of those
“wetters” outgrow their enuresis. This leaves a significant
number of bedwetters even at age nine and ten. Remember, these are healthy
children. They need reassurance that it will stop eventually. It has been
my experience that if the child is still wet every night at age seven it
often takes until age eleven to see the difference. The onset of early puberty,
with growth of other related organs, often brings the maturation needed
for night control. I usually do not recommend taking away the pull ups until
there have been a few dry nights.
There are medications and other methods that control bedwetting in older
children. I prefer not to use them unless the child, despite our reassurance,
is upset by the persistent wetting. If the bedwetting is causing him to
feel badly about himself I consider treatment. This could happen when he
sees the younger children becoming dry or if going to a friend’s house
to sleep is a problem or if going away to camp worries him. There are several
options to try. Each one addresses a different aspect of the problem.
1. Alarm systems—These are devices that will vibrate or ring when
wetness is first detected on the undergarment. The child will be awakened
and will stop urinating and get up and go to the bathroom. This method works
by causing the child, who has been awakened on the first few nights, to
sleep at a lighter level in order to avoid being woken. Often the alarms
fail to waken the deeply sleeping child so there is no improvement. The
earliest age when it is worth trying these alarms is five to six years of
age. They sometimes work.
2. DDAVP—This is a synthetic replacement for the brain hormone needed
to signal the kidneys to make smaller amounts of concentrated urine. It
also has an effect of enhancing the brain’s sensitivity to signals
from the bladder. It comes in pills or nasal sprays which are given at bedtime.
DDAVP is a very safe medication but it cannot be used if the child has had
a lot to drink right before bed. Doses should be increased if the initial
dose is not helping. The maximum dose is 4 tablets or four sprays per night.
It only works on the night that it is taken. We often use it just for sleepovers
or for camp in the older kids.
3. Imiprimine—This is an antidepressant, given in small doses, which
has two beneficial side effects. It causes the bladder to hold urine longer
and stretch to a larger capacity. It also causes the child to sleep a little
lighter so he will notice the full bladder. Imiprimine is an old drug. It
works well in some children. We can add it to DDAVP if either one doesn’t
DDAVP and/or Imiprimine can be used every night or intermittently as needed.
They should be stopped every three months just to see if they are still
needed. It should be noted that if a child was fully night trained and becomes a
bedwetter at a later time the management is completely different. The doctor
should be consulted and the urine checked for infection. It is not unusual
for an emotional problem to cause this secondary bedwetting. Family discord,
illness or death in the family or school problems sometimes are the source.
Daytime wetting is not at all the same problem. Children over age four who
are day wetters should be evaluated by a physician. They sometimes have
bladder spasms or are constipated or have dysfunctional voiding which interferes
with bladder control.
The most important thing to remember is that bed wetting is not anyone’s
fault. A child who is a deep sleeper with a small bladder should not be
shamed or punished. His or her parents should not feel frustrated or inadequate.
This problem often runs in families. If grandparents are asked they will
often tell of having the same problem with their kids. If everyone stays
cool about it the child will not perceive it as a major problem and will
emerge with his self esteem intact. The parents will also have saved themselves
a lot of unnecessary aggravation.