width= Why we need to be Patient with Bedwetters

By: Dr. Michelle MD
 
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 work alone.

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.
 
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