Enuresis is the involuntary emptying of the bladder. When it occurs during sleep ("bedwetting"), it is called nocturnal enuresis or nighttime wetting. Nocturnal enuresis is the most common bladder function disorder in children
Because girls achieve bladder control somewhat earlier than boys, the usual definition states that continued wetting in girls beyond the age of 5 years, and in boys beyond the age of 6 years, constitutes enuresis.
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In children with the most common type of enuresis (non-organic), the exact cause is generally not known. However, most physicians believe that it is due to delayed maturation of bladder function. In a small number of children, the cause of enuresis is organic, such as a temporary problem associated with a urinary tract infection or other illness. In these cases, the enuresis will end after the infection is successfully treated. In certain situations, enuresis can be caused by an anatomic problem of the urinary tract. If the urologist suspects this, additional tests may be ordered, including ultrasound or x-rays of the kidneys and bladder.
In many cases, a family history indicates that at least one of the parents also had enuresis as a child. If both parents had enuresis as children, there is a high probability that their children will be affected.
Most children under the age of 3 years have enuresis. However, by the age of 5 years, up to 85% of children have achieved bladder control. For this reason, enuresis is generally not diagnosed or treated in children younger than five years of age. Children between the ages of 3 and five years with bedwetting, if otherwise well, are usually diagnosed with delayed maturation of bladder function.
Bladder control is learned gradually, only after the child is old enough to understand that such behavior is desirable and can respond to praise and rewards. Just as some children learn to walk before others, some children learn bladder control earlier than others.
Children must overcome the pattern of voiding, or urinating, that occurs naturally in infants to achieve voluntary control of the bladder, by learning what a full bladder feels like. Since a full bladder can trigger reflex emptying, the child must learn to consciously resist the urge to void — in other words, to "hold it" longer until voiding can be done when a toilet is available. This is also referred to as “suppressing the automatic urge to void.”
The transition to consistent bladder control is not easy, and accidents are common. The conscious suppression of automatic emptying is first learned for daytime control. Eventually, the suppression signal to the bladder becomes automatic and does not require a conscious act by the child. Nighttime bladder control requires that the brain, during sleep, suppresses the automatic emptying reflex.
Since children mature at different rates, learning bladder control will also vary from child to child. Most children naturally seek parental approval and once they learn that bladder control is expected, learning to inhibit reflex contraction becomes motivation-driven.
There is no relationship between "early" or "later" onset of bladder control and learning disability in school. However, children with certain kinds of developmental disabilities are known to be more likely to have enuresis.
Enuresis is not a form of misbehavior in the sense of a child being "bad" or choosing not to comply with the wishes of the parent. A child must never be punished for having enuresis. Children are eager to please their parents, but a child with enuresis simply has not been able to achieve control. They should not be blamed or put under pressure to achieve bladder control. They just may not yet be ready.
Enuresis is not a psychological disorder, although secondary psychological problems may develop if there is tension between the child and the parent about the child's delay in learning bladder control. Harsh criticism of a child for being lazy or not being grown up will only lower self-esteem and increase emotional difficulties.
Parents can try several common interventions. However, these interventions are almost never successful by themselves. These include:
• Carrying the sleeping child to the bathroom during the night and trying to awaken them enough to void
• Restricting fluids after dinner time
• Playing a radio in the room so that sleep will not be "as deep"
The most successful treatment involves the use of an enuresis alarm. This is a device, designed to sense "wetness," which is attached to the child's underwear or pajamas. When wetting begins, an alarm is triggered (usually a bell, buzzer or tone), that awakens the child. Eventually, success is achieved when the child remains dry throughout the night. Since the automatic-type bladder is always on edge, it helps to use a bladder relaxant-type medication such as oxybutynin in combination with the alarm.
It is a good idea to combine the alarm with a reward system, such as a marking a special calendar with a gold star for every dry night. After a certain number of dry nights, the child receives a reward to reinforce the learning process. The alarm system is most successful in children who are relatively mature and highly motivated.
DDAVP is a medication closely related to a naturally occurring hormone (ADH, antidiuretic hormone, also known as arginine vasopressin) that causes the kidney to produce concentrated urine. There are clinical studies showing that children with enuresis are not able to put out as much ADH during sleep as other children and, since the amount of urine in the bladder exceeds the capacity to hold it, wetting occurs. Some medical studies have shown that DDAVP may be effective in children shown to have some limitation in the ability to produce concentrated urine.
However, it does not work for all children, and after it is discontinued, there is a high rate of recurrence. Even if it is not used on a regular basis, it may be helpful for those nights that a child would like to sleepover at a friend's house or go on a camping trip. If DDAVP is used, it is important to restrict fluids at dinner-time and before falling asleep.
The Bladder Function Improvement Training (BFIT) Program is a comprehensive approach to managing dysfunctional voiding (urinating) and includes expertise in the treatment of nighttime wetting. If you’d like to request an appointment with one of our specialists from the BFIT Program, call 1.800.543.7362 (1.800.KIDS DOC®).