When the bedwetting doesn't stop

Bedwetting has been accepted within Malaysian families as a perfectly normal occurrence which their children will naturally stop doing eventually.

As such, not many families come forward for help when it turns into a problem – that is, when a child is wetting the bed at least twice a week for three consecutive months.

Paediatrician Dr Margaret Kannimmel attributes this to a lack of awareness.

“A lot of parents think it's normal and that it's not a problem at all. They think it will go away,” she says.

If the problem seems to be improving and it is not affecting the child socially, nor does it have an impact on the family, then generally the doctor would not recommend any form of treatment.

Says Dr Kannimmel:

“If it is not affecting the child or the family per se from a psychological stand point, we normally just leave it alone or maybe try non-medical intervention like using a simple star chart, for instance, where we encourage the child to have dry nights and for every dry night we reward the child. Psychologically, this works for the child.

“Almost all children will outgrow bedwetting. For this reason, urologists and paediatricians frequently recommend delaying treatment until the child is at least six or seven years old. Physicians may begin treatment earlier if they perceive the condition is damaging the child's self-esteem and/or relationships with family/friends.

“When it affects the child psychologically, this usually manifests in poor self-esteem and behavioural problems because they are shy and don't want their friends to find out about their bedwetting. So, they don't participate in sleepovers or go travelling.”

She explains that when a patient comes in with a bedwetting problem, she would check if it's primary or secondary nocturnal enuresis. In the case of a primary, the child has not stayed dry on a regular basis in the absence of any urological, medical or neurological abnormality. In such cases, the child has wet the bed at least twice a week for three consecutive months.

In the secondary case, the child has been dry for at least six months and then started wetting the bed again after that.

“In the secondary case, the causes would be infection, diabetes or kidney problems. But even in the primary case we would need to rule out diabetes, infection or other medical causes.

“Having ruled out all that, then the primary cause is usually either genetic or the developmental delay of the bladder's capacity to hold urine. Then, there are other theories as well, such as hormones.

“It could also be recurring urinary tract infections (UTI) which don't present itself with the usual symptoms as it would in an adult. For adults, UTI presents itself by symptoms like a burning sensation and frequency in urinating. For children it may not present itself that way. They might just have bedwetting as a symptom. So, you wouldn't know until you check.

“The best way to find out is to do a basic urine test then just do a physical examination. The urine test can check for infection as well as sugar in the urine,” explains Dr Kannimmel.

Causes of bedwetting

- Genetics - 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.

- Developmental delay of the bladder – Some children's bladders need a bit more time and training to be able to hold urine through the night.

- Infection/disease - Infections and disease are more strongly connected with secondary nocturnal enuresis and with daytime wetting. Less than 5% of all bedwetting cases are caused by infection or disease, the most common of which is UTI or diabetes

- Physical abnormalities - Less than 10% of enuretics have urinary tract abnormalities, such as a smaller than normal bladder.

- Insufficient anti-diuretic hormone (ADH) production - A portion of bedwetting children do not produce enough of the anti-diuretic hormone. The body normally increases ADH hormone levels at night, signalling the kidneys to produce less urine. The diurnal change may not be seen until about age 10.

- Psychological – Stress and trauma like a death in the family, sexual abuse or extreme bullying are established as a cause of secondary nocturnal enuresis (a return to bedwetting), but are very rarely a cause of primary-type bedwetting.

- Constipation - Chronic constipation can cause bedwetting. When the bowels are full, it can put pressure on the bladder.

- Attention deficit hyperactivity disorder (ADHD) - Children with ADHD are 2.7 times more likely to have bedwetting issues.

- Caffeine - Caffeine in carbonated drinks increases urine production.

- More severe neurological-developmental issues - Patients with mental handicaps, such as Down Syndrome, have a higher rate of bedwetting problems. One study of seven-year-olds showed that “handicapped and mentally-retarded children” had a bedwetting rate almost three times higher than non-handicapped children (26.6% vs. 9.5%, respectively).

Treatment

According to Dr Kannimmel, there are a number of treatment and management options for bedwetting.

For treatment:

Bedwetting alarms - This is a special diaper with a sensor. An alarm sounds when the diaper becomes moist. On hearing the bell, the child wakes up to empty the bladder. This is for older children. It can't be used on children who are too young because they tend to sleep very deeply. It can be used for children aged five years right up to about 15 years, if necessary.

Medication – There are synthetic replacements for the anti-diuretic hormone, the hormone that reduces urine production during sleep.

For better management:

Diapers or absorbent underwear – These go up to adult sizes and can be worn by the child to reduce embarrassment and make cleaning up easier for parents. They come in handy when a child with a bedwetting problem wants to have a sleepover or go travelling in a group.

Other treatment options:

Dry bed training – This is where the child is woken up on a strict schedule at night to go to the toilet in an attempt to train the child to wake up to empty their bladder. Dr Kannimmel says studies show this training is ineffective by itself and does not increase the success rate when used in conjunction with a bedwetting alarm.

Star chart – The child is encouraged to have dry nights and is rewarded with a star. Dr Kannimmel says this seems to work.

Conclusion

Dr Kannimmel says it is better to treat children with bedwetting problems when they are younger rather than wait till they're 11 or 12 years old.

“When they are much older it's more difficult to treat them because sometimes they already have some behavioural problems. They might not want to comply with our methods of treatment. So, the younger they are the easier it is and the relapse rates are lower in younger children.

“I do not resort to medications on the first visit. I try other methods – all the advice above as well as using a simple star chart where for every dry night they are given a star, and we give them a goal – something that is achievable. If they've been wetting the bed more than three times a week, then maybe we start off with giving them the goal of three or four dry nights. Then slowly move the target higher and higher.

“Most of them have come out of the bedwetting problem at least to a point where their lives go back to normal. So, in my experience nothing is untreatable. There might still be one or two accidents when they are stressed up or if they've gone for a late party and had extra carbonated drinks late at night.

“Accidents do happen but it doesn't bother their life as much as it used to,” says Dr Kannimmel.

She emphasises that the concern is with the social impact, the child's school performance and the effect on the family as a unit.

At the end of the day, parents shouldn't have a punitive attitude.

“The more you punish the child, the worse the problem will become. A lot of patience and understanding is needed. Teasing among siblings won't help. The family needs to sit down as a unit and decide to be more understanding. Sometimes I do counsel them as a family,” she explains.

Ultimately, the child has to understand there is nothing wrong with her or him, which is what children in such cases do often assume.