Nocturnal enuresis is the medical term for bedwetting, which is involuntary urination during sleep. Bedwetting is quite common but it can be embarrassing for children. They may feel isolated and unable to talk to others about it. They may avoid certain social situations, such as overnight camps and slumber parties. They may be the target of bullying or even blamed for being wet even though they cannot help it. Bedwetting may cause problems such as decreased self-esteem and psychological distress for the child and the family.
How common is bedwetting?
Bedwetting is very common. In the United States, approximately five to seven million children wet the bed. 10-15 percent of children will continue to wet the bed until age 6. Each year approximately 15 percent of children who wet the bed will stop spontaneously, though 1-2 percent will continue to experience bedwetting into adulthood. Bedwetting is twice as common in boys as it is in girls. It is also more common in children who have a close relative with a history of bedwetting as well as in children with attention deficit hyperactivity disorder.
Types of bedwetting and their causes
Primary nocturnal enuresis is when a child has never been consistently dry at night. Most children who experience bedwetting have primary enuresis. It is not caused by psychiatric or emotional problems. It may be associated with increased urine production, small bladder capacity, or overactive bladder. These children do not wake to the body's signal for the need to void. The most common cause for this may be delayed development of the brain's regulation on the bladder.
Secondary nocturnal enuresis is when a child has made it through at least a six-month stretch of dryness at night and then starts wetting the bed again. Secondary enuresis is less common than primary nocturnal enuresis and accounts for approximately 25 percent of children with bedwetting. Associated medical problems may include a urinary tract infection or constipation, in addition to type I diabetes or sleep disordered breathing. Secondary nocturnal enuresis may also be associated with a change in the child’s life, including stressors such as divorce, moving, a new sibling, or a death in the family. A visit to your child’s doctor can help uncover the cause.
When should I speak with my child’s doctor about bedwetting?
Bedwetting may be problematic if a child is 5 years of age or older and wets the bed at least two times per week for at least three consecutive months. If your child has primary nocturnal enuresis and is not demonstrating improvement in terms of reduced volume or frequency of wetting by age 7, or if the family is experiencing difficulty at any age, consider speaking with your child’s doctor. However, if your child continues to have nocturnal enuresis at 8 years of age, without a family history of enuresis, ask that your child be evaluated by his or her doctor. Even though many children will outgrow bedwetting, the psychological effects or interference with the ability to socialize are the primary reasons to get treatment.
How is bedwetting evaluated?
Contact your child's doctor if you have any concerns regarding bedwetting. It may be helpful to complete an elimination diary documenting his or her voiding and stooling habits. It may also be useful to keep track of your child's daily fluid intake, including any caffeine intake. All this information can be very useful to your child's doctor. In addition, the doctor will complete a physical exam and a urinalysis may be collected. A urinalysis is a laboratory study completed on a sample of your child's urine, which can help evaluate concentration, signs of infection, or the presence of glucose.
Tips and treatments for bedwetting
Remember: Never punish your child for wetting the bed! It is not helpful as bedwetting is not a deliberate act. There are many different treatments options and ways to help empower your child. Of note, behavioral interventions are less likely to be successful if your child is not a motivated participant in the process. Your child’s doctor can assist you in deciding which treatment may work best for your child. Here are some tips and treatments:
- Be patient and understanding. Most children will attain continence with time, even without treatment.
- If a family member was affected by bedwetting, it may be helpful to have them speak with your child in order to minimize feelings of isolation.
- Respect your child’s privacy and do not discuss bedwetting in front of others, unless medically necessary.
- Restrict fluid intake in the evening; however, it is important that your child maintains adequate hydration throughout the rest of the day. In general, your child should consume approximately 2/3 of their daily fluid intake by the end of the school day and the remaining 1/3 after returning home. One caveat to this is children who participate in after-school sports, as hydration is essential. Advise against additional fluid consumption in the hour before bedtime.
- Establish a regular bedtime routine and sleep patterns, which will enable your child to be well rested.
- Encourage your child to void prior to going to bed and anytime he or she wakes up overnight.
- A bedwetting alarm is a first-line treatment, as it is very effective (approximately 2/3 of children will respond) especially in terms of long-term cure rate. It utilizes a sensor in the underwear that sets off an alarm, vibratory or auditory, when it gets wet. Use of the alarm is a family-team effort, as children with nocturnal enuresis require help waking up to the alarm in the beginning. Once the child wakes up, he or she should void in the toilet and assist in changing pajamas and bedding. This should be done in a matter-of-fact manner, as a means of taking responsibility for personal hygiene rather than as a punishment. The alarm should be used consistently for at least two to three months. The alarm should be used until at least 14 consecutive nights without a bedwetting incident. However, if nocturnal enuresis recurs after earlier success, replace the alarm until an additional month of successful use. Of note, consider using a reward system, such as a sticker chart, in conjunction with the alarm system to incentivize cooperation.
- Another first-line treatment is a medication named Desmopressin, which reduces urine production overnight. The recommended trial duration is approximately three months but it can be used intermittently for specific social events such as a sleepover. Of note, relapse may occur at a higher rate with Desmopressin as compared to the bedwetting alarm.
- In addition, if constipation is contributing to your child's bedwetting, working with your child's doctor to achieve regular stooling may be beneficial. Adequate fluid and fiber intake, as well as physical activity, may be helpful in achieving regular stooling habits.
Updated by Kimberly Levitt, MD, and reviewed by Barbara Felt, MD
Updated March 2018