Childhood Bed-Wetting

by Food and Drug Administration (FDA)

During grade school, Patsy (not her real name) never asked friends to spend the night. When invited to birthday party "sleep-overs," she declined. She worried about the possible lingering odor in her room. And she hated the plastic sheet that accompanied family vacations. Then, shortly after entering middle school, Patsy no longer had her "problem": bed-wetting.

Fourteen percent of 5- to 13-year-olds wet the bed, according to a recent population study. For many such children, like Patsy, the consequences are humiliation and damaged self-esteem. Fortunately, this common childhood affliction, known medically as "primary enuresis," usually disappears on its own, and proper treatment can often hurry it on its way.

Bed-wetting is considered normal up to age 5. When the problem persists, however, a visit to the doctor is in order. Bed-wetting rarely signals a health problem, but daytime wetting — which often occurs with bed-wetting yet may be overlooked if it's only a dribble — can represent serious illness. Indeed, if the wetting disorders known as dysfunctional voiding go untreated, kidney failure — even death — can result.

Delayed Development and Other Causes

The precise cause of bed-wetting is unknown. Most cases appear to be due to delayed physical development. Bladder capacity may be less than half what is considered normal for the child's age. Bed-wetting is up to three times more common in boys than girls — linked, perhaps, to boys' slower rate of maturation. Some researchers, in fact, have argued that boys aren't normally dry at night until age 8.

Several studies point to a genetic link in enuresis. When both parents had the problem as youngsters, 77 percent of the children in these studies developed it. But the figure dropped to 44 percent when only one parent had wet the bed in childhood. By contrast, when neither parent had enuresis, only 15 percent of the children did.

A frequent cause of bed-wetting is constipation. In fact, treatment of constipation in enuretic children often resolves the wetting, report Sean O'Regan, M.D., and others of the Pediatric Research Center, University of Montreal. In the March 1986 American Journal of Diseases of Children, they explained that, in chronically constipated children, the rectum is probably never empty so the rectal sphincter muscle remains contracted to hold back stool. This, in turn, can dilate the rectum, which then presses on the small, immature bladder to cause the enuresis.

Attempts to hurry toilet training may backfire and actually contribute to bed-wetting; experts advise letting a child develop bladder control at his or her own pace. Other contributing factors include hospitalization (especially between ages 2 and 4), arrival of a baby, loss of a parent, and entering school.

In rare cases, emotionally disturbed children may respond to their illness with loss of bladder and bowel control, according to Gordon McLorie, M.D., and D.A. Husmann, M.D., of Toronto's Hospital for Sick Children, in the October 1987 Pediatric Clinics of North America. But in other cases, they wrote, "emotional disturbances may be primarily a result of the enuresis."

Urinary tract infection also can result in bed-wetting. These infections often cause additional symptoms, such as painful urination, foul-smelling urine, and daytime wetting.

Diaries and Other Diagnostic Tools

Diagnosis at the Center to Assist the Regulation of Enuresis (C.A.R.E.) in Chicago involves use of a diary. Before the first appointment, parents complete a psychological questionnaire and keep a three-day record on their child's diet and wetting pattern (times, duration and volume of daytime urination and times of bed-wetting). The record may suggest a wetting pattern abnormality, recurring urinary tract infection, or unrecognized constipation.

"I do not believe that all children with these complaints merit a full scale urodynamic evaluation," wrote C.A.R.E. director Max Maizels in the April 1982 Journal of Urology. (Urodynamic tests use electrodes and flexible thin tubes called catheters to gain information about urinary tract flows, muscle movement, and pressure changes. A "hands off" approach is how Maizels describes C.A.R.E.'s diagnosis and treatment. "I have been content with eliciting a detailed history, performing a physical examination of the genitalia, and observing the voided stream to guide the need for . . . urodynamic evaluation."

What can a patient's history reveal? Compared with youngsters with normal bladder control, bed-wetting children are more likely to have experienced problems while still in the womb, such as maternal illness or bleeding or, after birth, colic or jaundice (skin yellowing from bile pigment buildup in the blood), according to Maizels. "Perhaps these ... are stresses that later lead to the 'maturational delay' believed responsible for primary enuresis," Maizels and Diane Rosenbaum wrote in the December 1985 Primary Care.

A thorough physical examination includes inspecting the rectum for impacted stool, checking the gait and reflexes of the legs and feet for nerve defects, and gently feeling the abdomen, genitals, buttocks, anus and spine for abnormalities. Observing the child's urination is important because different problems may be reflected by the nature of the stream, which may be weak, unusually forceful, intermittent, continuous, spraying, or painful. Intermittent flow, for instance, suggests obstruction.

Flow-rate measurements show how many ounces or milliliters of urine are passed in how many seconds. Ultrasound examination (a painless procedure, made by applying sound waves to the skin) may be needed to check the size and shape of the kidneys and to see how well the bladder empties. Laboratory analysis of urine screens for diabetes, kidney disease, or other disorders.

Among the candidates for further examination with more complicated tests are patients for whom conventional treatment has failed and those with recurrent urinary infection, wetting day and night without an obvious cause, coexisting loss of bowel control, and suspected dysfunctional voiding. Parents should ask questions to be sure they understand why a particular test is recommended and what is involved.

To Treat, or Not

But if the diagnosis is that the nighttime wetting is simply due to an immature bladder, the examination will probably end there. Physician and parents can move on to discussions about treatments. It's reasonable to consider doing no more than being patient and supportive until the child is older. Still, for families facing great stress over the problem and for children feeling shame and low self-worth, there are potentially effective therapies. The choice of therapy and effectiveness of individual treatments depend on the severity of the problem, the child's age and emotional maturity, and the level of commitment of the child and parents. Certainly, scolding and punishment are ineffective and inappropriate.

About the Author

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