Childhood Bed-Wetting : Part 2

by Food and Drug Administration (FDA)

(Page 2 of 3)

Behavior Modification

For behavior modification to be effective, child and parents must be highly motivated to follow the physician's instructions exactly and to persist long enough, which may mean several months. It's very easy to become lax or give up. Rewards alone — no punishments — are used. Among the techniques:

Responsibility reinforcement training. The child takes charge of making one last trip to the bathroom, changing and laundering soiled bed linens, and charting progress (dry nights earn rewards). These responsibilities should help improve the child's feelings of self-worth and prevent parental anger over a wet bed. Hints from the Mayo Clinic: Use a plastic mattress pad and pillowcases, and buy lots of inexpensive sheets and blankets for storage in a tightly sealed plastic bag for weekly washing.

Urinary alarm. Wetting sets off the battery-powered alarm; the child wakens, turns off the switch, and finishes urinating in the bathroom. Eventually, the child is supposed to learn to wake before wetting. Lightweight pajamas are best because thick ones slow down the time between the first drops of urine and the sounding of the alarm. It's a good idea to replace batteries at set intervals because weakened ones may not trigger the alarm and may damage the device. The success rate with the alarm is as high as 75 percent, but the relapse rate can be as high as 30 percent. Maizels says that, by combining the alarm with other therapies, he and his colleagues can correct about 80 percent of wetting within the first month or two, with a relapse rate of only around 13 percent.

Another treatment often reported involves retaining urine to enlarge bladder capacity. But Terry Allen, M.D., urology professor at Southwestern Medical School in Dallas, says "this is bad policy because it puts undue pressure on the urinary tract."

Drugs Have Drawbacks

The Food and Drug Administration has approved one drug as safe and effective for bed-wetting: imipramine (Tofranil), an antidepressant. It can immediately produce dry nights, but there are drawbacks. It can cause a number of side effects, including blood pressure changes, irregular heartbeat, anxiety, insomnia, dry mouth, blurred vision, nausea, vomiting, diarrhea, dizziness, drowsiness, and headache. Bed-wetting often resumes when treatment stops. And, while the drug is safe at recommended dosages, an overdose can cause convulsions, coma and death. "One third of the physicians who use the drug do not recognize its toxic potential," wrote Betsy Foxman of the University of Michigan School of Public Health, Ann Arbor, and others in the April 1986 Pediatrics. The researchers were commenting on the results of the Rand Health Insurance Experiment, a population study. "We suggest that physicians explore less hazardous alternatives before relying on pharmacologic [drug] treatment for this generally benign condition," they concluded. The April 1987 Mayo Clinic Health Letter advised: "We rarely recommend this drug for children with enuresis."

If the decision is nevertheless made to use imipramine, parents should take extreme care to give it exactly as prescribed, to keep it in a locked cabinet out of reach of children, and to seek immediate medical help in case of overdose. Any substance potentially poisonous to a child should be labeled with warning stickers, such as "Mr. Yuk." These are available from regional poison control centers (not emergency rooms), listed with emergency numbers at the front of the telephone directory.

Physicians are investigating enuresis treatment with oxybutynin chloride (Ditropan). The drug is approved by FDA for certain nerve-related bladder disorders, but its safety and effectiveness for bed-wetting remain unproven.

Counseling and Other Treatments

Some physicians may recommend psychological counseling or hypnosis. In the C.A.R.E. program, fluids are not restricted at bedtime, but patients are advised to drink nectars, apple juice, cranberry juice, and water rather than carbonated drinks. "As these beverages may be less interesting," says Maizels, "children tend to drink more for thirst than for recreation."

Dealing with bed-wetting can be frustrating, even traumatic. It might help to keep in mind that nearly every child will outgrow the problem.

When Potty-Training Goes Awry

Sometime between ages 1 and 2, a toddler first senses bladder fullness and, so, starts to hold back urine by contracting the sphincter muscle of the urethra, the urinary tract opening out of the body. As the bladder gradually stretches to hold more urine, increased inner pressure causes the bladder's powerful detrusor muscle to contract to expel its contents. By age 4 or 5, most children learn to suppress detrusor contractions so they can retain urine and to relax the urethral sphincter during detrusor contractions so they can pass urine. Daytime dryness usually comes before nighttime control.

Certain children, however, get stuck in this transition with a condition known as dysfunctional voiding. Some don't learn to coordinate the urinary muscles; others learn coordination, but so persist in holding back urine that the bladder greatly overstretches. In both abnormal patterns, the contained urine becomes stagnant and infected. Dysfunctional voiding reflects neither disease nor physical defect but, rather, a hitch in the child's beginning efforts at bladder control. Such children make up about 40 percent of the outpatient practice of pediatric urologists.

With early detection and muscle retraining, dysfunctional voiding is often cured. Allowed to progress, this abnormal wetting can lead to permanent damage to the urinary tract — even kidney failure and death.

Why do these abnormal wetting patterns develop?

"In a lot of cases, no clear cause can be found," says Terry Allen, M.D., who teaches urology at Southwestern Medical School in Dallas. Allen has studied dysfunctional voiding extensively. "Quite often," he says, "it's related to a broken home, alcoholism, child abuse, or other stress. But it occurs in stable families, too. Some children hold back their urine all day because they've decided the school bathroom is dirty, or they're so hyperactive and busy they don't take time to go. Some fear the potty because they've fallen into it. One child was terrified of the toilet because his father had a bowel disorder and the son associated it with the toilet.

"Also, trying to force children to urinate can push them into a wrong pattern. They aren't clear on what to do so they tighten the wrong muscles. We recommend letting children decide on their own when they want to be potty-trained. The fundamental effect, though, is the same: The child gets into this mode of holding back, instead of learning to relax and empty the bladder completely at regular intervals."

About the Author

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