Childhood Bed-Wetting : Part 3

by Food and Drug Administration (FDA)

(Page 3 of 3)

An abnormal wetting pattern can result in several serious problems, says Allen. "As the detrusor and the urethral sphincter strain against each other," he says, "the weaker sphincter eventually fails, so that the bladder can squirt out urine." Meanwhile, the straining builds very high pressures within the bladder. The detrusor reacts by contracting and, like any muscle given daily workouts, increases in size and strength. Ever stronger contractions become ever harder to control, causing abdominal cramps and more leaking. The bladder fails to empty completely, causing the child to have repeated urinary tract infection. The pressures inhibit urine flow from the kidneys to the bladder, causing the ureters and kidneys to overstretch, which in turn can be damaging.

The overstretched kidneys work hard to push the urine through the ureters into the bladder, but high pressure there provides resistance. So, while the valves at the ureters momentarily open to let urine into the bladder, this excessive pressure may push the urine back up into the kidneys. Over time, the abnormal urine flow can enlarge and distort the valves until they no longer work but allow the urine to move freely back up into the kidneys. To ward off this dangerous situation, proper diagnosis and treatment are vital.

Following are tests that may be used in diagnosis:

Intravenous urography (also called I.V. pyelogram) — to rule out anatomical defects. This X-ray study is made by injecting dye into a vein, filming the movement of the dye, and watching it progress through the kidneys, ureters, bladder and urethra until it is excreted from the body.

Voiding cystourethrogram — also to rule out anatomical defects. Another X-ray study, this procedure is done by filling the bladder with a dye and filming the dye in the bladder and as it moves along the urinary tract out of the body while the patient urinates.

Cystoscopy — to confirm suspicion of serious urinary tract damage or to determine why the child hasn't responded to outpatient treatments. The inside of the bladder and ureters are examined via a lighted, thin tube called a cystoscope that is threaded through the urethra. Some doctors use a general anesthetic for this examination.

Urodynamic testing — to evaluate how well the urinary tract works by examining pressure changes, flow rate, and muscle movement. The physician uses catheters (thin, flexible tubes) to measure bladder pressure and electrodes to measure activity of the urethral sphincter. With the catheters and electrodes attached to a recording monitor, the child urinates into a special receptacle or "potty chair" connected to a flow meter. Thus, bladder pressure, sphincter activity, and flow rate are recorded simultaneously. This takes about an hour and a half.

If the problem is detected before damage requires surgical correction, the child begins a simple retraining program that centers on urinating frequently, completely, and in a relaxed manner. This may require months or even years. The child goes to the bathroom at two-hour intervals, tries to maintain a continuous stream by remaining completely relaxed, and then tries to urinate again and again until unable to pass any more urine. Some investigators suggest intermittent catheterization (a catheter is threaded through the urethra into the bladder for complete emptying) and the use of any of a number of drugs: the tranquilizer diazepam (Valium) to relax the sphincter, the antidepressant imipramine (Tofranil) to help control wetting, and the antispasmodic oxybutynin chloride (Ditropan) to decrease bladder pressure.

Defining Enuresis

Primary enuresis (EN-you-REE-sis) is the medical term commonly used for bed-wetting in someone over age 5 who has never gone at least a year without wetting the bed. Secondary enuresis is bed-wetting in a child who has had bladder control. These terms do not apply to wetting problems due to physical illness or anatomical defect. Enuresis is diagnosed in 5- and 6-year-olds who have two or more monthly episodes and in older children who have one or more episodes a month, according to the American Psychiatric Association. The APA definition includes daytime wetting not due to disease or defect. But, generally, "enuresis" is used solely for wetting during sleep, so that is how it's used here. For every child with daytime wetting, it's reported there are six who wet at night.

Typically, bed-wetting occurs during the first third of sleep. When it takes place in REM sleep, the child may remember dreaming about urinating. (Rapid eye movement, or REM, accompanies the stage of sleep when most dreaming occurs.) It was once believed that wetting took place only during very deep sleep or when sleep moved from one stage to another. Recent studies, though, show wetting occurs in all sleep stages in proportion to the time spent in that stage and without relation to arousal patterns.

Some bed-wetting children walk in their sleep or have coexisting sleep terror disorder, in which nightmares waken them to great fearfulness.

Enuresis affects some 20 percent of children at age 5, 5 percent at age 10, and up to 2 percent at age 15. Only about 1 percent of adults have wet the bed since childhood.

About the Author

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