Bedwetting (Enuresis Nocturna)

Symptoms

In enuresis nocturna, a child older than 5 years empties the bladder repeatedly at night without an organic or medical cause. It does not wake up when the bladder is full and therefore cannot go to the toilet. During the day, on the other hand, everything works normally. The problem is slightly more common in boys than in girls. Adolescents and adults may also be affected, but the incidence decreases sharply with age:

Age Frequency
5 years 25 %
6 years 10 %
12 years 3 %
> 18 years 1 %

Causes

One common theory describes bedwetting as an inherited partial developmental disorder of the central nervous system. Those processes that control waking and bladder function are not yet fully developed. In addition, in some children, insufficient antidiuretic hormone (ADH, vasopressin) is secreted at night. Risk factors include young age and male gender. The role of heredity was also clearly shown. According to recent findings, psychological problems and diseases should not play a role; rather, they arise only as a consequence of bedwetting.

Complications

Bedwetting is a psychosocial problem, especially for older children and adolescents. Anxiety, feelings of shame and guilt can set in, and sleeping away from home becomes a problem (e.g., at a class camp, on vacation, or later at a girlfriend’s house). It can be frustrating for parents if it lasts for a long time, the bed always has to be changed and no solution is found. Unfortunately, there are still parents who punish their children for bedwetting, which is completely nonsensical.

Diagnosis

In medical treatment, serious causes should be excluded, such as diabetes insipidus, diabetes mellitus, kidney diseases, urinary tract infections, spinal cord diseases, tumors or anatomical anomalies of the genitourinary tract. In bedwetting, urinary incontinence is not present. Medications may also be involved, such as valproic acid, diuretics, sedatives, or lithium. Especially if urine is also passed involuntarily during the day, further clarification should be obtained.

Nonpharmacologic treatment

Alarms: alarms are among the most effective interventions, are first-line agents, and help the majority of children (e.g., AntiNass, Pipi-Stop). In case of bedwetting, an alarm is triggered by a sensor, the child wakes up and is sent to the toilet. Slowly, conditioning takes place, which allows the child to wake up better even without the alarm when the bladder is full. The treatment must be carried out for at least 3 months and it takes a few weeks to see an effect. The sensor is placed either directly in the pajamas or under the bed cover, depending on the product. Some children do not wake up when the alarm goes off (unlike the rest of the family). Initially, it can be helpful if a parent or older sibling is sleeping in the same room and helps turn off the alarm, get up and go to the bathroom. Further, children should be instructed to empty their bladders regularly during the day and not to wait. Many children do not go to the bathroom frequently enough at school, which promotes urinary retention during the day. Any constipation reduces bladder capacity and can be relieved with adequate nutrition or the use of well-tolerated laxatives. Do not drink or eat too much in the evening or before bed, and empty the bladder before sleeping. Drinks containing caffeine, such as black tea or cola, should not be consumed in the evening, as they have a diuretic effect. Children should be encouraged to use the toilet at night if they need to urinate. Diapers can be worn during sleep. For example, Huggies Drynites night diapers are available in stores. Positive feedback: the child receives a small reward for each dry night, such as a star in a calendar. Also, no treatment eventually leads to the goal. After a few months or years, the problem usually resolves itself. About 15% of children become symptom-free each year.

Drug treatment

Medications are 2nd-line agents that should be used cautiously because of the potential adverse effects. Nonpharmacologic measures should always be used first.Treatment is symptomatic, meaning relapses usually occur after discontinuation. Antidiuretics:

  • Desmopressin is a chemically modified version of the antidiuretic hormone ADH. It is fast-acting and well-acting, and like the natural hormone, it inhibits urine excretion, but it is longer-acting and has less effect on blood pressure. It is approved in children 5 years of age and older as a 2nd-line agent for short-term treatment (maximum 3 months) and is taken as a tablet before bedtime. The nasal spray may no longer be used in this indication in many countries because so-called water intoxication occurs more frequently with this application, i.e., water retention with hyponatremia, headache, nausea, vomiting, weight gain, oedema, and in severe cases convulsions, cerebral edema, and coma. It is therefore essential to minimize fluid intake 1 hour before to 8 hours after ingestion.

Antidepressants:

  • Tricyclic antidepressants such as imipramine and clomipramine have anticholinergic, antihistaminic, and antidepressant effects and are both approved for treatment from 6 years of age, excluding organic causes. There are several hypotheses regarding the mechanism of action (decreased bladder contractility, increased filling and capacity). The dose is administered after dinner or as early as 4 pm if children wet early. The numerous possible adverse effects, such as dry mouth, constipation, weight gain, or central nervous disturbances, pose a problem. Tricyclic antidepressants can be cardiotoxic and fatal in overdose. They are moderately effective according to clinical trials.

Parasympatholytics:

  • Oxybutynin is anticholinergic, antispasmodic and acts on the hypersensitive bladder muscle. It is approved for ages 5 years and older and is taken in the evening. Efficacy has not been reliably demonstrated in this indication. A trial of therapy is possible, but the anticholinergic adverse effects should be noted, such as dry mouth, constipation, central effects such as fatigue, dizziness, and confusion. In addition to oxybutynin, tolterodine and hyoscyamine are also commercially available in the United States.
  • Dimetinden maleate drops are available without a doctor’s prescription and have anticholinergic properties. They can potentially be used off-label.

Other options:

  • Chlordiazepoxide + clidinium bromide is approved for enuresis nocturna in adults.
  • Some homeopathics and other alternative therapeutics are commercially available for this indication. The efficacy of these agents has not been established.

Things to know

The AntiNass (Pipi-Stop) alarm was invented by Ernst Bieri (1914-2007) of Laupen in 1932 (Guignard, 2007).