Enuresis (Bedwetting at night)

Brief overview

  • What is enuresis? Involuntary enuresis at night after the 5th birthday and without organic cause. It mainly affects children, and boys more often than girls.
  • Forms: Monosymptomatic enuresis (only nocturnal enuresis), non-monosymptomatic enuresis (nocturnal enuresis plus impaired bladder function during the day), primary enuresis (nocturnal enuresis continuously since birth), secondary enuresis (renewed nocturnal enuresis after a dry period of at least six months).
  • Causes: probably several factors involved such as familial predisposition, maturation delay of certain brain areas, deficiency of antidiuretic hormone, low bladder capacity, psychological and psychosocial factors.
  • Diagnosis: taking medical history, bladder diary, 14-day protocol, physical examination, urine sample, ultrasound examination of kidneys and bladder, urine flow measurement (uroflowmetry), etc.
  • Treatment options: including keeping drinking and elimination logs, calendar entries for dry and wet nights, praising the child for dry nights, pelvic floor training if needed, biofeedback, apparative behavior therapy, medications.

Enuresis: Definition

Strictly speaking, enuresis is present when a child wets the bed at night at least once a month for a period of three months after his or her 5th birthday. In younger children, on the other hand, involuntary leakage of urine during sleep is considered normal (physiological urinary incontinence).

Daytime wetting

There are also children who only leak urine involuntarily during the day without any organic cause. Doctors refer to this daytime wetting as non-organic (functional) daytime urinary incontinence.

Enuresis: Forms

There are two main forms of enuresis: monosymptomatic (MEN) and non-monosymptomatic enuresis nocturna (Non-MEN):

  • Monosymptomatic Enuresis Nocturna (MEN): The affected children wet themselves exclusively at night during sleep. This is why it is also referred to as “bedwetting”. During the day there are no abnormalities.

Depending on how long the nocturnal enuresis has existed, doctors also distinguish between primary and secondary enuresis:

  • Primary enuresis: The affected children have been wetting at night without a dry phase since birth, without showing any other urological symptoms.
  • Secondary enuresis: After a dry phase of at least six months, children suddenly wet at night again. This form is less common than primary enuresis.

Enuresis: Causes

Enuresis can be caused by a wide variety of factors. In most cases, several factors are involved in its development.

Monosymptomatic Enuresis Nocturna (MEN).

The exact cause of isolated nocturnal enuresis without further symptoms has not been conclusively clarified according to the current state of scientific knowledge. However, in both the primary and secondary forms of MEN, a familial predisposition can be demonstrated: The probability of enuresis in the child is 44 percent if one parent also has enuresis. It increases to 77 percent if both parents had enuresis.

Based on the genetic predisposition, there is presumably a maturation delay in the brain: It is assumed that in MEN-affected persons, those nerve structures mature with a delay that are responsible for controlling the bladder.

Other factors that may play a role in the development of monosymptomatic enuresis (MEN) include:

  • extra deep sleep: Several studies and the experiences of numerous parents have shown that MEN children are exceptionally difficult to wake up. The extra deep sleep causes the children not to notice the urge to urinate. If the bladder is too full, it then empties involuntarily.
  • Low bladder capacity: sometimes the child’s bladder is simply too small for the amount of urine produced.
  • Polyuria: In polyuria, the bladder is normal in size but produces too much urine.
  • Incomplete bladder emptying: If, for example, the urethra is too narrow, the bladder cannot empty completely. As a result, residual urine remains after each visit to the toilet. As a result, the bladder fills more quickly, which can lead to nocturnal enuresis.
  • Drinking too much liquid in the evening: Drinking too much in the evening before sleeping can also lead to MEN. According to a study, an amount of 25 milliliters or more of fluid per kilogram of body weight can trigger nocturnal enuresis.

Non-Monosymptomatic Enuresis Nocturna (Non-MEN).

Nocturnal enuresis plus daytime symptomatology is either the result of a nonorganic disorder of bladder function or a mixture of genetic maturational delay (such as MEN) and nonorganic disorder of bladder function.

Non-MEN is most commonly observed in children with overactive bladder and decreased bladder capacity and habitual postponement of urination (micturition postponement):

Typical of an overactive bladder is a frequent, excessive urge to urinate that can hardly be suppressed. During the day, those affected are sometimes still able to hold back urine. But at night during sleep, when there is no conscious control, involuntary enuresis occurs.

Postponement of micturition occurs when a child gets used to holding his urine for a long time – for example, because he does not want to interrupt play to urinate. After some time, the bladder adapts to this, so that eventually even a clearly filled bladder no longer triggers an urge to urinate. During sleep, the bladder then empties itself unnoticed.

Psychological and psychosocial factors, as described under MEN, may also be involved in the development of non-monosymptomatic enuresis.

Associated disorders

Clinically relevant accompanying psychological disorders are found in approximately 20 to 30 percent of children with nocturnal enuresis (primarily with non-MEN). These include, for example, ADHD, disturbed social behavior, anxiety, and depression. Sometimes such concomitant disorders are a consequence of enuresis. In other cases, they precede enuresis, such as secondary enuresis following parental divorce or relocation.

Children who enuresis during the day also show accompanying psychological disorders in 20 to 40 percent of cases.

Sleep disorders (such as sleep apnea) and developmental disorders (such as speech) can also accompany enuresis.

Special case: enuresis in adults

It is assumed that about one percent of adults are also affected by enuresis. As with children, a wide variety of causes can be responsible. For example, delayed maturation in the brain is also occasionally found in adult enuresis patients. However, the prospects of the problem resolving “on its own” are extremely slim.

Enuresis: What to do?

A visit to the doctor is always recommended in the case of enuresis, and this applies equally to children and adults. It is not an emergency, but it should be ruled out that physical illnesses or psychological disorders are behind the involuntary urination. However, it should be ruled out that physical illnesses or psychological disorders are behind the involuntary enuresis. It is also advisable to see a doctor because enuresis can put a great deal of psychological strain on those affected.

The right medical contact for enuresis in children is the pediatrician and adolescent doctor. Adults should contact their family doctor.

Enuresis: Diagnosis

The physician’s goal is to rule out organic causes for involuntary enuresis and to classify enuresis according to its form (primary or secondary enuresis, MEN or non-MEN).

Medical history and protocols

First, the physician takes the patient’s medical history (anamnesis). To do this, he or she asks the affected person or the parents various questions such as:

  • When do you urinate – only at night or also during the day?
  • How often do you wet the bed?
  • Are there other symptoms besides wetting, such as frequent urination or fecal incontinence?
  • Does wetting occur only at home or also or exclusively in unfamiliar surroundings?
  • How many times a day do you or your child go to the toilet?
  • Do you or your child have to get up at night to urinate?
  • Has there ever been an inflammation of the urinary bladder or urethra?
  • How much, what, and when do you or your child drink?
  • Are there any signs of general developmental delay in the child?
  • Do you or your child exhibit behavioral problems?
  • Are there family and/or school problems or job or relationship stress?

The doctor may ask you to keep a so-called bladder diary. In this diary, you should record for at least 48 hours how often the person emptied the bladder, how much urine was passed and how much the person drank.

It is also helpful to keep a 14-day log in which involuntary wetting at night and during the day is documented, as well as the frequency of bowel movements, stool smearing or defecation.

Screening for psychological symptoms

As mentioned above, enuresis is often associated with psychological disturbances. Therefore, specific questionnaires on psychological disorders should also be used in the workup of enuresis. Validated broadband parent questionnaires such as the Child Behavior Checklist (CBCL) are recommended.

If the suspicion of a mental disorder is confirmed, parents or affected individuals should be counseled accordingly and, if necessary, appropriate treatment should be initiated.

Basic examinations

  • Physical examination: The aim is to rule out organic causes for the enuresis and to determine any accompanying disorders. Among other things, the doctor examines the anus and genital area (for signs of foreskin constriction, inflammation of the external genitalia, etc.), the sacrum (malformation?) and the legs (leg length discrepancy? movement and gait disorders? etc.).
  • Ultrasound examination: the physician examines the kidneys and bladder for structural changes. He also determines functional parameters such as the thickness of the bladder wall and the amount of residual urine that may remain in the bladder after urination.
  • Urine sample: the urine is examined to rule out urinary tract infections.

Further examinations

Other tests may be useful to clarify enuresis. Some examples:

A urine flow measurement (uroflowmetry) with residual urine determination helps to detect disorders of bladder emptying: Here, the patient urinates into a special measuring funnel. Urine flow (in milliliters per second), urine volume and duration are measured. Any residual urine is also determined. The examination should be repeated several times.

Treatment

Urotherapy is the basis of enuresis therapy. It includes all conservative, nonsurgical, and nonpharmacologic treatments used for lower urinary tract dysfunction. The goal is to improve bladder control and enhance quality of life through structured guidance.

Elements of what is called standard urotherapy include:

  • Information and demystification: the doctor explains to the child and his parents, among other things, how urine is formed and excreted in the body and where there may be problems. He also explains therapy concepts and any accompanying disorders.
  • Instructions for optimal urination (micturition behavior): The doctor explains how and how often the child should go to the toilet to urinate. Regular trips to the toilet are practiced according to a set plan. For example, reminder times (every two to four hours) can be programmed on a digital clock or cell phone, which the child should adhere to on his or her own responsibility.
  • Documentation of symptoms and micturition behavior: For example, the child and parent can record dry and “wet” nights (or days) together on the calendar with a sun and cloud symbol. If the parent praises the child for each sun, this reinforces the child’s motivation. Under no circumstances, however, scold or punish the child for clouds!
  • Regular care and support from the attending physician

Depending on the needs, methods of special urotherapy may also be considered in enuresis therapy. These include, for example:

  • Pelvic floor training
  • Biofeedback
  • electrostimulation (TENS)
  • apparative behavior therapy (AVT, alarm therapy, “bell pants”): The child (with the parents, if necessary) is alerted at night by an alarm device (portable device such as a measuring device in the briefs or a bedside device) by means of a ringing tone and/or vibration as soon as he or she wets – i.e. as soon as urine reaches the measuring sensor. The treatment lasts for at least two to three months and can be stopped when the child has remained dry for 14 nights in a row. After the end of AVT, around 50 percent of children remain dry in the long term.

The active ingredient desmopressin is the main drug available for the treatment of enuresis. It reduces the excretion of water and is used,

  • if an apparative behavioral therapy (AVT) does not help sufficiently against enuresis despite correct implementation,
  • AVT is rejected by the child and parents or is not feasible due to the family situation,
  • the family decides in favor of the latter when choosing between AVT and desmopressin
  • and/or the enuresis is causing a very high level of distress that needs to be reduced as quickly as possible.

In addition, short-term use of desmopressin can be used to bridge critical situations such as school trips or vacations.

Desmopressin is taken daily in the evening as a tablet or melting tablet (dissolves in the mouth), for a maximum of three months. During treatment, the child should drink no more than 250 milliliters of fluid in the evening. They should not drink anything at night.

About seven out of ten children respond quickly to treatment with desmopressin. However, enuresis often returns after discontinuation. However, the risk of relapse may be reduced if the drug is not stopped abruptly, but rather by gradually reducing the dose.

Enuresis: What you can do yourself

Children (and adults) with enuresis should drink enough fluids throughout the day, but less in the evening. Experts strongly advise against absolute drinking bans, which are not sensible!

In the case of frequent wetting, wearing diapers at night and/or a waterproof pad over the mattress can be helpful.

After nighttime wetting, the child should shower in the morning and put on fresh clothes. This avoids possible negative reactions in the kindergarten, at school or among friends to persistent urine odor.

The smell of urine can be eliminated from clothes and bedding by adding soda (baking soda) or eucalyptus oil when washing.

It is very important that you do not feel ashamed to see a doctor. This is because enuresis is a common symptom and can occur in any family. Under no circumstances should you embarrass or even punish your child for wetting. Your child is not acting out of malice, and the situation is probably uncomfortable enough for him. Instead, try to cheer your child up and make him realize that he is not doing anything wrong.

In most cases, enuresis in children disappears with the help of the appropriate therapeutic measures.