Bed-wetting

Overview

Bed-wetting ― also called nighttime incontinence or nocturnal enuresis ― means passing urine without intending to while asleep. This happens after the age at which staying dry at night can be reasonably expected.

Soggy sheets and pajamas — and an embarrassed child — are a familiar scene in many homes. But don't get upset if your child wets the bed. Bed-wetting isn't a sign of problems with toilet training. It's often just a typical part of a child's development.

Generally, bed-wetting before age 7 isn't a concern. At this age, your child may still be developing nighttime bladder control.

If your child continues to wet the bed, treat the problem with patience and understanding. Lifestyle changes, bladder training, moisture alarms and sometimes medicine may help lessen bed-wetting.

Symptoms

Most kids are fully toilet trained by age 5, but there's really no target date for having complete bladder control. Between the ages of 5 and 7, bed-wetting remains a problem for some children. After 7 years of age, a small number of children still wet the bed.

When to see a doctor

Most children outgrow bed-wetting on their own — but some need a little help. In other cases, bed-wetting may be a sign of an underlying condition that needs medical attention.

Talk to your child's doctor or other health care professional if:

• Your child still wets the bed after age 7.
• Your child starts to wet the bed after a few months of being dry at night.
• In addition to wetting the bed, your child has pain when passing urine, is often extra thirsty, has pink or red urine, has hard stools, or snores.

Causes

It's not known for sure what causes bed-wetting. Several issues may play a role, such as:

• A small bladder. Your child's bladder may not be developed enough to hold all the urine made during the night.
• No awareness of a full bladder. If the nerves that control the bladder are slow to mature, a full bladder may not wake your child. This may be especially true if your child is a deep sleeper.
• A hormone imbalance. During childhood, some kids do not produce enough anti-diuretic hormone, also called ADH. ADH slows down how much urine is made during the night.
• Urinary tract infection. Also called a UTI, this infection can make it hard for your child to control the urge to pass urine. Symptoms may include bed-wetting, daytime accidents, passing urine often, red or pink urine, and pain when passing urine.
• Sleep apnea. Sometimes bed-wetting is a sign of obstructive sleep apnea. Sleep apnea is when a child's breathing is interrupted during sleep. This is often due to swollen and irritated or enlarged tonsils or adenoids. Other symptoms may include snoring and being sleepy during the day.
• Diabetes. For a child who's usually dry at night, bed-wetting may be the first sign of diabetes. Other symptoms may include passing large amounts of urine at once, increased thirst, extreme tiredness and weight loss in spite of a good appetite.
• Ongoing constipation. A child who is constipated does not have bowel movements often enough, and the stools may be hard and dry. When constipation is long term, the muscles involved in passing urine and stools may not work well. This can be linked to bed-wetting.
• A problem in the urinary tract or nervous system. Rarely, bed-wetting is related to a difference in the structure of the urinary tract or nervous system.

Risk factors

Bed-wetting can affect anyone, but it's twice as common in boys as in girls.

Several factors have been linked with an increased risk of bed-wetting, including:

• Stress and anxiety. Stressful events may trigger bed-wetting. Examples include having a new baby in the family, starting a new school or sleeping away from home.
• Family history. If one or both of a child's parents wet the bed as children, their child has an increased chance of wetting the bed, too.
• Attention-deficit/hyperactivity disorder (ADHD). Bed-wetting is more common in children who have ADHD.

Complications

Although frustrating, bed-wetting without a physical cause does not result in any health risks. But bed-wetting can create some issues for your child, including:

• Guilt and embarrassment, which can lead to low self-esteem.
• Loss of opportunities for social activities, such as sleepovers and camp.
• Rashes on your child's bottom and genital area — especially if your child sleeps in wet underwear.

Diagnosis

Depending on your child's situation, the health care professional can check for any underlying cause of bed-wetting. A treatment plan can be made based on:

• Physical exam.
• Discussing symptoms, fluid intake, family history, bowel and bladder habits, and problems caused by bed-wetting.
• Urine tests to check for signs of an infection or diabetes.
• X-rays or other imaging tests of the kidneys or bladder to look at the structure of the urinary tract.
• Other types of urinary tract tests or assessments, if needed.

Treatment

Most children outgrow bed-wetting on their own. If treatment is needed, talk about options with your child's health care professional. Together you can decide what will work best for your child.

If your child is not especially bothered or embarrassed by an occasional wet night, lifestyle changes may work well. These include not having caffeine, limiting liquids in the evening and passing urine right before bed.

If lifestyle changes are not successful or if your child is upset or worried about wetting the bed, other treatments may be helpful.

If found, underlying causes of bed-wetting, such as constipation or sleep apnea, should be looked into by a health care professional.

Options for treating bed-wetting may include moisture alarms and medicine.

Moisture alarms

These small, battery-operated devices connect to a moisture-sensitive pad on your child's pajamas or bedding. When the pad senses wetness, the alarm goes off. You can buy these moisture alarms without a prescription at most pharmacies.

Ideally, the moisture alarm sounds just as your child begins to pass urine. This should be in time to help your child wake, stop the urine stream and get to the toilet. If your child is a heavy sleeper, another person may need to listen for the alarm and wake the child.

If you try a moisture alarm, give it plenty of time. It often takes 1 to 3 months to see any type of response. It may take up to 16 weeks to have dry nights. Moisture alarms are effective for many children. They carry a low risk of side effects and may provide a better long-term solution than medicine does. These devices may not be covered by insurance.

Medicine

If lifestyle changes do not help your child stay dry, your child may be prescribed medicine for a short period of time to stop bed-wetting. Certain types of medicine can:

• Slow how much urine is made at night. The drug desmopressin (DDAVP) reduces how much urine is made at night. But drinking too much liquid with the medicine can cause problems. Do not use desmopressin if your child has symptoms such as a fever, diarrhea or nausea. Be sure to carefully follow instructions for using this medicine.

  Desmopressin is an oral tablet. It's only for children 6 years or older. According to the U.S. Food and Drug Administration, nasal spray forms of desmopressin are no longer recommended for treatment of bed-wetting due to the risk of serious side effects.

• Calm the bladder. If your child has a small bladder, an anticholinergic drug such as oxybutynin (Ditropan XL) may help reduce bladder contractions and increase how much urine the bladder can hold. This may be especially helpful if daytime wetting also occurs. This medicine is usually used along with other medicines. It's generally only recommended when other treatments have failed.

Sometimes your child may be prescribed more than one type of medicine. But there are no guarantees that medicine will work, and medicine does not cure the problem. Bed-wetting typically starts again when medicine is stopped. This may happen until bed-wetting ends on its own at an age that varies from child to child.

Lifestyle and home remedies

Here are changes you can make at home that may help with bed-wetting:

• Limit fluids in the evening. It's important to get enough fluids, so there's no need to limit how much your child drinks in a day. But encourage drinking liquids in the morning and early afternoon. This may lessen thirst in the evening. But don't limit evening fluids if your child has sports practice or games in the evenings.
• Avoid drinks and foods with caffeine. Caffeine is not a good idea for children at any time of day. Because caffeine may stimulate the bladder, it should especially be avoided in the evening.
• Urge double voiding before bed. Double voiding is passing urine at the beginning of the bedtime routine and then again just before falling asleep. Remind your child that it's OK to use the toilet during the night if needed. Use small night lights, so your child can easily find the way between the bedroom and bathroom.
• Urge regular toilet use throughout the day. During the day and evening, suggest that your child pass urine every 2 to 3 hours or so, or at least often enough to avoid a feeling of needing to pass urine right away.
• Prevent rashes. To prevent a rash caused by wet underwear, help your child rinse their bottom and genital area every morning. It also may help to cover the affected area with a protective moisture barrier ointment or cream at bedtime. Ask your health care professional for product suggestions.

Alternative medicine

Alternative medicine is a popular name for health care practices that traditionally are not part of well-researched standard medicine. Complementary and integrative medicine, when based on solid research, may sometimes be used along with standard medicine.

Some people may choose to try complementary or alternative medicine approaches to treat bed-wetting. For hypnosis, acupuncture, chiropractic therapy and herbal therapy, evidence of effectiveness is weak, not conclusive or proved to not be effective. In some cases, the studies were too small or not done carefully, or both.

Be sure to talk to your child's health care professional before starting any complementary or alternative therapy. If you choose an approach that is not standard, ask if it's safe for your child. Also make sure that it will not interact with any medicines your child may take.

Coping and support

Children do not wet the bed to annoy their parents. Try to be patient as you and your child work through the problem together. Effective treatment may include several strategies and may take time to be successful.

• Be sensitive to your child's feelings. If your child is stressed or anxious, encourage your child to express those feelings. Offer support and encouragement. When your child feels calm and secure, bed-wetting may become less of a problem. If needed, talk to your child's health care professional about additional strategies for dealing with stress.
• Plan for easy cleanup. Put a plastic cover over your child's mattress. Use thick, absorbent underwear at night to help contain the urine. Keep extra bedding and pajamas handy. But avoid the long-term use of diapers or disposable pull-up underwear.
• Ask your child to help. If your child is old enough, consider asking your child to rinse wet underwear and pajamas or place these items in a specific container for washing. Taking responsibility for bed-wetting may help your child feel more control over the situation.
• Celebrate effort. Praise your child for following the bedtime routine and helping clean up after accidents. Use a sticker reward system if you think this might help motivate your child. Bed-wetting is not done on purpose, so it doesn't make sense to punish or tease your child for wetting the bed. For the same reason, rewarding dry nights is not helpful. Also, discourage siblings from teasing the child who wets the bed.

With support and understanding, your child can look forward to the dry nights ahead.

Preparing for an appointment

You're likely to start by seeing your child's pediatrician or other health care professional. You may be referred to a doctor who specializes in urinary disorders called a pediatric urologist or pediatric nephrologist.

Here's some information to help you get ready for your appointment and know what to expect.

What you can do

Before your appointment, make a list of:

• Any symptoms, including any major ones that may seem unrelated to bed-wetting. Consider keeping a diary of your child's bathroom visits and wet and dry nights. Note when your child goes to the toilet and whether your child felt a need to pass urine right away. Also note how much liquid your child drinks, especially after dinner.
• Key personal information, including any major stresses or recent life changes.
• Any family history of bed-wetting, including siblings or parents.
• All medicines, vitamins, herbs and other supplements that your child takes, and the doses.
• Questions to ask your child's health care professional so you can make the most of your time together.

Some basic questions to ask may include:

• What's causing my child to wet the bed?
• When might my child outgrow wetting the bed?
• What treatments are available, and which do you suggest? Are there any side effects?
• Are there any other options than the main approach that you're suggesting?
• Should my child limit drinking fluids at certain times?
• Are there any brochures or other printed material that I can have? What websites do you recommend?

Feel free to ask other questions during your appointment.

What to expect from your doctor

Your child's health care professional is likely to ask you some questions, such as:

• Is there a family history of bed-wetting?
• Has your child always wet the bed, or did it begin recently?
• How often does your child wet the bed?
• Are there periods of time when your child does not wet the bed?
• Is your child dry during the day?
• Is your child having stool accidents?
• Does your child complain of pain or other symptoms when passing urine?
• Is your child facing any major life changes or other stresses?
• If you're separated or divorced, does your child alternate living at each parent's home? Does the bed-wetting occur in both homes?
• How do you respond to your child's bed-wetting?

Be ready to answer questions so that you'll have time to talk about what's most important to you.