What is bedwetting?

Causes and Symptoms

Primary enuresis is defined medically as the inability to hold one’s urine during sleep. The condition is quite common and occurs most often in children; between 15 and 20 percent of children under the age of six suffer from the condition. These percentages decrease to about 5 percent at age ten, 2 percent at age fifteen, and only about 1 percent of adults. Secondary enuresis is bed-wetting in a child who had previously achieved bladder control. (These terms do not apply, however, to urination problems caused by physical illness, disease, or anatomical defect.) The condition is more common in boys than in girls. Bed-wetting usually occurs during the first third of sleep, although it can occur during all sleep stages and without relation to awakening periods.

It is important to realize that enuresis is considered to be a developmental concern rather than an emotional, behavioral, or physical one. Donald S. Kornfeld and Philip R. Muskin report in The Columbia University College of Physicians and Surgeons Complete Home Medical Guide (rev. ed., 1989) that “enuresis is due to a lag in development of the nervous system’s controls on elimination.” Many parents fail to understand this neuropsychological element and thus punish the child for a wet bed. Punishing, ridiculing, or shaming the child does not correct the situation; in fact, in many cases, it may prolong the problem as well as cause other unnecessary and undesirable psychological problems. Emotional problems have resulted from enuresis, as the child may be too embarrassed to partake in normal childhood activities such as camping or sleepovers.

Treatment and Therapy

Techniques for helping the enuretic child achieve dryness range from withholding liquids near bedtime to alarm systems to medical intervention. Generally, restriction of liquid intake after dinner is the first course of action. This treatment method, however, does not have a very high success rate. Should this treatment fail after a trial period of a few weeks, other methods may be employed.

Alarm therapy can help a child achieve control within four months, sometimes in only a few weeks. A beeper- or buzzer-type alarm sounds when moisture touches the bedding or underwear; the desired result is that the child, while sleeping, will eventually recognize the need to urinate and awaken in time to get to the bathroom. Electronic alarms are generally of two types. The first is a wired pad, consisting of two screens, which is placed under the sheets to detect wetness; when the child wets, the moisture activates the battery-operated alarm. The second is a device worn on the body, either in the underpants and connected by a wire to an alarm or a wristwatch-type alarm; the underwear serves as a separating cloth for the contact points. In either case, as wetness occurs, the alarm sounds, thus wakening the child; the child can then be directed to the bathroom to complete urination.

Barry G. Powell and Lynda Muransky cite several case histories in which alarm therapy proved to be effective in stopping enuresis. For example, a six-year-old who never had a dry bed achieved dryness within a week through the use of an alarm. In another case, a fifteen-year-old had been trying to overcome his bed-wetting problem for ten years. Several trips to the doctor showed that he had no physical cause for enuresis. His parents labeled him “lazy, inconsiderate, and difficult.” His desire to join his hockey team in overnight travel gave him the impetus to seek help. Powell and Muransky found his problem to be primary enuresis aggravated by family ridiculing. Through the use of his alarm, he achieved dryness within two weeks.

A case involving secondary enuresis is described as well. A child who had suffered through primary enuresis, then achieved dryness, was found to be wetting again. This second bout of bed-wetting seems to have been the result of his parents’ marital separation. After a medical examination revealed no physical problems, it appeared the problem was psychological, caused by emotional upset. He resumed dryness in three weeks (although an alarm system on his bed for six months gave him more confidence). It is important to note, however, that alarms can take up to several months’ time before a child feels comfortable in stopping its use. Also, parental supervision is imperative for this type of therapy to work properly.

Chiropractic spinal manipulation has been found to be effective in the treatment of some cases of enuresis. Some believe that a spinal reflex is involved in bed-wetting. As nighttime breathing slows down (a normal reaction), carbon dioxide builds up in the body. When the carbon dioxide buildup reaches a certain level, a breathing mechanism called the
phrenic reflex is triggered. This mechanism normally causes the diaphragm to return breathing to its normal pattern. If the mechanism does not work properly, however, the carbon dioxide continues to increase, resulting in an involuntary relaxation of the sphincter muscle at the opening to the bladder. Fluid (urine) is released and leaks out of the bladder. A child in a deep state of sleep does not recognize that the bed has been wet. Generally, chiropractors believe that the bed-wetting child sleeps in a state of high carbon dioxide intoxication.

While immature development of the phrenic reflex is the most common cause of bed-wetting, in some children a misalignment of the bones in the neck and spine (referred to as “subluxation” by chiropractors) is thought to cause pressure on the nerves that are related to the phrenic reflex. Through chiropractic adjustments, it is argued, the subluxation can be corrected, thus relieving pressure on the nerves. With the spine realigned and bodily functions working normally, enuresis can be eliminated. One child had never had a dry bed in his first ten years of life; after only two spinal adjustments by a licensed chiropractor, the child stopped wetting immediately. Chiropractors usually recommend a series of adjustments in order to realign the spine and nerves and keep them in the proper position.

Drug therapy solely for the treatment of enuresis is controversial. However, when an illness such as diabetes mellitus is the underlying cause of the bed-wetting, the use of drugs may be indicated. The drug imipramine hydrochloride (an antidepressant agent) has been studied to assist in contraction of the sphincter; however, because of the high toxicity and limited effectiveness of such antidepressants, its use is not widespread. Relapse rates are high, and cure rates are relatively low. More success has been achieved with desmopressin acetate, an antidiuretic drug. There is an immediate improvement in 70 percent of treated children. Relapse rates are lower than those associated with imipramine but higher than with the use of bed-wetting alarms, probably because the sphincter muscle is not fully developed in the enuretic child. In general, drug therapy yields a final success rate of about 25 percent.

Perspective and Prospects

The history of bed-wetting is probably a lengthy one. The term “enuresis” was coined around 1800, and the condition has plagued children from every ethnic background and socioeconomic level around the world. It continues to be a problem for many children today and probably will be so in the future as well.

Most enuretics are deep sleepers who are usually quite active during their waking hours. This sleeping pattern, combined with urinary systems that are not yet fully developed, is generally the main cause of bed-wetting. There are some indications that enuresis is hereditary; many children who suffer from the condition have a parent who was enuretic as a child. It is reassuring to know that almost all affected children outgrow the problem by adulthood. While no immediate cure is available, continued experiments with alarm systems and drugs will certainly alleviate the discomfort and embarrassment until the body’s lag in development corrects itself.

Bibliography

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American Medical Association. American Medical Association Family Medical Guide. 4th rev. ed. Hoboken, N.J.: John Wiley & Sons, 2004.

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Ronen, T., L. Hamama, and M. Rosenbaum. "Enuresis: Children’s Predictions of Their Treatment’s Progress and Outcomes." Journal of Clinical Nursing 22 no. 1–2 (January, 2013): 222–32.