Bedwetting

​Nocturnal enuresis, commonly known as bedwetting, is wetting that occurs during sleep in a child beyond the age of five years.

Bedwetting is a common and troublesome problem in children. Traditionally it is seen as part of growing up, but when bedwetting persists beyond early childhood, it becomes unacceptable and can often be stressful and distressing to the affected children and their families.

Most children seeking treatment for bedwetting in Singapore are :

• Five years or older, most frequently between seven and twelve years of age.
• Suffering from a bedwetting frequency of at least two times a week, with a majority being almost every night.

Is bedwetting a problem that needs therapy?

Yes, especially when the child is of school-going age and the wetting is frequent. Studies have shown that constant bedwetting can adversely affect the psychosocial development of the child causing low self-esteem and poor social adjustment. It can also cause much resentment and anxiety in parents and other family members towards the bedwetting child, and is a constant source of embarrassment that deters the sufferer from healthy outdoor activities like overnight camping and travelling.

In Singapore, it has been found that bedwetters and their parents sought treatment for the following reasons:

• Restricted activities involving overnight sleep outside home
• Parental fatigue
• Disrupted sleep for the household
• Fear of underlying disease

The exact cause of bedwetting is not known, but some known contributing factors are:

• Heredity – Bedwetting often runs in a family. There were few gene mutations detected and reported to cause bedwetting within the same family.
• Deep sleep – Many children with bedwetting have difficulty waking in response to a full bladder during sleep.
• Delayed development – A delay in maturation of bladder control at night. Bedwetting tends to improve with time and the majority of sufferers will ultimately become dry. But this may take years and a small percentage of them (1%) will continue bedwetting beyond puberty.
• Problem of hormone regulation – Children who wet the bed may have a lower level of a hormone called the antidiuretic hormone, which concentrates and reduces the total urine produced overnight. This means that they may produce more than the normal amount of urine during sleep and that predisposes them to bedwetting.

Most children with bedwetting do not have an underlying psychological problem. Bedwetting is involuntary, and children have little or no control over it during sleep. However, emotional stress may worsen bedwetting in some children or trigger recurrence after a period of dryness. Punishing or blaming a child for bedwetting is not helpful and may increase stress, potentially making the situation worse.

The vast majority of bedwetters are healthy with no underlying diseases. Only rarely is bedwetting associated with other diseases. When this occurs, it is almost always associated with symptoms like wetting in the day, pain on passing urine, fever, excessive thirst. large urine volume or failure to grow.

When a child who has been dry for several months starts bedwetting again, emotional stress or significant life changes may sometimes play a role. Occasionally, an underlying medical condition may be responsible. Parents should seek medical advice so that appropriate assessment can be carried out.

Majority of children with bedwetting can improve significantly and even overcome it. There are two main treatments for bedwetting:

1. Bedwetting Alarm Therapy (Nurse-led bedwetting therapy sessions after assessment by the treating doctor. Families receive counselling, training and follow-up support regarding alarm use.)
2. Medication (Prescribed by the treating doctor)

1. Bedwetting alarm

This is a form of conditional therapy. As bedwetting children are “deep sleepers” and do not wake up when the bladder is full, enuresis alarm training is targeted at this problem by training the child to wake up when the bladder is full.

The alarm comprises a moisture sensor that connected to the alarm unit. When the chid starts to pee when asleep, the sensor worn by the child sends a signal to trigger the alarm to sound or vibrate, awakening the child with the assistance of an adult to complete voiding in the toilet. Several nights of being awakened in this manner results in the development of a conditioned response, enabling the child to hold and wake up to go to toilet to pee when the bladder is full.

This method is effective in 70% to 80% of bedwetters but it requires high motivation and patience on the part of the bedwetters and their parents, as well as constant support from therapists. It takes time to train the bladder, and results are often seen only after weeks of therapy.

How do the nurse-led bedwetting therapy sessions help?

Upon referral from a doctor, trained nurses will assess a child’s suitability for therapy. The nurse then teaches the child and family how to use the alarm and set up a therapy program at home. As compliance and motivation are essential for success, the nurse will follow-up with the child until he/she has attained dryness. During these follow-up sessions, the nurse will work with the child and family to review progress and solve any issues or problems.

Consistent follow-up is critical in attaining dryness. Children who do not have follow-up may lose motivation resulting in lower compliance and treatment failure.

2. Medication (Desmopressin)

Some children with bedwetting produce large amounts of diluted urine overnight. To reduce this excessive urine production, the doctor may prescribe a medication called Desmopressin to reduce the production of urine. This can help the child to achieve dryness while waiting for the natural resolution of bedwetting. Seek advice from your doctor as to whether your child might be a suitable candidate for Desmopressin.

It is necessary to try out this medication over two weeks to assess the child’s response as only about 70 percent of children will respond to the medication. The doctor may adjust the dose depending on the response.

If the child responds well, the medication may be used nightly or on an as-needed bases for occasions such as sleepovers or camps. Treatment is continued for at least three months, after which periodic medication holidays can be used to check for natural resolution of bedwetting. Some children may need treatment for a longer period of time. If the child does not respond to the medication, the treatment is discontinued.