Nocturnal enuresis is known to be among the most common conditions of childhood, although prevalence estimates vary. Children who wet the bed often suffer acute shame and embarrassment, which affects how they interact with friends and family; the family often feels frustrated and helpless.1, 2

Yet health care providers, perhaps underestimating the condition's impact on children and families, often fail to assess for it or advise parents to defer treatment. In a recent telephone survey of 745 parents and guardians of children between the ages of three and 14 years, sponsored by the National Association of Pediatric Nurse Practitioners, 68% of the respondents revealed that "their children's pediatrician or primary care provider [had] never addressed bedwetting during a routine visit."3 Most respondents didn't know what causes bedwetting, and nearly half reported that they would feel uncomfortable raising the subject with their health care providers. Although most children will outgrow the condition, a wait-and-see approach is not appropriate if bedwetting is affecting the child's self-esteem or causing stress within the family.1, 4

DEFINITIONS AND PREVALENCE

According to a review by Thiedke, an estimated 15% to 25% of five-year-olds wet the bed.5 The condition, which occurs more often in boys than girls, generally resolves spontaneously with age at a rate of 15% per year6; but for some children it persists into adolescence. Thiedke's review estimates that by age 12 prevalence falls to 4% to 8%; among adolescents, only about 1% to 3% continue to wet the bed.5 For a small percentage, nocturnal enuresis may persist even into adulthood, although prevalence is difficult to ascertain. One review reported that 1% to 2% of adults suffer from nocturnal enuresis.7 A study indicated that if untreated, at least 5% of children who wet the bed will continue to do so into adulthood.8

EFFECTS ON CHILDREN AND FAMILIES

Although the effects of bedwetting vary, the condition usually causes some degree of discomfort and anguish. In a review, Butler stated that children who wet the bed often face "a raft of distressing repercussions."9 These can include feeling cold on waking, being teased by siblings, being punished by parents, and being afraid that friends will find out. The same review stated that bedwetting among older children can be associated with "feelings of guilt and shame, avoidance of social activities, a sense of difference from others, victimization, and a loss of self-esteem."9 (Whether bedwetting causes low self-esteem remains a subject of debate, but several studies have found that self-esteem improved with management of the condition.10, 11)

Other studies and reviews have resulted in similar findings. In a survey study of 48 children and 50 adolescents with nocturnal enuresis, bedwetting was ranked high in terms of the severity of its psychological impact.12 The children ranked bedwetting as the third most stressful life event, after parental divorce and parental fighting; the adolescents ranked it a joint second with parental fighting. In a study of 40 children ages five through 15 years, 60% reported feeling unhappy or very unhappy about their bedwetting, and many families reported feeling helpless and isolated.13

A literature review described the results of a 1987 study of personality traits in 3,375 seven-year-old Finnish children.4 The children who were enuretic were more fearful, anxious, and impatient and had more feelings of inferiority than those who weren't enuretic. A review examining the impact of bedwetting on behavior and self-esteem found that older children and those who experienced more treatment failures had more behavior problems, although the overall incidence of significant behavior problems was low and a causal relationship has not been established.10

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Treatment of adolescents can be particularly difficult because the condition may be more severe. In a study of 107 enuretic adolescents in Italy, Nappo and colleagues found that 80% wet the bed at least three times a week, and 45% did so every night.8 They also found that 40% had received no previous therapy. Of those who received drug therapy, 79% experienced improvement or resolution. Yet 23% of all respondents either refused therapy or were noncompliant with it. The researchers commented, "[persistent] enuresis can be dramatically distressing as age increases."8

The majority of parents are concerned about the impact of bedwetting on their child's social and emotional development, according to literature reviews.14, 15 Most parents understand that the condition is not within their child's control.15

However, a review by Schulpen cites two studies that found that as the child grew older, mothers became less tolerant and were more likely to blame the child.15 A review by Butler found that about one-third of parents punish their children for bedwetting,14 which can degrade the parent-child relationship and exacerbate an already stressful situation. A small study of 19 families of enuretic children found that most "were frustrated by the bedwetting and wanted it to stop."2 Frustration levels rose in response to having to do more laundry and attend to the child's hygiene. Among families of adolescents, the issue of who should remove and launder wet bedsheets caused particular conflict. Tension may occur among family members who hold disparate views of the child's ability to control bedwetting. Frustration may also arise during treatment, particularly if results are not immediate.14

Nocturnal enuresis can also cause financial strain, and the cost of home management increases with episode frequency. A European study examined the impact of nocturnal enuresis on family finances and estimated the annual costs associated with nightly episodes to be about $1,000, including costs for additional laundry, extra sheets, disposable absorbent garments such as diapers, and mattress replacement.16

DEMYSTIFYING BEDWETTING

Historically, bedwetting was thought to be associated with psychological or emotional disturbances. Two recent literature reviews have concluded that most children, particularly those with no daytime symptoms, do not have clinically significant behavior problems and are psychologically well adjusted.7, 14 However, both authors emphasize-as do most experts-that when distress is present, helping parents and children understand the causes of bedwetting can bring relief and reassurance.

Physiologic factors that commonly play a role include difficulty arousing from sleep when prompted to void by a full bladder, diminished functional bladder capacity, and nocturnal polyuria.4 Genetic factors may also be involved.

Sleep

A review of studies examining the roles of sleep and arousal in cases of nocturnal enuresis has shown that enuresis occurs at all stages of sleep, not just the deepest stage.17 It's the child's inability to be roused by the sensation of a full bladder or, if roused, to hold urine long enough to get to the bathroom that contributes to bedwetting.

Bladder capacity

A reduced functional bladder capacity at night can be a contributing factor in nocturnal enuresis, particularly in children who have not responded to treatment. In a study of 95 children with refractory nocturnal enuresis, all exhibited about a 50% reduction in bladder capacity during sleep (in some, this was associated with marked nocturnal detrusor instability).18 The result is the need to void before the bladder is actually full, and the child may wet the bed more than once per night. These children may also experience daytime urinary urgency or a need to void more frequently than their peers.

Nocturnal polyuria

Normally, the release of the antidiuretic hormone arginine vasopressin (AVP) increases at night, resulting in lower urine production. It has been postulated that some children with nocturnal enuresis respond inadequately to the nocturnal release of AVP, resulting in higher nocturnal urine production. One study found that children with the condition had elevated levels of AVP, which suggested to the researchers that "the AVP-plasma osmolality feedback mechanism is less sensitive in children suffering from enuresis," possibly because of defective receptor function.19

Genetics

According to a 1998 German study, earlier research has shown that if both parents had nocturnal enuresis, there is a 77% chance that their child will have it; if only one parent had the condition, there is a 43% to 44% chance that the child will.20 The German study, which examined blood samples from 172 family members of 42 children with nocturnal enuresis, found "[a possible] linkage [horizontal ellipsis] to at least three different gene loci on chromosomes 13q, 12q, and 8q."20 Children are often relieved to learn that another family member had the same condition.

Other factors

Underlying diseases that may cause nocturnal enuresis must be ruled out, particularly in new cases. These include diabetes insipidus, diabetes mellitus, and chronic renal disease.21, 22 Some medications, including diuretics and lithium, can cause polyuria; and drugs that have a sedating effect can make it difficult for a child to awaken during the night to void. Urinary tract infections and constipation can cause increased bladder irritability, reduced functional bladder capacity, and incontinence. Anatomic causes of bedwetting are rare; they include posterior urethral valves or urethral stricture in boys, ectopic ureter in girls, neurogenic bladder, or spinal cord pathology. Such conditions can generally be ruled out with careful assessment that includes history, physical examination, and in some cases imaging studies.

ASSESSMENT

Nocturnal enuresis can be categorized as either monosymptomatic or polysymptomatic. Children with monosymptomatic nocturnal enuresis wet only at night and during the day are dry and void without urgency or excessive frequency. Those with polysymptomatic nocturnal enuresis may have one or more of the following symptoms: noticeable daytime urgency, occasional accidental daytime voiding, voiding more frequently than peers, urinary tract infection, constipation or infrequent bowel movements, neurologic impairment, emotional stressors, or sleep apnea.4 A detailed history, and in some cases a urine and stool diary, are necessary to elucidate symptoms that a parent may be unaware of or a child may not reveal. Attempts to manage bedwetting before addressing underlying conditions are usually unsuccessful.

Ask whether the family has experienced any recent changes or stressful events. It's important to understand the parents' attitudes toward bedwetting and to determine whether the child is being blamed or punished for having the condition. How the family handles episodes should be discussed. Both child and parents may be frustrated by unsuccessful attempts to manage the condition or concerned that there is an underlying physical cause. The child's level of motivation should be assessed to determine whether he is ready to begin treatment. Previous interventions should be discussed in detail, including medication regimens and behavior modification efforts. If a method was tried and abandoned, ask both the parents and the child why. Their perceptions and experiences should be taken into account when designing a treatment plan because these can significantly affect the outcome.4

When to treat

It's important to ensure optimal function of the bowels and bladder before starting treatment for nocturnal enuresis. Excessive stool in the colon can affect bladder capacity and cause the sensation of a full bladder. Relief of constipation has been shown to reduce the incidence of enuresis as well as symptoms of daytime urgency.23 One literature review reported that parents are generally unaware of their child's bowel habits.4 Constipation may be present if the child has daily bowel movements but passes only a small amount or has hard, pellet-like stools. Infrequent passage of very large stools can also indicate constipation. Stool softeners and increased dietary fiber may be necessary.

Normal functional bladder capacity (in ounces) can be calculated as the sum of the child's age in years plus two.24 A child's functional bladder capacity can be determined by measuring the volume of urine voided after the child has held it for as long as possible. Retention control training (RCT), also called bladder training, may improve functional bladder capacity in some children.25 It involves having the child increase daily fluid intake, particularly water, and at least once daily, retain urine to the point of urgency. Drinking enough during the day may help avert excessive thirst and drinking in the evening. Studies in adults indicate that caffeine acts as a bladder irritant; therefore, caffeinated beverages should be avoided, especially in the evening.26

TREATMENT

Behavioral therapy that helps the child understand how the body works, increases awareness of the urge to void, and helps establish regular voiding patterns has been shown to reduce episode frequency.27

Alarm therapy, which involves using an enuresis (or bedwetting) alarm, is generally considered to be the safest, most effective method for treating nocturnal enuresis. The device consists of a moisture sensor linked to an alarm; there are several versions available. Some are completely wearable: the moisture sensor fits inside the child's underwear and the alarm attaches to the shoulder of the pajamas. Others involve placing a pad sensor under or over the bottom bedsheet and connecting this to either a bedside alarm or a shoulder-worn alarm. As soon as the child begins to urinate, the sensors trigger the alarm; the child can then go to the toilet. Over time the child becomes conditioned to awaken during an episode and to do so more quickly. Eventually the child awakens when the bladder is full and before urination occurs. This intervention may also condition the child to inhibit detrusor contractions or contract the pelvic floor muscles when urine is about to be released during sleep. According to a literature review by Hjalmas and colleagues, this method succeeds initially in 62% to 78% of cases.4 Although 29% to 66% of children relapse, they often respond to a second course of alarm therapy.4 Perceived disadvantages of alarm therapy are that it requires significant time and effort and that it disrupts the child's sleep.

The nurse should demonstrate the alarm for the child and the family so that they know exactly how it works. Some parents report that their child sleeps through the alarm even though it's loud enough to wake others. Hjalmas and colleagues state that although most children won't awaken at first, most will reflexively stop urinating at the sound's onset.4 It may be helpful initially for an adult to sleep in the child's room and help the child to get to the bathroom when the alarm sounds. Once awake, the child should be responsible for turning off the alarm (usually done by disconnecting the sensor), finish voiding in the bathroom, and if necessary, help to change the bedsheets. As the child becomes conditioned to awaken with the alarm, the need for parental involvement declines.

The motivation levels of both the child and the family and their commitment to using the device are critical to treatment success. A child's motivation tends to increase when he begins to receive overnight invitations and realizes that most of his peers don't wet the bed. Typically it takes several weeks of alarm use to see improvement, and the child may need encouragement to continue. Effective treatment usually requires consistent alarm use for three to four months. If a 50% reduction in weekly enuretic episodes is not achieved after two months, medication, either alone or in combination with alarm use, should be considered.4

Not all children are good candidates for an enuresis alarm as sole therapy. Those who regularly wet more than once or twice per night may benefit from using an alarm in conjunction with medication.4, 28 Alarm therapy may need to be deferred in households without a supportive adult or those in which stress levels are already high. Children who aren't sufficiently motivated may have difficulty cooperating with the months-long course of alarm therapy. In such cases, medication may be the best approach.4

Other behavioral methods, such as motivational therapy and RCT, have been only modestly effective in reducing episode frequency. However, the effects of alarm treatment can be enhanced with their selective use.4, 14

Motivational therapy involves giving positive reinforcement for achieving a desired result. A token-and-reward system such as a "star" chart-a chart of the child's progress is kept; the child receives a gold star for each success and gets a desired reward upon receiving a certain number of stars-is often used. The initial goal may be simply for the child to awaken immediately upon wetting the bed. The ultimate aim is to condition the child by rewarding dry nights and placing less emphasis on wet beds.29

RCT as a treatment for nocturnal enuresis has met with mixed results.7, 25 Blum noted that one large 12-week study found that RCT was effective in reducing the frequency of bedwetting, from four times weekly to less than once every two weeks, in 23% of patients.7 De Wachter and colleagues observed that it was less successful in children whose reduced functional bladder capacity was associated with detrusor instability, and that it was most successful when used in combination with medication.25 Complete resolution of bedwetting through RCT alone is rare.

Fluid restriction, often the first method parents use in an attempt to control a child's bedwetting, has not been shown to be effective.7

Lifting the child from bed and taking him to the bathroom during the night is another method commonly used by parents. Parents generally report that the child wasn't fully awake and later had no recollection of visiting the bathroom. The efficacy of this method has not been well studied. Blum reports one study that found lifting "may teach the child to empty his or her bladder while asleep and deny the child the chance of associating a full bladder with waking."7

Medication

Desmopressin acetate (DDAVP), a synthetic analogue of the antidiuretic hormone vasopressin, increases renal tubular reabsorption of water, resulting in decreased urine output. One study found it to be effective in 68% of children with six months' use; those with no diurnal symptoms and those who typically wet soon after going to bed had the highest success rates.30 Desmopressin can be administered orally or intranasally; it may be given nightly or, once its efficacy has been demonstrated, as needed on occasions such as overnight trips. Evening and nighttime fluids must be restricted. The onset of the medication's action is rapid, and the drug lasts at least six hours, with a maximum antidiuretic effect two hours after administration.31 Patient response may be assessed by comparing the number of wet nights a child has in the two weeks before starting medication with the number of wet nights he has in the two weeks after starting medication. Adverse effects of desmopressin include headache and, if fluids aren't restricted in the evening, hyponatremia.

Imipramine (Tofranil), a tricyclic antidepressant, has been used to manage nocturnal enuresis since the 1960s.32 The mechanism of action isn't well understood; the drug is believed to alter the sleep pattern, so that the child arouses more easily when the bladder becomes full, and to have an anticholinergic effect, thus decreasing detrusor instability and increasing functional bladder capacity. A retrospective analysis stated that approximately 50% of children with enuresis "respond favorably" to imipramine32; another study cited a 36% success rate at six months.30 Adverse effects, which can be significant, include nausea, mood and behavior changes, insomnia, and electrocardiographic changes. An overdose of imipramine can be lethal, so safety precautions must be discussed with families.

One disadvantage of any drug treatment for nocturnal enuresis is that it stops bedwetting only while the regimen is followed; it doesn't cure the condition. The relapse rate is high when any of these medications is discontinued. One study found that six months after stopping medication, only 16% of patients treated with imipramine and 10% of those taking desmopressin remained dry at night.30

NURSING IMPLICATIONS

In counseling children with nocturnal enuresis and their families, it's important early on to help them feel comfortable discussing this sensitive topic. Explain that the condition is not within the child's control and that it's not the result of laziness or poor toilet training. Newly released guidelines from the Canadian Paediatric Society suggest counseling parents "about eliminating guilt, shame, and punishment."33

1. Landgraf JM, et al. Coping, commitment, and attitude: quantifying the everyday burden of enuresis on children and their families. Pediatrics 2004;113(2):334-44. [Context Link]

2. Morison MJ. Living with a young person who wets the bed: the families' experience. Br J Nurs 2000;9(9):572-4, 576, 578. [Context Link]

3. Dunlop A. Meeting the needs of parents and pediatric patients: results of a survey on primary nocturnal enuresis. Clin Pediatr (Phila) 2005;44(4):297-303. [Context Link]

4. Hjalmas K, et al. Nocturnal enuresis: an international evidence based management strategy. J Urol 2004;171(6 Pt 2):2545-61. [Context Link]

5. Thiedke CC. Nocturnal enuresis. Am Fam Physician 2003;67(7):1499-506. [Context Link]

6. Jones EA. Urinary incontinence in children. In: Litwin MS, Saigal CS, editors. Urologic diseases in America: interim compendium. Washington, DC: Government Publishing Office; 2004. p. 137-52. NIH Pub. No. 04-5512. http://www.cdc.gov/std/research/2004/Urologic_Diseases_in_America.pdf. [Context Link]

7. Blum NJ. Nocturnal enuresis: behavioral treatments. Urol Clin North Am 2004;31(3):499-507, ix. [Context Link]

8. Nappo S, et al. Nocturnal enuresis in the adolescent: a neglected problem. BJU Int 2002;90(9):912-7. [Context Link]

9. Butler RJ. Impact of nocturnal enuresis on children and young people. Scand J Urol Nephrol 2001;35(3):169-76. [Context Link]

10. Redsell SA, Collier J. Bedwetting, behaviour and self-esteem: a review of the literature. Child Care Health Dev 2001;27(2):149-62. [Context Link]

11. Hagglof B, et al. Self-esteem before and after treatment in children with nocturnal enuresis and urinary incontinence. Scand J Urol Nephrol Suppl 1997;183:79-82. [Context Link]

12. Van Tijen NM, et al. Perceived stress of nocturnal enuresis in childhood. Br J Urol 1998;81 Suppl 3:98-9. [Context Link]

13. Morison MJ, et al. 'You feel helpless, that's exactly it': parents' and young people's control beliefs about bed-wetting and the implications for practice. J Adv Nurs 2000;31(5):1216-27. [Context Link]

14. Butler RJ. Childhood nocturnal enuresis: developing a conceptual framework. Clin Psychol Rev 2004;24(8):909-31. [Context Link]

15. Schulpen TW. The burden of nocturnal enuresis. Acta Paediatr 1997;86(9):981-4. [Context Link]

16. Pugner K, Holmes J. Nocturnal enuresis: economic impacts and self-esteem preliminary research results. Scand J Urol Nephrol Suppl 1997;183:65-9. [Context Link]

17. Neveus T. The role of sleep and arousal in nocturnal enuresis. Acta Paediatr 2003;92(10):1118-23. [Context Link]

18. Yeung CK, et al. Reduction in nocturnal functional bladder capacity is a common factor in the pathogenesis of refractory nocturnal enuresis. BJU Int 2002;90(3):302-7. [Context Link]

19. Eggert P, et al. Regulation of arginine vasopressin in enuretic children under fluid restriction. Pediatrics 1999;103(2):452-5. [Context Link]

20. von Gontard A, et al. Molecular genetics of nocturnal enuresis: clinical and genetic heterogeneity. Acta Paediatr 1998;87(5):571-8. [Context Link]

21. Kanemitsu N, et al. Familial central diabetes insipidus detected by nocturnal enuresis. Pediatr Nephrol 2002;17(12):1063-5. [Context Link]

22. Rasmussen PV, et al. Enuresis nocturna can be provoked in normal healthy children by increasing the nocturnal urine output. Scand J Urol Nephrol 1996;30(1):57-61. [Context Link]

23. Loening-Baucke V. Urinary incontinence and urinary tract infection and their resolution with treatment of chronic constipation of childhood. Pediatrics 1997;100(2 Pt 1):228-32. [Context Link]

24. Berger RM, et al. Bladder capacity (ounces) equals age (years) plus 2 predicts normal bladder capacity and aids in diagnosis of abnormal voiding patterns. J Urol 1983; 129(2):347-9. [Context Link]

25. De Wachter S, et al. Value of increase in bladder capacity in treatment of refractory monosymptomatic nocturnal enuresis in children. Urology 2002;60(6):1090-4. [Context Link]

26. Creighton SM, Stanton SL. Caffeine: does it affect your bladder? Br J Urol 1990;66(6):613-4. [Context Link]

27. Pennesi M, et al. Behavioral therapy for primary nocturnal enuresis. J Urol 2004;171(1):408-10. [Context Link]

28. Butler RJ. Combination therapy for nocturnal enuresis. Scand J Urol Nephrol 2001;35(5):364-9. [Context Link]

29. Glazener CM, Evans JH. Simple behavioural and physical interventions for nocturnal enuresis in children. Cochrane Database Syst Rev 2004(2):CD003637. [Context Link]

30. Monda JM, Husmann DA. Primary nocturnal enuresis: a comparison among observation, imipramine, desmopressin acetate and bed-wetting alarm systems. J Urol 1995;154(2 Pt 2):745-8. [Context Link]

31. Skoog SJ, et al. Oral desmopressin: a randomized double-blind placebo controlled study of effectiveness in children with primary nocturnal enuresis. J Urol 1997;158(3 Pt 2):1035-40. [Context Link]

32. Gepertz S, Neveus T. Imipramine for therapy resistant enuresis: a retrospective evaluation. J Urol 2004;171(6 Pt 2):2607-10. [Context Link]

33. Canadian Paediatric Society. Management of primary nocturnal enuresis. Paediatr Child Health 2005;10(10):611-4. [Context Link]

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