Nocturnal Enuresis

The International Children’s Continence Society defines nocturnal enuresis as episodes of urinary incontinence during sleep in children ≥5 years of age. It is estimated that 15% of children age 5 have nocturnal enuresis. A child with nocturnal enuresis wets only during sleep and urinates normally when awake. Only 1% of all 16 year olds still have nocturnal enuresis and with time, the only real “cure” for bedwetting, they will outgrow this.

There are many factors that may be involved, and many theories that are given for why children wet the bed at night. The following is a list of some of the possible reasons for the problem:

• Constipation
• Maturity of a child’s bladder function
• Small bladder capacity
• Poor sleep habits or the presence of a sleep disorder
• Medication that affects sleep

A thorough history and physical will be conducted.

• A urine analysis may be performed (if not already completed by the primary care physician) to rule out medical reasons for bedwetting, such as infection or diabetes.
• A renal/bladder ultrasound may be performed to evaluate the anatomy of both kidneys and bladder to ensure no abnormalities.
• Assessment of daytime voiding and stooling habits.
• A voiding and stooling diary may be used to assess these habits as well as the size of bladder.

Tools to help improve bed wetting include healthy daytime bladder and bowel habits:

• Fluid restriction after dinner (limit fluids two hours before bedtime).
• Adequate fluid intake throughout the day.
• Avoid bladder irritants (specifically caffeine, carbonated (“fizzy”) beverages, colored or dyed beverages, citric acid and chocolate.
• Timed voids every 2-3 hours. This is to encourage bladder emptying on a regular schedule and promote healthy bladder cycling. This would also discourage withholding.
• Proper voiding techniques. In order to prevent vaginal voiding (backwash of urine into vagina), girls are encouraged to fully remove underwear at the toilet so the legs can be maximally abducted. Using a step stool under feet while urinating relaxes the pelvic floor muscles and allows adequate emptying of the bladder.
• Double voiding after each void. Have the child urinate, wait a few seconds (can have child say the alphabet or count) then have the child urinate again. This will help ensure complete emptying of the bladder.
• Avoiding constipation with a daily soft stool is recommended. Increasing the amount of fiber and healthy fruits and vegetables, as well as increasing water intake may be sufficient. Some children require a gentle stool softener to help achieve a soft stool daily.

Other management options include:

• The bed wetting alarm. This is a type of conditioning therapy to help your child identify the need to wake up and use the bathroom. The type of alarm should have both a vibrating mechanism and an auditory alarm to help wake the child. Proper use of this requires consistency and patience. This should be used nightly with maximization of daytime bladder and stooling habits. This may take a few months to see progress, but it is estimated 60-70 percent of children will see improvement when properly used.
• Medications:

DDAVP (desmopressin): This drug decreases the amount of urine output at night. If this is effective in the patient, it is only used for special occasions such as sleep overs or overnight camps. Only 50% of patients will even respond to DDAVP.The medication should be taken two hours prior to sleep and to fluid restrict with use of medication. The side effects of hyponatremia and possible seizures were discussed.

Imipramine (tricyclic antidepressant): Imipramine works by several means as a bladder relaxant, increases external sphincter tone, and may work via unknown CNS mechanisms. Cardiac toxicity with large amounts of imipramine have been reported. This drug is not commonly prescribed for nocturnal enuresis.

Ditropan (anti-muscarinic): The use of ditropan is typically best for patients with daytime symptoms as well, but can occasionally help with nightime-only wetting, particularly if a small bladder.