As I glance at the schedule to see who my next patient will be, I am pleased to learn that Jonathan is coming in for his kindergarten physical. I have taken care of Jonathan since his birth five years ago, and I have watched him grow up to be a polite and well-adjusted little boy. I anticipate an "easy" visit since he has been in excellent health. To my surprise, both mom and dad are present for the visit...there is a certain tension in the air. Before we even get started, dad informs me that they are "very concerned" because Jonathan still wets the bed. As the words roll off his tongue, I see Jonathan's eyes look downward as he slumps in his chair. The sparkle leaves his eyes. He looks like a wounded bird.
Later that day, Caitlin comes in for her yearly exam. She just turned six years old. She did well in kindergarten last year, and is looking forward to first grade. As I systematically go through my questions we come to the urinary tract. Her mom states casually that Caitlin wets the bed around 3-4 nights a week. It is no "big deal", and we proceed with the rest of the exam.
Two very different scenarios dealing with the same problem. Yet the impact on one family is significant, and in the other family it is not even an issue. What is the difference, or better stated, should there be a difference?
Nighttime bedwetting, nocturnal enuresis, is very common in children. Around 15% of all 5 year olds wet the bed. This resolves without any intervention at the rate of about 15% each year. As more and more children are going to pre-school and are expected to be out of pull-ups or diapers, voluntary control of urine has become more of a social milestone rather than a developmental milestone.
Most studies report that enuresis is more common in boys than girls, and there is usually a strong family history of bedwetting (a parent, aunt or uncle).
In evaluating a child with bedwetting, it is important to do a thorough exam to be sure that there is not a medical cause such as constipation, a urinary tract infection, or an anatomical/neurological abnormality. Rarely does this prove to be the case.
The exact cause of enuresis is not known, but simply stated, the bladder is not yet large enough to hold a full night volume of urine, or the child has not yet developed the ability to respond to the sensation of a full bladder by waking up. Regardless, it is important for the child and the parents to realize that this is a common problem and one that is not done on purpose. The child has absolutely no control over this.
When counseling parents about this, I ask them if the bedwetting bothers the child. If not, then it is usually not a problem. It typically doesn't interfere with a child's life until they are school age and want to participate in sleep-overs, or go to camp. If they are self-conscious about the enuresis, or shy away from these fun social activities, then it has become a problem.
In Jonathan's case, the bedwetting not only impacted his life, but greatly affected his parents as well. His father just couldn't fully accept that Jonathan could not control his bedwetting. Although he never became angry with Jonathan, the frustration and disappointment in his body language cut Jonathan to the quick. When his mom would come to Jonathan's defense, it usually ended up in an argument and Jonathan would quietly slip into his bedroom. He missed out on many sleep-overs for fear he would "have an accident". He always used the same excuse, "My parents won't let me". In this family, the enuresis had become a major issue and something had to be done.
Caitlin's case was entirely different. Mom had a healthy outlook on the bedwetting, and Caitlin couldn't care less about it. In this situation, the best thing to do is to leave well enough alone.
After ruling out a medical cause, the first step is to insure that the parents and child understand that this is not a voluntary act on the part of the child. Getting frustrated, angry, punishing the child, or setting unattainable goals are only going to work in a negative way.
If the child expresses a desire to be dry at night, the parents must have a "game plan" to operate from. A first step might be to have the child avoid excessive fluids right before bed, especially citrus juices or caffeinated soft drinks. The child should be made to urinate right before going to bed. They can set an alarm clock for the middle of the night (before they usually wet the bed) at which time they can get up and urinate before they wet the bed. If they have an accident, have them change their clothes on their own. They should be allowed to take responsibility, not out of punishment, but to give them control of the situation. I encourage parents to be very supportive and positive...try not to get frustrated. They should almost adopt a "laissez-faire" attitude. When the child has a dry night, give them the praise that they deserve. If they have an accident, down play it. Tell them it's not a big deal, try again tonight.
If this approach doesn't work, there is an alarm system that can be used. It is a cloth pad that fits in the front of the underpants and connects to a beeper-sized alarm that clips onto the pajamas. When the child starts to void and the urine makes contact with the pad, the alarm sounds. This wakes up the child and they can get up and empty their bladder. Before long the child will subconsciously stop the act of voiding before the alarm goes off. They will either get up and go to the bathroom, or successfully fall back to sleep without wetting. This method is successful in around 50-75% of all cases.
If this doesn't work, there is a medication that can be used called DDAVP(vasopressin). This is a hormone that is produced by the body and it is marketed in the form of a nasal spray. It is safe and is approved by the FDA for the treatment of enuresis. At bedtime, the child puts one spray in each nostril (they should blow their nose beforehand to facilitate the absorption). This is done every night. After a few weeks, if unsuccessful, this can be increased to three sprays and so on up to a maximum of four sprays a night. This has proved to be successful, and can be used in conjunction with the alarm system. Over time, the DDAVP can be gradually weaned off.
Jonathan had excellent results with the alarm system within a couple of weeks. Things were much better at home, and Jonathan and his father were going on a camping trip for the weekend with three other father-son pairs.
Caitlin was never bothered by her bedwetting and as a result nothing was done. I saw her six months later for a sore throat and as she and her mom were leaving, her mom told me, "Oh by the way, Caitlin hasn't wet the bed in over two months. I thought you'd like to know for her records.