Enuresis

What is it?

Enuresis (enn-your-ree-siss) means passing urine without control, in someone who is at a stage of development when we would expect them to have control. Most children are toilet trained for urine, at least by day, between 2 and 4 years of age. Children older than 4-5 years old who have never had bladder control have "primary enuresis." Children who had bladder control by a normal age, but who later develop enuresis, have "secondary enuresis." Nocturnal, or night-time enuresis is also called bed-wetting. Nocturnal enuresis is very common, and up to 5% of 5-year-olds have it. Bed-wetting can distress and embarrass children and their families. Children who wet the bed can develop low self-esteem. They may become fearful of joining in with common childhood activities, like sleepovers and going to camp. Punishment by parents and teasing by siblings and peers makes things much worse.

Children with enuresis are not lazy or mentally retarded. Bed-wetting is actually an inherited problem. Treatment of bed-wetting can be very effective. Doctors usually want to be sure to rule out other conditions that can cause enuresis, like diabetes or bladder infections. Changes or turmoil in a child’s life can also cause bed-wetting. This can occur along with other signs of "regression," like thumb-sucking or asking for a bottle. For example, a new baby in the house can cause a previously dry 4-year-old to regress for a few months.

The first concern is to be sure there is not a medical problem causing a child to wet the bed or have "accidents" during the day. Usually a few simple tests can help determine this. Urine tests can detect a bladder infection. We can find diabetes with urine and blood sugar tests. One note of caution is that a single blood or urine sugar test can be normal in the early stages of diabetes. If the child has a family history of diabetes, many doctors will check for sugar more than once.

The other big concern, of course, is the impact of the enuresis on the child’s self-esteem and comfort, and on the parents’ peace of mind. As we’ve mentioned, enuresis is not a sign of laziness or poor discipline. Children do not wet their pants or the bed in order to punish or manipulate their parents. There is no role for punishment in treating enuresis. It is important to make sure that everyone who cares for your child knows this.

When we do find a cause for enuresis, such as an infection or diabetes, we treat that. In most cases the enuresis goes away rapidly. If after a careful search for a cause, we do not find one, we then turn to behavioral techniques and, if necessary, medication. Punishment, reward charts alone, and fluid restriction do not work well, and most doctors do not recommend them. The most effective treatment for bedwetting is a urinary alarm system. These systems have a thin wire mesh that covers the bed, and is very sensitive to a tiny amount of liquid. At the first sign of moisture, the system sets off an alarm that wakes the child up so that s/he can get to the bathroom in time. These alarms do not give children electric shocks. In fact, some of these systems come with a "star chart" to provide positive feedback each time the system works. The alarm system is part of a learning technique. That means it is not effective instantaneously. Each time the alarm goes off, the child’s body learns more and more about the feeling of having a full bladder. Over time, the child becomes aware of this feeling and can wake him or herself up before moisture sets off the alarm. You can help your child by having him or her empty the bladder just before bedtime, and avoiding drinking liquids, especially those with caffeine in them, for several hours before bed.

Even if an alarm system works, children may still relapse weeks or months later. One way to avoid this is a technique called "over-learning." Some doctors use this after the child has been dry all night for some time. In "over-learning," parents actually give extra fluids before bed-time. This causes the child to have a full bladder sooner. The child then develops extra-sensitive reflexes for waking up in time. Alarm systems do not cause emotional or behavioral problems.

If the alarm system does not work after three months, your doctor may decide to try a medication. Desmopressin (dess-mow-PRESS-in) (DDAVP®, Desmospray®, and others) is a hormone medication. It comes as a nasal spray, so it is easy to use. Please be sure to use it exactly as recommended. You can read our Aftercare Instruction on giving Inhaled Medications.  Some doctors use the combination of an alarm and medication in some cases. More than 90% of children with bed-wetting get better after using an alarm system, desmopressin, or the combination.

Enuresis is not dangerous so long as we have ruled out one of the medical conditions that could be causing it. Here are some things to look out for that might suggest a medical cause for enuresis:

• Any child with secondary enuresis – that is, any child who has previously been dry through the night who is now wetting
• Fever
• Pain with urination, or crying during urination
• A reluctance to urinate
• Redness, swelling, or tenderness of any part of your child’s penis or vagina
• Discharge of any fluid or material from the penis or vagina
• A foul smell or cloudy appearance of the urine
• Low back pain or abdominal pain
• Constipation
• Having very frequent urinations
• Drinking excessive amounts of fluids
• A child who seems unusually sad, quiet, angry, or uncooperative, or who suddenly wants to avoid a specific place or person

Even when they know that enuresis is not a child’s fault, many parents can’t help feeling angry or frustrated at their child. This is a normal feeling. Parents often feel as if they have somehow failed if a child keeps having "accidents" despite everything they’ve done or tried. This is also a normal feeling. Unfortunately, some parents and caregivers give in to their feelings of anger, frustration, embarrassment, or failure. They may punish or injure the child. This is not normal. Intentionally causing a child pain or humiliating him or her is never OK, no matter what the parent is feeling. Every year, hundreds of children suffer bruises, burns, and other physical and emotional injuries as a result of toilet training "discipline." Please be sure that no one who takes care of your child uses any form of physical or verbal threat in toilet training your child.

Some of the things that can cause urine "accidents" in children that we can treat are:

• Bladder infections – these are common in children right around the time of toilet training. Children who are trying to be extra-careful about potty training sometimes wipe themselves too vigorously. This can cause a bladder infection in girls. Children with bladder infections usually complain of pain with urination. They may have abdominal pain or foul-smelling urine. If your child has any fever or complains of back pain, please see your doctor right away; these could be signs of a kidney infection.
• Diabetes – children who begin to urinate more frequently and to drink large amounts of fluids may be showing early signs of diabetes. These are reasons to see your doctor right away.
• Bone or nerve damage – very rarely children with injuries to a spinal column bone, disk, or nerve can lose control of their bladders and/or bowels. These can be the results of trauma, like a serious car accident or fall. Even more rarely, they can be signs of a tumor or mass pressing on a nerve. If your child has had a recent serious injury, develops loss of bladder control very suddenly, or complains of numbness, tingling, or weakness of legs or feet, please see your doctor right away.
• Obesity – girls who are overweight or obese sometimes have trouble getting all of the urine out of their bladders, through the vagina into the toilet. They may retain a small amount of urine in their vagina even after they are finished urinating. In this case, the child usually has a wetness episode minutes to hours after she last used the toilet. If it persists, this can cause infection or inflammation in the area of the vagina (non-specific vaginitis). Many doctors recommend that overweight or obese girls with this problem try sitting on the toilet backwards when they urinate. This position helps to drain urine out of the vagina more completely. Of course, if your child of either sex is overweight or obese, you will want to work with your doctor on a weight-loss program.
• Sexual abuse – unfortunately, one of the causes of enuresis in children can be that they are experiencing sexual abuse. These children often develop urine or bowel problems as a result of physical injuries to their genitals or anus. They may be indirectly trying to make themselves less appealing to an abuser (children are not aware of doing this intentionally). Children who are being sexually abused or touched inappropriately often have sudden changes in their behavior. They may become quiet and sad, they may become angry or uncooperative, or they may develop a fear or dislike of being in a particular place or with a particular person. If you have any reason to be concerned that your child is the victim of sexual abuse, please call your doctor immediately.

Having a sick child at home can be tiring and frustrating. As badly as you feel for your child, you yourself may feel out of control, inadequate, or even angry – these are normal feelings. Babies and children who are sick are often fussy and irritable, and parents often feel stressed to the breaking point, especially when there are other children or adults to take care of. One of the best things you can do for your child is to be sure you take care of yourself. If possible, try to have other adults take care of your child for an hour or two each day so you can get some rest or just some quiet time. If you get so stressed that you are worried about your baby’s safety, call your local Parents’ Anonymous Hotline or visit the Parents Anonymous website to find a group near you.