Bed-Wetting (Enuresis)

What is enuresis?

Enuresis (bed-wetting) is the term used for urinating while asleep. It is considered normal until at least age 6.

What is the cause?

Most children who wet the bed have inherited small bladders, which cannot hold all the urine produced in a night. In addition, they are deep sleepers who don't awaken to the signal of a full bladder. The kidneys are normal. Physical causes are very rare, and your healthcare provider can easily detect them. Emotional problems do not cause enuresis, but they can occur if it is mishandled.

Measure your child's bladder size to help you understand how important it is for him to get up at night. Do this by having your child hold his urine as long as possible on at least three occasions. Have your child urinate into a container each time. Measure the amount of urine in ounces. The largest of the three measurements can be considered your child's bladder capacity. The normal capacity for children is 1 or more ounces per year of age.

How long does it last?

Most children who are bed-wetting overcome the problem between ages 6 and 10. Even without treatment, all children eventually get over it. Therefore, treatments that might have harmful complications should not be used. On the other hand, treatments without side effects can be started as soon as your child has had complete bladder control during the daytime for 6 to 12 months.

How can I help my child?

1. Encourage your child to get up to urinate during the night.

   This advice is more important than any other. Tell your child at bedtime, "Try to get up when you have to pee."

2. Improve access to the toilet.

   Put a night light in the bathroom. If the bathroom is at a distant location, try to put a portable toilet in your child's bedroom. Boys will do fine with a bucket.

3. Encourage daytime fluids.

   Encourage your child to drink a lot during the morning and early afternoon. The more your child drinks, the more urine your child will produce, and more urine leads to larger bladders.

4. Discourage evening fluids.

   Discourage your child from drinking a lot during the 2 hours before bedtime. Give gentle reminders about this, but don't worry about normal amounts of drinking. Avoid any drinks containing caffeine.

5. Empty the bladder at bedtime.

   Sometimes the parent needs to remind the child. Older children may respond better to a sign at their bedside or on the bathroom mirror.

6. Take your child out of diapers or Pull-ups.

   Although this protective layer makes morning clean-up easier, it can interfere with motivation for getting up at night. Use Pull-ups or special absorbent underpants selectively for camping or overnights at other people's homes. Use them only if your child wants to use them. They should rarely be permitted beyond age 8.

7. Protect the bed from urine.

   Odor becomes a problem if urine soaks into the mattress or blankets. Protect the mattress with a plastic mattress cover.

8. Include your child in morning clean-up.

   Including your child as a helper in stripping the bedclothes and putting them into the washing machine provides a natural disincentive for being wet. Older children can perform this task independently. Also, make sure that your child takes a shower each morning so that he or she does not smell of urine in school.

9. Respond positively to dry nights.

   Praise your child on mornings when he wakes up dry. A calendar with gold stars or happy faces for dry nights may also help.

10. Respond gently to wet nights.

    Your child does not like being wet. Most bed-wetters feel quite guilty and embarrassed about this problem. They need support and encouragement, not blame or punishment. Siblings should not be allowed to tease bed-wetters. Your home needs to be a safe haven for your child. Punishment or pressure will delay a cure and cause secondary emotional problems.

When Your Child Reaches Age 6

Follow the previous recommendations in addition to the guidelines given below:

1. Help your child understand his goal.

   The key to becoming dry is to learn how to self-awaken every night and find the toilet. Getting up and urinating during the night can keep your child dry regardless of how small the bladder is or how much fluid he drinks. Help your child assume responsibility for doing this. Some children think that enuresis is the parent's problem to solve; they need to be reminded that "only you can solve this."

2. Have a bedtime pep talk about self-awakening.

   To help your child learn to awaken himself at night, encourage him to practice the following routine at bedtime:

   • Lie on your bed with your eyes closed.
   • Pretend it's the middle of the night.
   • Pretend your bladder is full.
   • Pretend you feel the pressure.
   • Pretend your bladder is trying to wake you up.
   • Pretend your bladder is saying, "Get up before it's too late."
   • Then run to the bathroom and empty your bladder.
   • Remind yourself to get up like this during the night.
3. Daytime practice of self-awakening.

   Whenever you have an urge to urinate and you're home, go to your bedroom rather than the bathroom. Lie down and pretend you're sleeping. Tell yourself this is how your bladder feels during the night when it tries to awaken you. After a few minutes, go to the bathroom and urinate (just as you should at night).

4. Parent-awakening.

   If self-awakening fails, use parent-awakening to teach your child the correct goal: urinating into the toilet during the night. It makes much more sense than putting your child back into pull-ups and having him urinate in bed every night (the wrong goal). Your job is to wake your child up; his job is to locate the bathroom and use the toilet. You can awaken him at your bedtime. Try a hierarchy of prompts (the minimal one being the best), ranging from turning on a light, saying his name, touching him, shaking him or turning on an alarm clock. If your child is confused and very hard to awaken, try again in 20 minutes. Once he's awake, he needs to find the bathroom without any directions or guidance. When he awakens quickly to sound or touch for 7 consecutive nights, he's either cured or ready for an enuresis alarm.

5. Encourage changing wet clothes during the night.

   If your child wets at night, he should try to get up and change clothes. First, if your child feels any urine leaking out, he should try to stop the flow of urine. Second, he should hurry to the toilet to see if he has any urine left in his bladder. Third, he should change himself and put a dry towel over the wet part of the bed. (This step can be made easier if you always keep dry pajamas and towels on a chair near the bed.)

   The child who shows the motivation to carry out these steps is close to being able to awaken from the sensation of a full bladder.

When Your Child Reaches Age 8

Follow the previous recommendations. Talk with your healthcare provider about possibly using enuresis alarms or drugs as well, as described below:

1. Bed-wetting alarms

   Alarms are used to teach a child to awaken when he needs to urinate during the night. They go off when they become wet. One type awakens you with a loud noise (buzzer), the other type with an annoying vibration. They have the highest cure rate (about 70%) of any available approach. They are the treatment of choice for any bed-wetter with a small bladder who can't otherwise train himself to awaken at night. The new transistorized alarms are small, lightweight, sensitive to a few drops of urine, not too expensive (about $50), and easy for a child to set up by himself. Some children as young as 5 years want to use them. Children using alarms still need to work on the self-awakening program.

2. Alarm clock

   If your child is unable to awaken himself at night and you can't afford a bed-wetting alarm, teach him to use an alarm clock or clock radio. Set it for 3 or 4 hours after your child goes to bed. Put it beyond arm's reach. Encourage your child to practice responding to the alarm during the day while lying on the bed with eyes closed. Have your child set the alarm each night. Praise your child for getting up at night, even if he isn't dry in the morning.

3. Medicine

   Most bed-wetters need extra help with staying dry during slumber parties, camping trips, vacations, or other overnights. Some take an alarm clock with them and stay dry by awakening once at night. Some are helped by temporarily taking a drug at bedtime. One drug (given by pill or nasal spray) decreases urine production at night and is quite safe. Another drug (taken as a pill) temporarily increases bladder capacity. It is safe at the correct dosage but very dangerous if too much is taken or a younger sibling gets into it.

   If you do use a medicine, be careful about the amount you use and where you store the drug, and be sure to keep the safety cap on the bottle. The drawback of these medicines is that when they are stopped, the bed-wetting usually returns. They do not cure bed-wetting. Therefore, children taking drugs for enuresis should also be using an alarm and learning to get up at night.

When should I call my child's healthcare provider?

Call during office hours if:

• Urination causes pain or burning.
• The stream of urine is weak or dribbly.
• Your child also wets during the daytime.
• Your child also drinks excessive fluids.
• Bedwetting is a new problem (your child used to stay dry).
• Your child is over 12 years old.
• Your child is over 6 years old and is not better after 3 months of following this treatment program.