Bed-wetting

The main symptom of bedwetting is involuntary urination during sleep. It is considered a medical condition only when it occurs at least twice a week in children older than 5 years of age for at least 3 months.

The presence of more than four episodes of urination in a week is termed as frequent.

Individuals with lower urinary tract dysfunction may experience the following additional symptoms:

• Pain in the lower urinary tract
• Increased frequency of urination (≥8 times/day)
• Repeated leakage of urine, even during daytime
• A sudden and immediate urge to urinate
• Pain while urinating
• Straining (application of pressure at the abdomen while urinating)

The different proposed theories behind bedwetting are:

• Increased urine production at night: Typically, the production of urine diminishes at night due to the increased production of a hormone known as ADH (antidiuretic hormone), a natural process in the body. Some studies have shown that decreased nocturnal ADH production at night might contribute to bedwetting.
• Bladder overactivity: The bladder's fullness causes contraction of the muscles, leading to emptying. Any defect in these muscles can cause bedwetting. Children with bladder overactivity usually also have daytime symptoms such as urgency of urination.
• Role of the central nervous system: Sleep cycle and urination are both controlled by the brain. Several studies have found that some individuals experience frequent arousals with an inability to awaken completely. This can cause bladder-brain dysfunction, which may lead to bedwetting.

Risk Factors For Bedwetting

• Age: Bedwetting is mostly observed in children.
• Gender: Bedwetting is more common in boys compared to girls. Boys are also found to experience more severe bedwetting than girls.
• Family history: Children with one affected parent have a higher chance of developing bedwetting. This risk increases further if both parents suffer from the condition.
• Fluid intake at bedtime: Excessive intake of certain foods and drinks is associated with increased urine production at night. Some children are more sensitive to this intake; however, this can be easily prevented by avoiding fluid intake 1-2 hours before sleep.
• Sleep fluctuations: Deep sleepers or children with excessive daytime sleepiness are more prone to bedwetting.
• Psychological or behavioral disorders: The following psychological or behavioral disorders can increase the risk of bedwetting:
  • Attention deficit and hyperactivity disorder
  • Autism spectrum disorder
  • Oppositional defiant disorder
  • Mood disorders
  These disorders cause bedwetting due to associated disturbed sleep patterns.
• Non-psychological disorders: Some non-psychological conditions can also contribute to bedwetting through different mechanisms. Examples include:
  • Constipation
  • Obstruction in the urinary system
  • Ectopic ureter (a ureter that does not connect properly to the bladder)
  • Urinary tract infections
  • Cystitis (infection of the urinary bladder)
  • Small bladder capacity
  • Overactive bladder
  • Kidney disorders
  • Sickle cell anemia
  • Sleep apnea
  • Diabetes Mellitus
  • Diabetes insipidus
  • Anxiety
  • Stress

Here are some common triggers of childhood stress and the role of parents in managing that.

The diagnosis of bedwetting involves a series of steps based on the presence of other symptoms.

1. Medical History and Clinical Examination

Obtaining the history and tracking the symptoms are crucial for all children who present with bedwetting. The essential aspects that are considered include:

• Determining the pattern of bedwetting episodes in one night and the number of nights per week
• Asking about the intake of caffeine or other fluids before going to bed
• Determination of the amount of urine
• Raising questions regarding increased thirst, difficulty in urination, urgency, frequency, daytime incontinence, abnormal urinary stream, and constipation
• Obtaining a family history of involuntary urination
• Determining history of recurrent urinary tract infections
• Asking about sleep disorders, snoring, or a diagnosis of sleep-disordered breathing
• Knowing about the use of chronic medications
• Screening for psychological or behavioral disturbances, including attention deficit hyperactivity disorder and learning disabilities
• Identifying stressors

2. Physical Examination

In some cases, bedwetting can be due to spinal malformations. A back examination can rule these disorders out. Dimples and hairy patches over the back are signs of a disturbed spine at birth.

3. Urine Routine and Microscopy

A complete urinalysis is the preferred test in children without other symptoms. The urine is tested for the presence of:

• Urinary tract infections
• Glycosuria (glucose in urine)
• Proteinuria (protein in urine)
• Hematuria (blood in urine)

In various cases, blood urea nitrogen (BUN) and creatinine tests are also performed to assess kidney function.

4. Imaging Studies

These tests are usually recommended in children who present with multiple other symptoms along with bedwetting. It includes:

• Kidney ultrasound (to look for kidney damage)
• KUB ultrasound (to assess the condition of the kidneys, ureters, and urinary bladder)
• Spine MRI (to check for spinal malformations)

Are you looking for a trusted lab to get your tests done? Get tested with Tata 1mg labs for accurate and timely results. Book Now.

There is no sure way to prevent bedwetting. However, several factors that act as triggers for bedwetting can be minimized through lifestyle modifications. These include:

• Inculcate healthier eating habits in your child: Healthy eating habits help in the prevention of obesity and diabetes, which can trigger bedwetting. The following eating habits should be followed:
• Limit spicy foods, chocolate, artificial sweeteners, and caffeinated beverages as they may cause irritation and inflammation of the bladder.
• To avoid constipation, include high-fiber foods such as whole-grain cereals (such as porridge, brown rice, wholemeal pasta, wholemeal bread, or pulses such as lentils and beans). Aim for at least 25-30 grams of fiber each day.
• Encourage consumption of fruits and vegetables to facilitate easy defecation.
• Keep your child hydrated: Insufficient water intake is associated with constipation and bladder irritation, which can increase the risk of bedwetting. To prevent dehydration:
• Encourage them to drink at least 6 to 8 glasses of water every day.
• Promote the habit of frequently sipping water, even when they are not feeling thirsty.

Quick byte: The color of the urine can help identify hydration levels. Pale yellow urine indicates adequate hydration, while dark yellow urine suggests dehydration.

• Follow good toilet habits: Bedwetting can be prevented by teaching good toilet habits to your child, which includes:
• Avoiding holding urine for extended periods.
• Taking sufficient time to fully empty the bladder.
• Sitting in a full crouching squat position while urinating.
• Going to the toilet when the bladder is full.
• Using correct posture while passing urine, which involves sitting upright with elevated feet.

The goal of treatment of bedwetting includes:

• Reducing the total number of enuretic nights
• Avoiding enuresis on specific nights in specific locations
• Mitigating the stress of the child
• Avoiding recurrence

Treatment options for monosymptomatic bedwetting include:

1. Behavioral therapy: In this approach, children are educated about bedwetting. They are advised to make specific lifestyle changes, such as limiting fluid intake 1-2 hours before bedtime and practicing timed voiding every 3 to 4 hours.
2. Enuresis alarms: These devices are used if behavioral therapy is ineffective. They are designed to awaken the child during urination. The devices can be worn or placed in bed and produce a loud noise when they detect an episode of urination. They have been proven more effective than some medications in children with good learning capacity.
3. Medications:
   • Desmopressin: A synthetic analog of the antidiuretic hormone that decreases urine output from the kidneys.
   • Oxybutynin: This medication relaxes the bladder's smooth muscle and is mainly effective in children with an overactive bladder.
   • Polyethylene glycol: A stool softener that can help resolve nighttime bedwetting, even in children without constipation.
   • Imipramine: An antidepressant that reduces the episodes of bedwetting through multiple mechanisms, mainly used as a second or third line of treatment.

1. Adjust the intake of fluids
   • Avoid soda and caffeinated beverages such as tea and coffee.
   • Keep the child hydrated.
   • Consume 2/3 of the fluids during the morning to early afternoon and the remaining 1/3 in the late afternoon and evening.
   • Avoid any fluid consumption 1-2 hours before bedtime.
2. Practice timed voiding

   Encourage regular bathroom visits instead of waiting for the urge to go. This helps prevent bladder overfilling and reduces the chances of bedwetting. Inculcate a habit of going to the washroom every 3-4 hours.

3. Empty bladder before bedtime

   It is crucial to empty the bladder right before bedtime to significantly reduce the incidence of bedwetting.

4. Improve sleep hygiene

   Maintaining a consistent sleep routine can enhance symptoms of various sleep-related disorders, including bedwetting, and improve nocturnal bladder control.

   Here are 8 effective ways to improve the child’s sleeping habits.

5. Maintain a diary

   Parents should keep a journal for a few days to record the following activities:

   • Any leakage of urine during the daytime.
   • Frequency of bedwetting episodes.
   • Ability to reach the washroom on time.
   • Conditions that trigger bedwetting.

Bedwetting negatively impacts the quality of life of both the child and family. It can lead to:

• Low self-esteem
• Mood problems
• Stress

Did you know these 6 fruits could help you beat stress? Know Now

The alternative therapies for bedwetting include:

• Urotherapy: This involves providing the child with behavioral training, which includes limiting fluid intake before bed, enhancing awareness of daytime voiding, and voiding before bedtime.
• Motivational therapy (positive reinforcement): This involves giving children prizes or stickers for adhering to the urotherapy guidelines. It is especially beneficial for children who are motivated to address their bedwetting. This technique has demonstrated a reduction in relapse rates and bedwetting frequency in children aged 5 to 7 years with mild symptoms (less than 7 nights per week).
• Biofeedback: This technique records individuals' responses, such as heart rate, muscle tension, and brain activity, after stimulation. By analyzing these triggers, it helps alleviate physical and emotional symptoms.

Bedwetting can have both physical and emotional impacts on a child’s life. It does not resolve immediately with treatment. The journey to dry nights is a progression that requires a lot of patience from both the child and the caregiver.

Role of Caregivers - Managing the Emotional Aspect

Bedwetting can be a frustrating and embarrassing condition for an older child. These children may suffer from poor self-esteem. According to studies, children with chronic bedwetting problems are more likely to develop behavioral issues, such as aggressive behavior and attention problems.

The following measures from a parent or caregiver can help manage the emotional fluctuations in a child:

• Reassure and educate the child about bedwetting.
• Provide answers to every question the child may have.
• Support the child and let them know that many kids experience the same problem.
• Minimize the number of investigations by preparing in advance and recording symptoms.
• Understand that bedwetting is not within the child's control, rather than blaming them.
• Establish a no-teasing rule in the family, ensuring no one is allowed to tease the child.
• Avoid punishing or reprimanding the child, as this can exacerbate feelings of shame.
• Reward the child not for dry nights, but for adhering to the treatment guidelines.
• Reduce anxiety or stress during bedtime by creating a calm environment. Consider reading a book together, giving a massage, or telling stories.