Bed-wetting in children: your questions answered by Miss Marie-Klaire
Farrugia MD FRCSEd(Paed.Surg), Consultant Paediatric Urologist
Bed-wetting and other children’s continence problems are not uncommon: in the UK, an estimated 900,000, or 1 in 12, 5-19 year olds, suffer from bowel and bladder conditions. These include bedwetting, daytime wetting, constipation and soiling. Most bowel and bladder problems are avoidable and treatable, yet it’s estimated that only 11% of those affected ask for help. In England alone, there are 15,000 hospital admissions for paediatric cases of chronic constipation and urinary tract infections (UTIs) each year. 80% of these could be avoided if the problems were spotted early and dealt with properly, according to the National Institute for Health and Care Excellence (NICE). Miss Farrugia is Paediatric surgeon and urologist and deals with a spectrum of continence issues on daily basis – ranging from bed-wetting in otherwise healthy children, to major bladder and bowel continence issues in children with anatomical abnormalities. She answers common questions parents ask in her clinic.
At what age should my child be dry at night?
Every child is different and there is no rule. However, the International Children’s Continence Society (ICCS) does not consider wetting below the age of 5 years as abnormal. The recommendation is that “general advice should be given to all bed wetting children, but active treatment should usually not be started before the age of 6 years”.
What are the causes of bed wetting?
This depends on whether bed-wetting is isolated (“monosymptomatic enuresis”), i.e. the child has a normal voiding pattern and is dry in the day; or whether it is part of a day-time and night-time problem. Isolated bed-wetting involves an imbalance between bladder volume and urine production at night, compounded by high arousal thresholds. The child often wets the bed in the early hours of the morning… and sleeps through it. Combined day-time symptoms (frequent accidents, going to the toilet very frequently, last-minute dashes to the toilet, inability to control the bladder) and bed-wetting are a result of “dysfunctional voiding” also known as “bladder overactivity”, whereby the bladder muscle contracts erratically and is difficult to control. The child often wets the bed soon after falling asleep, and sometimes more than once a night.
Could childhood incontinence run in families?
Possibly! An on-going population study called The Avon Longitudinal Study of Parents and Children (ALSPAC) showed that in a cohort of 8,230 children, the prevalence of daytime urinary incontinence was 7.8%. The odds ratio of a child with a maternal history of daytime incontinence, developing urinary incontinence, was 2.64 – and 5.47 if the father had suffered from daytime urinary incontinence. The odds ratios were even greater in children with severe enuresis (night-time wetting) reaching 3.28 with a maternal history and 10.1 if the father had a history of childhood enuresis.
What is the treatment for bed wetting?
See to the basics first!
- Make sure your child is drinking enough
“Won’t that make them wet more?!”, I hear you cry in dismay! But the opposite is true – the more they drink, the more the bladder stabilises and gains capacity. What they drink is equally important: water is best, but milk, fresh juice, and orange and lemon squash are also fine. Avoid sugary blackcurrant and dark-coloured drinks, and fizzy or caffeinated drinks (including Red Bull and Lucozade) as these irritate the bladder muscle. Good fluid intake allows the bladder to develop a larger capacity, helping to prevent bed wetting. Restricting drinking in children is counter-productive. Encourage drinking first thing in the morning, and through-out the school day, but stop drinks 1-2 hours before bed time. Food can also stimulate the kidneys so allow 1-2 hours between dinner and bed-time where possible.
How much should a child drink?
The National Institute for Clinical Excellence (NICE) guidelines on fluid intake are:
- 4-8 years – 1000-1400ml
- 9-13 years – 1200-2300ml
- 14-18 years – 1400-3000ml
Children should be encouraged to go to the toilet first thing in the morning then every three hours (or every break-time) during the day. This “trains” the bladder muscle to work properly. Children often get distracted, or avoid toilets in public places, but “holding on” will only exacerbate the bladder dysfunction.
3. Be aware of the child’s stooling habits
Children (and their parents) often aren’t aware of how often they open their bowels, or what the stool looks like! Constipation (not stooling for more than 3 days, or passing small hard rocks or painful motions) loads the rectum and affects how the bladder functions and empties. Treating constipation alone is often sufficient to resolve wet nights. Children should stool every day or every other day with a soft stool. Your GP will be able to advise and prescribe a gentle laxative where required.
4. Check toileting position
This mostly applies to girls – who commonly suffer from recurrent cystitis and “smelly urine” in addition to wetting. They should be seated comfortably with their feet on a step to help them balance and relax the pelvic muscles. One leg out should be taken out of their underwear, this allows the bladder to empty properly and avoids reflux of urine into the vagina. You should always wipe from front to back. “Leaking” soon after a wee and “smelly” urine could be due to pooled urine in the vagina leaking out.
Do bed-wetting alarms work?
Yes they do! They work best in children who want to be dry and are ready to work at it, and in those who wet once in the night, usually in the early hours of the morning. The initial “drip” makes the alarm (or vibration) go off and allows the child to wake up and go to the toilet. Unfortunately children often sleep through the whole event, but they’re worth a try, especially in older children. See www.eric.org.uk for a list of alarms.
What if the basics fail?
This is the right time to consult a Paediatric Urologist. We will take a detailed history and examine the child, as subtle anatomic findings could require further investigation. An initial assessment is usually enough to establish the next course of action, which may involve medical treatment. Occasionally investigations such as a urine analysis, a renal tract ultrasound scan and bladder emptying studies (also known as non-invasive urodynamics) are requested. No invasive investigations will be required in most cases.
What medical treatment is available?
The initial medical treatment will depend on what the sub-type of wetting, which the Paediatric Urologist will determine. Common treatments include anti-cholinergics (such as Oxybutynin and Tolterodine), which “calm” the bladder muscle and reduce urinary frequency, urgency and urge incontinence – a prolonged treatment (at least 4 weeks) will improve bladder “compliance” i.e. the ability of the bladder to stretch and grow in response to an appropriate fluid intake.
Desmopressin is sometimes prescribed for children over 5 years of age who wet the bed. When we go to sleep, we normally make more of a hormone called vasopressin. This hormone has an antidiuretic effect. That is, it tells the kidneys to make less urine while we are asleep. Some children do not produce enough vasopressin. These children make almost as much urine during the night as they do during the day. Because of this, the bladder is full before the morning. The child then has to wake up and go to the toilet or, if they are not able to wake up to the full bladder signals, as is the case for most children, their beds get wet while they are asleep.
Combined treatment with Desmopressin and bed-wetting alarms has shown good results in clinical studies.
How long will it take for my child to be dry?
This depends on a number of factors including how much the child wants to be dry, and if the basics are adherent too. Some children will become dry without medical treatment. Others may need support for a few months. On rare occasions the problem persists, but other strategies are available.
Please visit your GP and request a referral to Chelsea & Westminster Hospital Paediatric Urology
Miss MK Farrugia
Please e-mail [email protected] or book an appointment in Chelsea & Westminster Hospital (0203-315-8599) or BUPA Cromwell Hospital (0207-460-5700)