Bedwetting

A. JABBAR DENTAL CLINIC KARACHI

Sadia Khan

Overview

Bedwetting, also known as nocturnal enuresis, refers to the involuntary release of urine during sleep, occurring at least twice a week for three consecutive months, after the age when the individual should have bladder control. 
&nbsp;

The condition is typically associated with young kids, especially when they are being toilet trained. However, bedwetting affects people of all ages.

The prevalence of bedwetting varies across different regions. For instance, in China, the prevalence of bedwetting was reported to be significant in children but lower than in most Western countries, which was attributed to cultural differences like living in rural areas.<a href="#accordion">[4]</a> 
&nbsp;

A study in Iran highlighted that bedwetting is three times more common in boys than in girls.<a href="#accordion">[9]</a> Research also showed that 21% of enuretic children in Southeast Anatolia experienced daytime bedwetting.<a href="#accordion">[5]</a>

On the other hand, 1 in 10 children in the US have nocturnal enuresis, with 30% of cases presenting in children 7 of age or younger and 5% of them aged 10 or older. Additionally, 2-3% of adults in the US (18+) have primary nocturnal enuresis.<a href="#accordion">[7]</a>

Further, there is a 70% chance of a child developing the condition if both parents have it.<a href="#accordion">[8]</a> 
&nbsp;

Bedwetting in a child older than 5 years old can be classified into:<a href="#accordion">[1]</a>

<ul>
	<li>Monosymptomatic Nocturnal Enuresis (MNE) &ndash; No urinary symptoms during the day</li>
	<li>Non-Monosymptomatic Nocturnal Enuresis (NMNE) &ndash; Includes daytime urinary symptoms 
	&nbsp;</li>
</ul>

Depending on how long the person has had the condition, enuresis can also be categorized as:<a href="#accordion">[6]</a>

<ul>
	<li>Primary Nocturnal Enuresis &ndash; The person&rsquo;s bedwetting since they were a baby</li>
	<li>Secondary Enuresis &ndash; The person developed the condition 6 months &ndash; or several years &ndash; after they acquired bladder control; usually due to a medical or psychological issue 
	&nbsp;</li>
</ul>

Sign and Symptoms

Bedwetting is a problem if the individual is 7 years of age or older, or if they develop it suddenly after a few months of staying dry at night.

The characteristic signs and symptoms include the involuntary release of urine during the day or night.<a href="#accordion">[2]</a> The individual is also visibly emotionally distressed, avoiding social interactions and trying to hide wet sheets so others would not know about these &lsquo;accidents.&rsquo;

Further, there may be pain while passing urine, increased thirst, snoring, pink or red-colored urine, and hard stools. 
&nbsp;

Causes

The most common causes of bedwetting include:<a href="#accordion">[3][6]</a>

<ul>
	<li>Impaired ability to wake up when the bladder is full due to impaired or absent perception of fullness during sleep</li>
	<li>Bladder dysfunction due to the small size of bladders</li>
	<li>Hormonal imbalance, like insufficient antidiuretic hormone produced at night</li>
	<li>Medical conditions, such as hyperthyroidism, nerve problems, and sickle cell anemia 
	&nbsp;</li>
</ul>

Diagnosis

The doctor takes a detailed medical history to assess the frequency and duration of symptoms as specified by diagnostic guidelines, such as the DSM-V.

They will then proceed with a physical examination to identify any signs of underlying medical conditions, such as hyperthyroidism or diabetes insipidus.

Sometimes, additional assessments, such as urinalysis and urodynamic studies, are required to evaluate bladder function and rule out lower urinary tract dysfunction. 
&nbsp;

Treatment

The available treatment options for bedwetting include:

<ul>
	<li>Behavioral Therapy &ndash; To train the brain to respond timely to a full bladder</li>
	<li>Pharmacological Interventions &ndash; Desmopressin and oxybutynin, for instance, regulate urine production and improve bladder function</li>
	<li>Surgical Interventions &ndash; Improve bladder contractions and stimulate the pelvic floor, bowel, and bladder in cases where other noninvasive forms of treatment fail</li>
	<li>Alternative Medicine &ndash; Hypnosis, chiropractic therapy, and herbal therapy, along with standard medicine</li>
	<li>Home Care Measures &ndash; Moisture-sensitive alarm, limiting liquids in the evening, or passing urine before going to bed can support the overall management</li>
</ul>

Note: More research is needed to validate the effectiveness of alternative medicine. 
&nbsp;

The complications associated with bedwetting include:

<ul>
	<li>Psychological impact, like embarrassment and guilt, which leads to low self-esteem</li>
	<li>Rashes on the genital area if the child sleeps in wet underwear</li>
	<li>Missed social opportunities that reduce the quality of life 
	&nbsp;</li>
</ul>

The most common risk factors for developing bedwetting include:

<ul>
	<li>Genetics &ndash; Teens who experience episodes of nocturnal enuresis usually have a parent who experienced bedwetting at around the same age</li>
	<li>Lifestyle &ndash; Caffeine intake and deep sleep often cause nocturnal enuresis</li>
	<li>Underlying Conditions &ndash; Emotional trauma or stress, ADHD, obstructive sleep apnea, diabetes, constipation, UTI, and urinary tract abnormalities can trigger bedwetting</li>
	<li>Age &ndash; Post-menopausal women are more likely to have incontinence</li>
	<li>Gender &ndash; It&rsquo;s 2-3 times more common in boys than girls<a href="#accordion">[8]</a> 
	&nbsp;</li>
</ul>

Common preventive measures for reducing the risk of bedwetting include:

<ul>
	<li>Encouraging regular use of the toilet throughout the day, every 2-3 hours or so.</li>
	<li>Using small night lights to ensure toilet accessibility during the night.</li>
	<li>Support and understanding from family and friends may address the stress factors and motivate them to be in more control over the situation. 
	&nbsp;</li>
</ul>

Key Points

<ul>
	<li style="list-style-type: none;">Bedwetting is the involuntary release of urine during sleep, occurring at least twice a week for three consecutive months, after the age when the individual should have bladder control.</li>
	<li>The causes of bedwetting include impaired ability to wake up when the bladder is full, hormonal changes, and underlying medical conditions.</li>
	<li>Treatment options include behavioral therapy, pharmacological interventions, surgical interventions, and home care measures to support the overall management of bedwetting.</li>
	<li>Complications of bedwetting include psychological impact, rashes, and reduced quality of life.</li>
	<li>Risk factors for developing bedwetting include age, gender, genetics, lifestyle, and individual health.</li>
	<li>Preventive measures include encouraging regular use of the toilet, ensuring toilet accessibility at night, and providing support.</li>
</ul>

[1] Azarfar, A., Ravanshad, Y., Aval, S., Khamnian, Z., & Mehrad-Majd, H. (2017). A systematic review and a meta-analysis of using acupuncture for the treatment of nocturnal enuresis. Journal of Nephrology & Therapeutics, 07(02).

[2] Bereda, G. (2022). Enuresis: nocturnal enuresis and diurnal enuresis. Archives of Clinical Investigation, 1(1), 01-03.

[3] Schultz-Lampel, D., Steuber, C., Hoyer, P., Bachmann, C., Marschall-Kehrel, D., & Bachmann, H. (2011). Urinary incontinence in children. Deutsches Ärzteblatt International.

[4] Wang, Q. W., Wen, J. G., Song, D. K., Jing, S., Zhu, Q., Liu, K., … & Wei, J. (2007). Bed‐wetting in chinese children: epidemiology and predictive factors. Neurourology and Urodynamics, 26(4), 512-517

[5] Özkan, K. U., Garipardıç, M., Toktamiş, A., Karabi̇ber, H., & Şahinkanat, T. (2004). Enuresis prevalence and accompanying factors in schoolchildren: a questionnaire study from southeast anatolia. Urologia Internationalis, 73(2), 149-155.

[6] Durani Y, ed. Bedwetting (nocturnal enuresis) (for teens) - nemours kidshealth. KidsHealth. March 2023. Accessed November 28, 2023.

[7] Bedwetting (nocturnal enuresis) causes &amp; treatment. Cleveland Clinic. Accessed November 28, 2023

[8] Bedwetting in children &amp; teens: Nocturnal Enuresis. HealthyChildren.org. Accessed November 28, 2023.

[9] Seyfhashemi, M., Ghorbani, R., & Zolfaghari, A. (2015). Desmopressin, imipramine, and oxybutynin in the treatment of primary nocturnal enuresis: a randomized clinical trial. Iranian Red Crescent Medical Journal, 17(7).