Nocturnal Enuresis

What is nocturnal enuresis?

Nocturnal enuresis is when a child, five years of age or older, wets the bed while sleeping. With nocturnal enuresis, your child wets the bed at least two times each week. Your child may wet the bed every night. When your child has nocturnal enuresis, he cannot control when he urinates during the night. Some children with nocturnal enuresis have never had a dry night. Other children may have been dry for at least six months before beginning to wet the bed.

What causes nocturnal enuresis?

The exact cause of your child's nocturnal enuresis may not be known. Ask your caregiver for more information about the following causes of nocturnal enuresis:

• Bladder size and function: Your child's bladder is an organ that stores urine. When your child's body makes more urine than his bladder can hold, he may wet the bed. This can occur if your child's bladder is small, or if he sleeps for many hours at a time. Sleeping for many hours means the bladder may fill with more urine than it can hold. Normally, your child's bladder muscles tighten when the bladder is full. Sometimes the bladder muscles tighten before the bladder is full, causing your child to urinate while he sleeps.
  
  
• Nocturnal polyuria: Nocturnal polyuria means your child's body makes large amounts of urine while he sleeps. Normally, the hormone (body chemical) vasopressin decreases the amount of urine a person makes during the night. Without enough vasopressin, your child's body may make too much urine, causing him to wet the bed.
  
  
• Deep sleep: Your child may not wake to the feeling of a full or tightening bladder if he sleeps very deeply. When your child's bladder tightens and he does not wake up, he may wet the bed.
  
  
• Delay in central nervous system development: Your child's central nervous system (CNS) includes his brain and spinal cord. The CNS controls how each part of your child's body works. If your child's CNS develops slowly, he may not be able to control his bladder, leading to nocturnal enuresis.

What increases the chance that my child will have nocturnal enuresis?

If your child drinks a lot of liquid before going to bed, his risk for nocturnal enuresis increases. Drinks that increase your child's risk for nocturnal enuresis include sugary drinks, fizzy drinks, and drinks with caffeine. Caffeine can be found in coffee, tea, and soft drinks. The following may also increase the chance that your child will have nocturnal enuresis:

• Constipation: Constipation occurs when your child has hard, dry bowel movements (BMs) that may hurt to push out. BMs are normally stored in your child's rectum. When large amounts of BM are stuck in the rectum, the rectum may put pressure on the bladder. Pressure on your child's bladder makes it harder for your child to control when he urinates.
  
  
• Genetics: Genes are little pieces of information that tell your child's body what to do or make. Genes are passed to children from their parents. Parents who had nocturnal enuresis are more likely to have children with nocturnal enuresis.
  
  
• Infection: A urinary tract infection (UTI) may cause nocturnal enuresis. The urinary tract includes organs that make, store, and release urine, such as the bladder and kidneys.
  
  
• Learning and behavior problems: Children with learning or behavior problems are at higher risk for nocturnal enuresis. This includes children with attention deficit hyperactivity disorder (ADHD). Ask your child's caregiver for information about learning and behavior problems that may lead to nocturnal enuresis.
  
  
• Medical conditions: Medical conditions, such as diabetes (high blood sugar) and seizure (convulsion) disorders, may increase your child's risk. If your child has obstructive sleep apnea (OSA), he may also be at higher risk. With OSA, your child may not breathe well enough when sleeping to get the oxygen his body needs. OSA may increase the hormones that tell your child's body to make urine. OSA may also decrease the hormones that reduce the urine your child makes while sleeping. If your child has large tonsils in his throat, his risk for OSA and nocturnal enuresis increases. Ask your child's caregiver for information about these and other medical conditions that may lead to nocturnal enuresis.
  
  
• Stress: Increased stress may lead to nocturnal enuresis. Your child may have stayed dry for a period of time before the stress occurred. Your child may feel stress if he is afraid of the dark and being alone at night while he sleeps. Divorcing parents, fighting parents, or a hospital stay may cause stress and lead to nocturnal enuresis. Sexual abuse also increases the risk for nocturnal enuresis in children.

How is nocturnal enuresis diagnosed?

Your child's caregiver will ask about your child's signs and symptoms. Your child's caregiver will check your child's belly, back, and genitals (penis or vagina). Your child's caregiver will check your child's leg movement and feeling. The caregiver will check your child's nose and check his throat for large tonsils. Tell your child's caregiver when your child began wetting the bed and if he ever stayed dry. Tell your child's caregiver if your child takes any medicines, and if your child has trouble sleeping at night. Tell the caregiver if you have trouble waking your child in the morning. Also tell your child's caregiver about any stress in your child's life, such as a divorce or new school. The following may also help diagnose your child's nocturnal enuresis:

• Diary recordings: Your child's caregiver may have you write down when your child is wet or dry during the night. You may need to record wet and dry nights for about two weeks. You will need to write down when your child urinates and has a BM during the day. Your child's caregiver may also have you write down how much liquid your child drinks, and how often. A diary may help your child's caregiver better understand why your child has nocturnal enuresis.
  
  
• Urine tests: A sample of your child's urine may be collected to check for an infection. Your child's caregiver may also test the urine for sugar and the amount of water in your child's urine.
  
  
• Imaging tests: Imaging tests, such as an ultrasound or cystoscopy may be done to look at your child's urinary tract. Imaging tests may show if your child has problems with his urinary tract that are causing his nocturnal enuresis. Ask your caregiver for more information about these or other tests your child may need.

How is nocturnal enuresis treated?

Your child may stop wetting the bed on his own without treatment. Your child may also need treatment for many months before he is dry at night. Treatment is more successful when both the child and parents work together. If a medical problem caused your child's nocturnal enuresis, your child's caregiver may treat the medical problem first. Treatment may help decrease or stop your child's nighttime wetness. Treatment may also help improve your child's self-esteem so that he feels better about himself. Treatment may include any of the following:

• Alarm system: An alarm system may be used to help wake your child if he begins to urinate while sleeping. The alarm system may be a bed pad, or your child may wear the alarm. The alarm goes off when it senses wetness from urine. The alarm sound may be a buzzer or bell, or it may vibrate. When the alarm wakes you or your child, your child can get up to go to the bathroom. You should use an alarm system until your child is dry for 14 nights in a row.
  
  
• Overlearning: Your child's caregiver may suggest overlearning once your child has stayed dry for 14 nights. With overlearning, your child drinks extra fluids before bedtime. This trains your child's bladder to hold more urine during the night. Your child will keep using the alarm system until he is dry for another 14 nights in a row.
  
  
• Dry bed training: During dry bed training, you set your alarm to wake your child to urinate at certain times each night. You will wake your child when the alarm goes off, whether he is wet or dry.
  
  
• Pelvic muscle exercises: Caregivers may teach your child exercises to help strengthen his pelvic floor muscles. Your child's pelvic floor is the area between his pelvic (hip) bones. Your child can do these exercises by tightening and relaxing his pelvic muscles. The exercises may help improve your child's control of his bladder. Ask your child's caregiver about pelvic floor muscle exercises, and how often your child should do them.
  
  
• Medicine: Your child may need the following:
  
  
  • Anticholinergic medicine: Anticholinergic medicine helps your child's bladder hold more urine. The medicine may help keep the bladder muscles relaxed, and decrease your child's need to urinate while he sleeps.
    
    
  • Antidiuretic medicine: Antidiuretic medicine helps decrease the amount of urine your child's body makes at night.
    
    
  • Tricyclic antidepressants: Tricyclic antidepressant medicine may help decrease how often your child wets the bed.

How can I help my child with nocturnal enuresis?

• Follow the treatment plan: If your child has an alarm system, get up to help your child when the alarm sounds. You may need to wake your child and help him to the bathroom. Following the treatment plan may help your child become, and continue to stay, dry at night.
  
  
• Have your child go to the bathroom regularly:
  
  
  • Ask your child to urinate about every two hours, or at least 2 to 3 times during the school day. Your child should also urinate right before going to bed each night. Leave a soft night light on in the bathroom for your child. Tell your child to relax when he urinates, so his bladder can empty completely. Boys should unzip their pants all the way, or pull their pants down, so the penis is not bent. This will allow urine to flow more easily out of the bladder.
    
    
  • Your child should have a BM every day to decrease his risk for constipation. Ask your child to try to have a BM each day after breakfast, or before going to school. Make sure your child is not rushing when trying to have a BM. A child's toilet seat or a stool to support his feet while sitting on the toilet can help. If your child has constipation, he may need medicine to soften his BMs. Ask your child's caregiver for information about this medicine and if your child needs it.
  
  
• Limit liquids before bedtime: Limit the liquids your child drinks to small amounts in the late afternoon and evening. Try to avoid giving your child liquids right before bed. If your child has liquids in the evening, he should avoid drinks with sugar or caffeine, and fizzy drinks. This may include fruit juices and soft drinks. To decrease your child's thirst at night, have him drink up to eight cups of liquid during the day. Drinking liquids should start at breakfast and continue until late afternoon.
  
  
• Support your child: Praise your child when he has a dry night. You may want to make a sticker or star chart to show your child's successes. You may want to reward your child with a prize after he has a certain number of dry nights. If your child is afraid of the dark, try sitting with your child while he falls asleep. Never punish or shame your child for wetting the bed.

What are the risks of nocturnal enuresis?

• If your child uses a bed alarm, it may not go off when he wets the bed. The alarm may ring when your child has not wet the bed. The alarm may not wake your child, may scare your child, and may wake others in your home. Medicines used to treat nocturnal enuresis may cause your child to have headaches and blurry vision. Your child may have a stuffy nose, nosebleeds, cough, or sore throat. Medicines may cause stomach cramps, nausea (upset stomach), and a loss of appetite for food. Your child may get a bad taste in his mouth. Your child may have an allergy to medicines that causes a skin rash or itchy skin. An allergy may also cause swelling of your child's face, lips, tongue, or throat.
  
  
• Medicines may cause your child to have trouble sleeping, or he may sleep more than usual and feel drowsy. Your child may become depressed (very sad), or suddenly anger easily. Anticholinergic medicine may cause your child to have abnormal heartbeats. The day after taking medicine, your child may need to urinate more often. Rarely, medicines may decrease the amount of sodium your child has in his body and he may get water intoxication. If your child gets water intoxication, he may have a seizure, go into a coma, and he may die. A coma is when your child looks like he is asleep but you cannot wake him. Even with successful treatment, your child may begin wetting the bed again.
  
  
• If your child's nocturnal enuresis is not treated, his bedwetting may not stop. Your child may feel embarrassed and bad about himself. Your child may miss out on activities with others, such as overnight outings. Your child may be teased by his siblings or friends if they know he wets the bed. Nocturnal enuresis may cause your child to feel isolated (alone) and he may become depressed. If an infection, such as a UTI, caused your child's nocturnal enuresis, the infection may get worse without treatment. Without treatment, your child may keep wetting the bed as an adult. Talk with your child's caregiver if you have questions or concerns about your child's condition, medicines, or care.

Where can I find support and more information?

Nocturnal enuresis can be hard for you and your child. It is important to remember that your child cannot control his bedwetting. Children who wet the bed often feel embarrassed and upset. They may worry about activities, such as sleepovers, and about being teased by others. As a parent, having a child with nocturnal enuresis may make you feel worried and angry. You may be unsure about how to help your child. These feelings are normal. Talk with your child's caregiver or contact the following:

• American Academy of Family Physicians
  11400 Tomahawk Creek Parkway
  Leawood , KS 66211-2680
  Phone: 1- 913 - 906-6000
  Phone: 1- 800 - 274-2237
  Web Address: http://www.aafp.org
  

• American Academy of Pediatrics
  141 Northwest Point Boulevard
  Elk Grove Village , IL 60007-1098
  Phone: 1- 847 - 434-4000
  Web Address: http://www.aap.org
  

When should I call my child's caregiver?

Call your child's caregiver if:

• Your child has a stuffy nose, sore throat, cough, or trouble seeing well.
  
  
• Your child has stomach cramps, no appetite for food, or a bad taste in his mouth.
  
  
• Your child is having nosebleeds.
  
  
• Your child is not sleeping well, or is sleeping more than usual.
  
  
• Your child seems depressed, or suddenly angers easily.

When should I seek immediate care?

Seek care immediately or call 911 if:

• Another child takes the medicine used to treat your child's nocturnal enuresis.
  
  
• Your child's face, lips, tongue, or throat swell.
  
  
• Your child seems very confused, and is very sleepy or hard to wake during the day.
  
  
• Your child suddenly gets a headache, feels sick to his stomach, and vomits (throws up).

Care Agreement

You have the right to help plan your child's care. Learn about your child's health condition and how it may be treated. Discuss treatment options with your child's caregivers to decide what care you want for your child.

Copyright © 2012. Thomson Reuters. All rights reserved. Information is for End User's use only and may not be sold, redistributed or otherwise used for commercial purposes.

The above information is an educational aid only. It is not intended as medical advice for individual conditions or treatments. Talk to your doctor, nurse or pharmacist before following any medical regimen to see if it is safe and effective for you.

Learn more about Nocturnal Enuresis