Managing bedwetting

14 November 2018

First published December 2010

How does nocturnal enuresis affect children and their families?

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Intended learning outcomes

This learning module aims to raise your awareness of the issues and solutions relating to the problem of nocturnal enuresis in children. After studying this module and completing the self-assessment questionnaire, you should:

  • Understand more about nocturnal enuresis and how it affects children and their families.
  • Be able to identify the key triggers.
  • Gain confidence in reversing common but often unhelpful belief systems about bedwetting.
  • Increase your knowledge of the evidence-based solutions you can suggest to help manage and solve the problem.

Nocturnal enuresis: the facts

It's a childhood problem that's rarely discussed, but nocturnal enuresis affects up to half a million children aged between four and 12 at some point.1 Primary nocturnal enuresis refers to night­time wetting that occurs at least twice a week for at least three consecutive months in children aged five or over.2

About 15% of seven year olds wet the bed infrequently. This supplement is aimed at the 2.6% who suffer with nocturnal enuresis, and their parents. 3 In these children, the problem doesn't improve with age but evidence-based treatments have been shown to help. Secondary nocturnal enuresis is night-time wetting that occurs after six months or more of being dry at night and is often linked to stressful emotional events. While the triggers may be different, the causes are often the same, so although we do not focus specifically on secondary nocturnal enuresis here, it's treatable using the same methods outlined in this supplement with additional emotional support. For further information read the Three Systems Model, a conceptual way of understanding nocturnal enuresis devised by Professor Richard J. Butler and Professor Philip Holland.

Less than a third of families seek help for nocturnal enuresis3, with many attempting to solve the problem at home. We should be actively encouraging parents to seek help as the evidence suggests children who wet twice a week or more will not become dry simply by waiting. Early assessment of the child (from five years) and use of Butler and Holland's Three Systems Model, which we will go on to look at in more detail in this educational supplement, is linked with successful treatment.

It's essential that as a community practitioner you're aware of the problem, know how to use the model to identify triggers and can explain to parents that while you understand why they're using certain self-help measures there are alternative and more effective evidence-based solutions that you and their GP are able to provide. To ensure the problem is referred to in parent and child-friendly language, hereafter nocturnal enuresis will be referred to as bedwetting.

What causes bedwetting?

For all children, bedwetting occurs because of difficulties with at least two, sometimes all three of the three systems, as a result of age, genetic or stress-related factors.

Children wet the bed because they release too little of the hormone vasopressin, which concentrates urine at night, or because they have an overactive bladder, meaning the muscles (detrusors) contract before it's actually full, or both. Children who bed wet will also have a problem with waking up to the sensation of a full bladder (in the case of lack of vasopressin) or with being unable to wake up to bladder contractions (in the case of bladder over­activity). Urinary tract infections and constipation may increase a child's vulnerability to bedwetting and a physical or learning difficulty can also occasionally contribute.

If a child starts to wet the bed after a period of being dry, it is likely the bedwetting is provoked by some sort of stress, anxiety or emotional upheaval. This is secondary nocturnal enuresis and so the emotional cause may need to be addressed, as well as using the Three Systems Model to tackle the problem itself.

How does it impact children and families? Bedwetting can leave children feeling anxious and isolated from their friends especially if the problem continues as they grow older (see Figure 1). Those who suffer severely are vulnerable to low self­esteem, (5) especially if a variety of treatments fail.4

Parents tend to be worried about their child and often feel guilty and helpless. Many struggle to find information about what to do and research has shown that some parents also find the implications of bedwetting a burden. Up to 10% believe that their child is lazy or 'not trying' and could become dry if they really wanted to.6 This can lead to a vicious circle of punishment and continued wetting.

Dispelling bedwetting myths

Many parents find it hard to get help with bedwetting and so understandably try to manage the problem at home using tactics such as restricting drinks before bed, 'lifting' their child to the toilet during the night while they're asleep or punishing them if they're wet, none of which are proven to help solve the problem. Lifting, by not waking to void, essentially maintains the cycle of bladder emptying during sleep; fluid restriction may reduce the child's capacity to release vasopressin at night or cause bladder over­activity and rewards for being dry imply effort, which children cannot increase during sleep. Lastly punishment may increase stress, which provokes bladder over­activity and may inhibit vasopressin release.

Evidence suggests that an effective way parents can help solve the problem at home is to encourage their child to both drink and use the toilet regularly during the day.7

Encouraging children to drink 6-8 water-based drinks spread evenly over the day with a smaller one about 1 ½ hours before bed. Fizzy drinks, coffee and tea can make the situation worse (though there is no solid evidence), so advise parents to keep a record of what they're drinking to establish whether this is the case. Introducing discreet absorbent overnight pants such as UnderJams can help families manage the problem while the various clinically ­proven interventions are explored further.

 

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Your role

As a community practitioner, you're well placed to engage with children and parents, assess the situation, help parents understand any misguided beliefs that could be exacerbating the problem and then offer evidence-based advice to help families work with their doctor to solve it. If you can successfully help to debunk bedwetting myths and persuade parents to instead consider the effective evidence-based treatments, you empower them to help increase their child's chances of a dry night.

Is there a problem?

Bedwetting is not defined as a 'problem' until a child is five or older; the majority will have the odd accident as they learn to control their bladder. But as children grow older, it can lead to embarrassment and frustration for both them and their families. Many parents feel isolated, don't know what to do to help solve the problem and worry they're the only family to have a child who wets the bed.

The first step towards helping a family solve bedwetting is to identify that there's a problem in the first place. If they don't actively seek your help, often asking 'is your child dry at night?' at a routine appointment is enough to establish that there's a problem and give you the opportunity to provide information and support.

Bedwetting explained

Bedwetting is never caused by laziness or lack of willpower and it's important you help parents to understand this. The three main causes of nocturnal enuresis are outlined in the Three Systems Model below. First published in 2000 and based on published research by Professor Richard Butler and Professor Philip Holland, the model helps you to treat children according to their individual specific needs. All children who wet the bed will have a problem with system one, and many may also have a problem with system two or three, or both. By helping parents identify the problem using the Three Systems Model you can then help find potential solutions:

  1. Lack of arousal from sleep - the signal from a child's bladder to their brain that their bladder is full and they either need to wake up or 'hold on' is not getting through.
  2. Nocturnal polyuria caused by low nocturnal vasopressin levels - our bodies produce the hormone vasopressin at night to slow down urine production while we sleep. If a child is producing too little of this hormone, it can mean their kidneys create more urine overnight than their bladder can cope with.
  3. Bladder overactivity- the child's bladder holds only small amounts of urine before contracting to tell the brain it's 'full'. The child's natural voided volume may also be relatively low - parents may notice their child has to rush to the loo urgently or needs to urinate frequently during the day, but produces very little when they go.

IDENTIFYING THE CAUSE

An initial assessment should cover a general history and the pattern of bedwetting over the past few weeks to help establish whether the child is suffering from primary or secondary enuresis. Useful initial questions to ask include: 

  • If the child has previously been dry (for six months or more) and recently started wetting the bed - this indicates emotional issues or a recent trauma may be provoking their bedwetting.
  • If the child's urine is extremely dark or smells "fishy" - this could indicate a urinary tract infection. 
  • These questions will help establish the need to refer the child to their GP for urine tests or seek support for emotional issues alongside assessing them for treatment using the Three Systems Model. 
  • The number of instances of night-time wetting per week.
  • If the child has any day-time accidents.
  • How often the child needs the toilet during the day and if they need to go urgently.
  • How much urine they produce during the day.
  • What the child is having to drink and when.
  • When the child wets the bed, how dark their urine is and how much they produce.
  • Whether the size of the wet patch varies.
  • What self-help measure(s) the parents are currently using, such as restricting drinks before bed, initiating regular toilet trips during the day, lifting their child while they're still asleep, offering rewards for waking up dry or punishing their child.


SELF-HELP MEASURES: DEBUNKING THE MYTHS

Understanding why parents try at-home bedwetting solutions and helping them to realise why these solutions are rarely helpful may resolve the issue without further intervention. Lifting a child to the toilet while they're still asleep is a strategy 62% of parents adopt. While recent research has shown lifting can be beneficial to younger children, as long as they're fully awake when lifted, there's no evidence it helps older children become dry. Many parents choose to lift as it limits the need to change a wet bed, so if it's a tactic they wish to employ, ensure they're aware that their child should be lifted at different times every night and should always be fully awake. If frequent accidents during the night are causing problems for parents, protective pants mean they can allow their child to learn when their bladder is full, without having to change the bedding or clean up.

EVIDENCE-BASED TREATMENTS

If self-help treatments prove ineffective, there are four evidence-based bedwetting treatments a GP can offer. 

FOR A CHILD WITH A LACK OF VASOPRESSIN RELEASE, THERE ARE TWO OPTIONS:

  1. Desmopressin: The most widely prescribed bedwetting medicine, desmopression is a synthetic analogue of the naturally occurring antidiuretic hormone vasopression, which reduces nocturnal urine output. By limiting the amount of urine produced overnight when taken just before bedtime, it leads to rapid improvement in seven out of 10 children.9
  2. Enuresis Alarms: These can be used to alert the child as they begin to wet, causing them to wake up to a full bladder, or as a means of helping the child concentrate urine. Gradually the child learns to wake up or hold on without the alarm. Every child is different and whereas for some enuresis alarms can prove successful in under a week, others can take up to four months to respond to treatment. Evidence has shown that when parents are annoyed by alarms8,9 by being woken up or by temperamental equipment, treatment drop out is high, so with this in mind it's vital to ensure parents are prepared for disrupted sleep until the alarm begins to work and know this may take some time.10 Enuresis alarms are not recommended when families are under stress. 

FOR A CHILD WITH BLADDER OVERACTIVITY, THE OPTIONS ARE:

  1. Bladder Training: Helping children to become aware of the need to go to the loo before it becomes urgent, by encouraging them to go frequently and increasingly the regularity of their fluid intake during the day.
  2. Anticholinergic Medication: These are drugs commonly used to treat bladder overactivity, such as Oxybutynin, often in conjunction with bladder training. Anticholinergics help by relaxing the bladder ( detrusor) muscles. They may be prescribed in conjunction with desmopressin. 

If children have both lack of vasopressin release and bladder over-activity, then both problems need treatment. Thus desmopressin might be combined with bladder training and anticholinergics; or an enuresis alarm can be combined with bladder training and anticholinergics.


Case studies

 

Situation one

Mum Anne has told you that seven ­year-old Jamie is bedwetting. He wets at least twice a week, needs to go to the toilet frequently during the day and sometimes has daytime accidents, too. Anne is worried it's affecting Jamie's confidence and has tried but had no success with both limiting what Jamie drinks and offering him rewards for staying dry.  


POINTS TO CONSIDER 

Jamie's daytime accidents alongside frequent bedwetting suggest an overactive bladder. Jamie is old enough to understand his bedwetting and may be embarrassed or frustrated. Anne may also be suffering from regularly interrupted sleep and the extra burden of excessive washing. 


SUGGESTED ACTION 

Explain to Jamie and his mum that bedwetting is much more common than many people know and it's no­one's fault. Reassure them that there are a number of treatments that have been proven to help. Firstly assess whether Jamie exhibits any of the other overactive bladder symptoms, such as an urgent need for the loo during the day, producing only small amounts of urine when he goes and waking up after he's wet the bed. Explain to Anne the benefits of helping Jamie at home by encouraging regular daytime trips to the loo. You may also wish to recommend they see a GP for a routine urine test, to make sure Jamie doesn't have an infection. Once their doctor has reviewed this information and an infection is ruled out, the family should be advised to focus on regular drinks and toilet visits during the day while other medication, such as anticholinergic drugs, are considered by their GP. 

Situation two

You're visiting Emily to check on her newborn son Tom and she reveals she's exhausted; her five-year-old daughter Evie hardly ever as a dry night and Tom sleeps badly too. She wasn't sure how to solve the problem so has started lifting Evie to the toilet after Tom's 2am feed and wants to know how long it will take for this to help with Evie's bedwetting problem. 

POINTS TO CONSIDER

Emily's decision to lift Evie to the toilet is likely to stem from her tiredness and her belief that it will help. A lack of vasopressin, bladder overactivity or an inability to wake up when her bladder is full could all be causing Evie's bedwetting, so it's important to determine the root cause by asking her mum to look for certain symptoms, while suggesting more effective self-help methods she could try.

SUGGESTED ACTION

Explain that while you understand Emily's decision to lift Evie there are more effective ways to help with her bedwetting. If Emily wishes to continue lifting, you'll need to explain to her that she must do it at different times and make sure Evie is always awake. If she decides to stop lifting, suggest Emily uses protective pants to help minimise changing the sheets, while allowing her to aid you in an assessment of Evies urinary output. Let her know she's not done anything wrong and encourage her to take regular drinks and toilet trips during the daytime. Point out that evidence suggests this is an effective way to help solve the problem. Make sure Emily isn't using any other self-help tactics to manage Evie's bedwetting, such as limiting her fluid intake, and stress that with her help, you and their GP will be able to suggest clinically-proven medical treatments or refer Evie to a specialist who can help. 

Situation three

Six-year-old Lukas has been wetting the bed since he was potty trained age three. His parents have tried an enuresis flarm with no success and now believe hejs just lazy, so have begun to withhold privileges every time he wets. 

POINTS TO CONSIDER 

If his parents seem cross with him, Lukas may be picking up on this and so feeling anxious. His parents' withdrawal of privileges shows they're frustrated and believe punishment is the only answer. You need to enlist his parents to help assess the root cause of Lukas's bedwetting so that their doctor can suggest alternative, evidence-based treatments. 


SUGGESTED ACTION 

As punishment can have a negative effect on a child and lead to a vicious circle of bedwetting, it's important to let Lukas's parents know it's not his fault, or due to laziness, and withholding privileges could actually be making him wet the bed more often. Explain that while some children stop bedwetting in a matter of days with an enuresis alarm, others using them can take up to four months to stop, so it's not Lukas's fault. Then go on to give them the knowledge they need to understand why Lukas could be wetting by outlining the Three-Systems Model. Give them back control of the situation by asking them to assist you and their GP with a diagnosis. Ask them to keep a diary of the kinds of signs you need them to look for, such as the quantity and colour of his urine, his daytime toilet habits and if he needs to go urgently. In the meantime, suggest they can help Lukas by rewarding him for actions he has some control over, rather than punishing him. Encourage them to stick with the enuresis alarm and reassure them that although it may not have worked yet, that doesn't mean it won't in time. 

 

Learn more about NMC revalidation here.

 

REFERENCES


1. Dr Penny Dobson (2006). Nocturnal enuresis: systems for assessment and treatment.
2.Mellon & McGrath (2000). Empirically Supported Treatments in Pediatric Psychology: Nocturnal Enuresis. Journal of Pediatric Psychology. 25 ( 4), 193-214.
3. Dobson & Weaver. (2006). Nocturnal enuresis: systems for assessment and treatment. Available: http://www.nursingtimes.net/ nursing-practice-clinical-research/nocturnal­enuresis-systems-for-assessment -and-treatment/201366.article. Last accessed 22nd September 2010.
4. Heunis, Van & Paesbrugge (2001). Impact of Nocturnal Enuresis on Children and Young People. ScandJ UrolNephrol. 35 (3), 169-176.
5. Joinson, Heron, Emond & Butler (2007). Psychological Problems in Children with Bedwetting and Combined ( day and night) Wetting: A UK Population-Based Study. Journal of Pediatric Psychology. 32 (5), 605-16.
6. Butler, Redfern & Forsythe (1992). The maternal tolerance scale and nocturnal enuresis. Behaviour Research and Therapy. 31 (4), 433-36.
7. Joinson, Heron, Emond & Butler (2007). Nocturnal enuresis: a survey of parental coping strategies at 7½ years. Child: Care, Health and Development. 31 ( 6), 659-67.
8. Hagglof, Andren, Bergstrom, Marklund & Wendelius (1998). Self-Esteem in Children with Nocturnal Enuresis and Urinary Incontinence: Improvement of Self-Esteem after Treatment. European Urology. 33, 16-19
9. Butler, Robinson, Htlland & Doherty-Williams (2004). Childhood 
10. Dobson (2006). Bedwetting: A Guide for Parents. Bristol: ERIC. 1-12.
 

 

 

 

 




 

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