What Is It?

Bed-wetting, also called nocturnal enuresis, means that a child accidentally passes urine at night during sleep. Because this is normal in infants and very young children, bed-wetting is not considered to be a medical problem unless it happens in a child who is already in elementary school or who was completely dry day and night and then begins to wet the bed again during the night. By the age of 5, 80 percent to 85 percent of children are consistently dry throughout the night. After age 5, the number of children who still wet the bed decreases by about 15 percent per year, even without treatment. Only 1 percent to 2 percent of children still wet the bed by the time they are 15 years old.

To help make diagnosis and treatment easier, doctors sometimes classify bed-wetting into two types, primary and secondary nocturnal enuresis. In primary nocturnal enuresis, the child has never been consistently dry at night. In secondary nocturnal enuresis, the child has been dry at night for at least three to six months (or one year, according to some experts) and has begun to wet the bed again. It is very important to remember that neither type of bed-wetting is something that the child does on purpose.

Primary Nocturnal Enuresis

This is the most common type of nocturnal enuresis, affecting 90 percent of the estimated 6 million American children who wet the bed. It is a problem that pediatricians consider to be caused by several different developmental, genetic and hormonal factors, acting together.

• Developmental factors — Children with prolonged bed-wetting may not yet be able to recognize that the bladder is full, or may not have developed enough control over the bladder’s urinary sphincter (muscle that controls the bladder opening) to stop urination during sleep. In some children, arousal-control areas of the brain also may be affected, allowing the child to “sleep through” a full bladder rather than waking up to urinate.
• Genetic (hereditary) factors — If both parents wet the bed when they were younger, three out of four of their children also will have bed-wetting problems. If only one parent did, this decreases to slightly less than half and to one out of seven if neither parent wet the bed when he or she was younger. Recently, researchers have pinpointed chromosome 13 as the home of the bed-wetting gene, and further research continues in this area.
• Hormonal factors — Under normal circumstances, the body’s level of a hormone that decreases urine production by the kidneys (antidiuretic hormone) rises during sleep and causes the bladder to fill more slowly. In some children who wet the bed, this nighttime rise in antidiuretic hormone does not happen as expected. Therefore, the amount of urine made remains the same as it was during waking hours, so the bladder continues to fill as much as it would during the daytime.
• Other factors — Some children with prolonged nighttime bed-wetting may simply have smaller bladder capacities compared with their “dry” peers.

Although the specific combination of factors varies from child to child, the end result is the same. In a small number of cases, primary nocturnal enuresis arises from a purely medical problem, such as a physical defect in the child’s urinary tract, a neurological problem related to the spinal nerves or brain, or a urinary-tract infection.

Secondary Nocturnal Enuresis

When a child starts to wet the bed again after being dry for months or sometimes even years, often there is some identifiable cause. One of the most common is stress, when a sudden change rocks a child’s world. Almost any change in the environment — good or bad — can be a trigger; for example, a new baby, a death in the family, parents’ divorce or marriage problems, a new home or school, or even a long visit from relatives. Secondary bed-wetting also may be related to sexual abuse or to extreme bullying. Rarely, this form of bed-wetting is related to a medical problem, such as a urinary-tract infection or diabetes, and in these cases there are usually other obvious symptoms of medical illness.

In most children with bed-wetting, soaked sheets and wet pajamas are all that parents will see. In the rare cases caused by a medical illness, such as urinary-tract infection or diabetes, other symptoms may be present. It is especially important to watch for such symptoms in an older child who starts wetting the bed after having been dry in the past:

• Urinary-tract infection — If a child’s bed-wetting is being caused by a urinary-tract infection, he or she may urinate more often than normal day and night. The child also may complain of an uncomfortable, painful or burning feeling when urinating, and his or her urine may look cloudy or have a very strong smell. Other symptoms may include fever, chills and pain in the back or abdomen.
  
• Diabetes — Diabetes can be another cause of bed-wetting. This illness affects one out of every 360 children younger than 16, with many cases beginning around age 5 to 7 or at the time of puberty. Typical symptoms include frequent trips to the bathroom to urinate, excessive thirst (wanting to drink liquids all the time), unusual fatigue (tired all the time) or inactivity, and weight loss even though the child may have a healthy appetite and eat a lot.

The doctor will begin by asking about any family history of bed-wetting. If one or both parents were affected during childhood, the doctor will want to know the age when a parent’s bed-wetting stopped. In many cases, a child’s bed-wetting will stop at the same age.

In addition, the doctor will ask about your child’s eating and drinking habits, especially the habit of drinking right before bedtime, or eating snacks that melt into liquids, such as ice cream or gelatin desserts. In a child who has been dry in the past, your doctor will want to know about any unusual stresses, either at home or at school, that might be triggering the bed-wetting.

To rule out medical illnesses and conditions as a cause of your child’s bed-wetting, the doctor will ask about additional symptoms related to a urinary-tract infection or diabetes. The doctor also will ask whether there is anything unusual about the way your child urinates, including a need to strain during urination or changes in his or her urine stream.

The doctor will examine your child, paying special attention to your child’s abdomen (belly), genital area, and lower spine, looking for any physical changes in these areas. In addition, your doctor will order a simple test of your child’s urine (urinalysis) to look for signs of a urinary-tract infection or diabetes. In most cases, your doctor can make a correct diagnosis based on your child’s age, the history of bed-wetting, any additional symptoms, and the results of the physical examination and urinalysis.

If your child has symptoms that suggest a urinary-tract infection, diabetes or other problems, additional tests may be needed. X-rays and other tests of bladder size, shape or function are not done routinely for children with primary nocturnal enuresis.

Almost all children stop bed-wetting by the time they reach their mid-teens, even without treatment. By age 15, only one out of 100 children is not completely dry at night.

To help your child achieve his or her first dry night, try these suggestions:

• Provide encouragement and praise for dry nights. Never punish, shame or blame.
• Remind your child to urinate before going to bed. If he or she doesn’t feel the need to urinate, tell your child to try anyway.
• Limit liquids in the last two hours before bedtime. Also limit solid foods that melt into liquids, such as ice cream and flavored gelatin (Jell-O).
• Use real cloth underwear rather than diapers or plastic pants. “Grown-up” pants help remind your child to stay dry.
• Try waking your child once each night for a bathroom trip. Set an alarm near your child’s bed or your own.
• To make cleanup easier, place a rubber liner or large plastic bag under cloth sheets.

Even after your child has become completely toilet trained, occasional accidents will happen. It is important that you remain calm and casual as you change his or her bed sheets and underpants. You can do this with your child’s help. Also, try not to show disgust or disappointment.

When bed-wetting is caused by a medical problem, treatment depends on the specific diagnosis.

If your child has no specific medical problem causing him or her to wet the bed, but has never been dry at night, there are several treatment options:

• Motivational therapy — Your doctor may suggest that you begin by trying a “token and reward system” to motivate your child to stop bed-wetting. This typically involves using a colorful chart to keep track of your child’s progress, with a gold star for every dry night. When the chart is filled, you can let your child select a treat. Many doctors encourage the use of three to six months of motivational therapy before trying other treatment options.
• Behavioral therapy — After age 8, your doctor may recommend behavioral therapy with an enuresis alarm. An enuresis alarm uses sounds or vibrations to wake a child who wets the bed or his or her underwear. In some cases, behavioral therapy is combined with motivational therapy to reinforce successful behavior by rewarding the child for dry nights.
• Bladder-training exercises — A few children with bed-wetting respond to bladder-retention training. In this treatment approach, the child is encouraged to hold his or her urine for longer and longer periods during the daytime.
• Medications — Several medications are available to treat primary nocturnal enuresis, though these rarely are used as first-line therapy.

One of the safest and most commonly used medications for treating bed-wetting is desmopressin acetate (DDAVP), a synthetic drug that is similar to the body’s natural antidiuretic hormone. The initial treatment usually lasts for three to six months. If DDAVP is successful in keeping the child dry during this treatment period, the drug is tapered gradually and eventually stopped. Often the problem returns after the child has stopped taking the medication. Some children can use DDAVP to stay dry on an as-needed basis, such as when the child is away at summer camp or at a friend’s sleepover party.

• Combination therapy — In some children, a combination of medications and behavioral therapy will stop bed-wetting when other treatments have failed.
• Other options — Hypnosis, diet therapy (especially eliminating caffeine) and psychotherapy also have been used to treat children with bed-wetting. Because studies show that these treatments work in some cases, they are options for some patients.

Call your doctor immediately if your child has started bed-wetting after being dry for several months or if your child has symptoms of a urinary-tract infection or diabetes.

Call your doctor to discuss whether treatment would be recommended for your child who has never been dry at night and has started elementary school.

Since almost all children eventually outgrow bed-wetting, the prognosis is excellent, even without treatment.

When treatment is used, the success rate depends on the type of therapy. For example, motivational therapy succeeds in about 25 percent of children, behavioral therapy in about 70 percent, and bladder training in about 66 percent. Although the success rate of DDAVP varies widely in research studies, it may be as high as 70 percent.

Diseases and Conditions Center

All ArmMed Media material is provided for information only and is neither advice nor a substitute for proper medical care. Consult a qualified healthcare professional who understands your particular history for individual concerns.