Dr. Sweeney Explains Bedwetting for Yahoo Life

As a parent, it's natural to be concerned when your child experiences bedwetting. However, it’s important to remember that bedwetting, or nocturnal enuresis, is a common and usually temporary part of childhood development.  Most children outgrow it as they get older, but there are some situations when it may be a cause for concern.

Vamio Health pediatric urologist Danielle Sweeney, MD recently contributed to an article about bedwetting for Yahoo Life. She shared expertise on what is considered bedwetting, the common causes, and when parents should speak with their pediatrician or pediatric urologist. The entire article can be found here or read Dr. Sweeney’s answers to frequently asked bedwetting questions below.

How common is bedwetting?  

Bedwetting is extremely common.  In children over five years of age, 15% will still have nighttime wetting accidents.  In children over the age of 15, 1-2% will still experience bedwetting.  Put another way, for every 100 children over 15 years old, one to two of them will still be having bedwetting accidents.

What is considered bedwetting?

By the strictest of definitions, bedwetting or nocturnal enuresis is the non-intentional passing of urine while an individual is asleep, after the age at which staying dry at night is expected.  This is typically around 5-7 years of age but can vary.
Bedwetting is also defined in other ways. Monosymptomatic enuresis, the most common type of bedwetting, is nighttime wetting accidents that occur in children without any other lower urinary tract symptoms or problems.  Monosymptomatic enuresis can further be defined as primary, which is in children who have never achieved a satisfactory period of nighttime dryness or secondary, in which children develop bedwetting after a dry period of at least six months.  
Non-monosymptomatic enuresis is bedwetting that occurs with other lower urinary tract symptoms and complaints such as UTIs, daytime incontinence, urgency, holding, and incomplete emptying/dribbling.  This type of bedwetting should be further worked up by the pediatrician or pediatric urologist.

What causes bedwetting?  

The most common cause of bedwetting is a lack of bladder maturity and control.  However, other common causes include genetic factors, increased nighttime urine production (nocturnal polyuria), children that are heavy deep sleepers, individuals with a small bladder capacity, children with overactive bladder and constipation.

When should parents worry about bedwetting?

Families should consider additional evaluation if the child has daytime incontinence and other bladder complaints such as recurrent UTIs, lower urinary tract symptoms such as urgency holding or increased or decreased voiding.  Additionally, If the child has a history of weak urinary stream, continuous incontinence or history of urinary retention they should seek further medical evaluation.  History of protein in the urine, weight loss, fatigue, persistent nausea or vomiting or excessive thirst and need for nighttime drinking may be a sign of kidney disease and should be worked up further by a medical provider.  
Children with clinical or radiographic abnormalities of the spine and bedwetting should be referred to a neurosurgeon for evaluation for spinal abnormalities, and children with enuresis and disordered sleep, sleep apnea, or enlarged tonsils should be evaluated by an Ear, Nose and Throat specialist or sleep specialist, as these may be the primary cause of their issues.  

How can parents offer support?

The best way to react is to be positive and reassuring.  Do not punish or blame the child for the accidents as this can make it worse.  Reward dry nights and efforts to work through treatment options.  Most importantly avoid shame or blame during times of accidents.  A study published in the Journal of Urology in 2020 found that psychological intervention for caregivers of children with enuresis that focused on strategies to improve understanding of the disorder, and efforts to reduce conflict and encourage cooperation with treatment was associated with improved caregiver understanding and empathy with reduction of punishments towards bedwetting.  This resulted in increased dry nights and greater rates of complete resolution of the nighttime accidents.  

What should be avoided?

Sodas, high sugar and caffeine based drinks should be avoided in children with bedwetting especially in the evening hours.  Fluid shifting, which encourages 40% of daily fluid intake to be consumed in the morning before lunch, 40% of fluid intake to occur in the afternoon and only 20% in the evening, with no fluids two hours prior to bedtime can be helpful too.  Also, it is key to remind children to urinate just prior to going to bed to ensure that the bladder is empty prior to falling asleep.
For children with bedwetting that participate in sleepovers, it is always helpful to get a plan in place.  Talk to you child about what steps they can take to help reduce the likelihood of an accident (fluid shifting, avoiding caffeine and high sugar drinks, urinating prior to bedtime).  Ask if they would like to bring or wear a pull-up or diaper and what steps they will take if an accident was to occur.  It’s important to have the child feel empowered and in charge of their own bodies!

Other bedwetting  treatment options

The appropriate timing of when to start treatment for bedwetting will vary between children. The key to success is having the child be motivated to participate in their own treatment program. Treatment should not be undertaken if it is being pushed on the child by the caretakers and the child is not ready or is unwilling to assume some responsibility for their treatment plan. Before treatment is started, other issues like constipation, sleep apnea or ADHD should be managed adequately.  
Prior to treatment the establishment of goals and expectations is extremely important.  The child should be able to verbalize their treatment priorities, like reducing the number of wet nights, or avoiding recurrences of wetting accidents and the clinician should make it clear that often a variety of modalities may be used or tried to see sustained results.   Additionally, keeping a calendar of wet and dry nights helps maintain a visual graphic of the effects of the treatments.
For children and families that want to move beyond just behavioral therapy, medication and/or a bedwetting alarm are other great options to consider.  Medications like DDAVP (Desmpspresson) are good for children that desire a quicker approach to addressing wetting accidents.  This is ideal for children who will be sleeping outside the home (camps, sleepovers, etc) and have nocturnal polyuria with normal daytime voiding volumes and habits.  It is important to keep in mind that DDAVP does not cure bedwetting but rather masks it by affecting the hormones that control urine production.  This medicine is safe, but it needs to be monitored by a physician and a medication holiday every 6 months should be planned to see if there is natural resolution of the bedwetting.   Another medication, Oxybutynin, is a great choice for children with overactive bladders and nighttime accidents, however this medication is best given under the supervision of a pediatric urologist.  
Non-medication options include a bedwetting alarm which is highly successful.  The alarm conditions the child over time to pick up on subtle body cues that occur before urination. The bedwetting alarm has the lowest accident relapse rate compared to all other treatments, however it requires a longer time period of treatment (3 months or more) and works best in highly motivated children and families that can adhere to getting up multiple times per night.  

Bedwetting and ADHD

Children with ADHD are six times more likely to have bedwetting than children without ADHD, and have slightly lower success rates when treating it, but it is not directly known why.  We do know that children who have difficulty focusing due to ADHD or other neurodivergent disorders, do not pick up on the subtle cues from the body regarding bladder emptying and urination and this may play a role.  It can take longer to achieve resolution of the bedwetting in these children, and the best chances for success is to ensure that the ADHD is being addressed appropriately.  

Bedwetting Telehealth: After Hours and Weekend Availability

At Vamio Health, our team of pediatric urology specialists offer convenient access to bedwetting treatment through a secure telehealth platform. Schedule a telehealth consultation today to speak with a bedwetting specialist who can help you and your little one get back to living life comfortably.

To schedule a bedwetting consultation visit www.vamiohealth.com.

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