Nighttime Bedwetting (Nocturnal Enuresis)

What is Enuresis Nocturna?

Bedwetting at night, even after the age of five for girls and six for boys, is a problem called “enuresis” in medical language and “bedwetting” in colloquial language. The same problem also applies to daytime sleep.

In general, around 90% of 4-5 year olds have day and night urinary control. Of the rest, about 15-20% become continent (urinary retention) every year. Enuresis Nocturna persists in about 1-3% after puberty.

Enuresis Nocturna is called Primary Enuresis if the child is dry at night for less than 6 months and Secondary Enuresis if the child is dry for longer. For the diagnosis to be made, urinary incontinence must continue for at least 3 months in a row and urinary incontinence must occur at least 1 night each month.

What is the Frequency of Enuresis Nocturna in Children?

Approximately 20-25% around the age of 5, 5-8% around the age of 10 and 0.5-1% in adulthood. It is approximately 2-3 times more common in boys than in girls.

Is there a reason why enuresis nocturna is more common in boys?

There is no known reason for this, but physiologically all development occurs later in boys. It is likely that the development of the nerves and muscles involved in micturition also occurs later in boys than in girls, so that the maturation of the micturition function occurs later in boys.

Are There Underlying Causes of Enuresis Nocturne?

Although it is not certain, some reasons have been put forward.

Genetic Predisposition; Familial predisposition plays an important role. If one of the parents has this complaint, the incidence in children is 40%, if both parents have this complaint, it is approximately 70%.

Sleep Apnea; In children, especially large tonsils and adenoids cause sleep apnea by obstructing the respiratory tract. Sleep apnea can also cause nocturnal enuresis in children from time to time.

Constipation: Untreated, long-term constipation can cause enuresis by impairing the function of the bladder muscles and pelvic muscles involved in urinary control.

Small bladder volume: This may be congenital or may occur later due to nerve damage. The bladder volume is not enough to store the urine produced by the kidney during the night and causes enuresis.

Psychological Causes: Stress and anxiety can cause nocturnal enuresis, although rare. Here, family problems, negativities in school and social environment should be questioned in general. However, the main cause of nocturnal enuresis cannot be called psychological; on the contrary, nocturnal enuresis may cause psychological problems, especially in older children.

In addition, sleep in these patients is usually very deep and urinary incontinence can occur at any stage of sleep. As a result of delayed maturation of the central nervous system, bladder contractions cannot be suppressed during sleep.

Hormonal disorders: In some patients, the hormone called ADH cannot be released sufficiently, so the kidney urinates excessively and the amount of urine exceeds the bladder capacity.

Do Environmental Factors such as Lifestyle, Socioeconomic Status, etc. Play a Role in Enuresis Nocturne?

Yes, it can happen. Enuresis is more common in communities with low sociocultural level, in families with many children and in low income groups.

In addition, the main factor in many bedwetting incidents is that children drink little fluid at school during the day and lose water by sweating a lot, then increase the amount of fluid they drink in a short time when they come home in the evening and drink a lot of fluid especially in the evening hours. Just a change in lifestyle can prevent enuresis in many children.

What Psychosocial Problems Can Enuresis Nocturne Cause If Left Untreated?

Children can develop serious psychosocial problems such as loss of self-confidence, low self-esteem, becoming withdrawn, isolating themselves from their friends and social environment, declining school achievement, depressive tendencies and feelings of guilt.

The child wants to stay with friends, go camping or on a school trip, sleep with relatives, as many of his/her peers do, but cannot do so out of fear and shame. Gradually bedwetting may turn into a phobia.

Can Enuresis Nocturne be Accompanied by Other Problems?

Actually, there is no serious accompanying disease in this disease. However, some children may have severe constipation and they should be questioned in this respect and treated if necessary. Many cases of enuresis can be treated just by correcting constipation.

Main accompanying problems;

• Daytime urinary incontinence
• Urge incontinence
• Difficulty in initiating voiding
• Dripping after voiding
• Voiding by straining the abdominal muscles
• Inability to empty the bladder completely
• Painful voiding

Who Should Diagnose and Treat Patients with Enuresis Nocturne?

These patients should first be evaluated and treated by a Pediatric Surgeon, Pediatric Urologist or Urologist who deals with children, and if necessary, cooperation with Pediatricians and Child Psychiatry should be made.

How is Enuresis Nocturne Diagnosed?

The most important thing is a good history and physical examination. Physical examination should include all systems. The story is typical in these children, families say that the child sleeps very deeply at night and does not wake up if you beat a drum next to him at night. If necessary, a voiding-defecation chart should be kept, a complete urinalysis and urinary system ultrasound should be performed. These are usually sufficient for diagnosis, but if your doctor suspects a more complicated condition, special tests may be performed.

Does the Early Start of Toilet Training or Improper Toilet Training in Children Have an Effect on this Problem?

Too early and oppressive toilet training is known to play a role in bedwetting and incontinence. In particular, it is extremely unfavorable to punish and pressure children in the belief that they will get used to holding urine.

Are There Any Misconceptions About Enuresis Nocturna?

Yes, it does. Withholding water and waking the child at random times of the night does not cure the disease, it only keeps the bed dry during those nights. Instead, it is necessary to support the child with rewards, encouragement, motivation and to start treatment without losing too much time.

Bedwetting cannot be treated with punishment. On the contrary, punishment may have the opposite effect and may also break the child's self-confidence and resistance and cause psychological problems. Despite this, it is known that families not infrequently use punishment.

Will the problem resolve itself when the child grows up?

Yes, it can usually be solved, but it can have negative psychological and social effects on the child as the process can take too long. In children who do not miss every night, for example 2-3 nights a week, this possibility is high, while in children over the age of 10 who miss every night, this possibility is almost negligible.

What Mistakes Can Families Make on the Subject?

The most common mistakes families make are restricting meaningless liquids and trying to solve the problem with punishment. They also restrict the child's social life from time to time. All these approaches hurt the child's self-confidence instead of solving the problem.

How is Enuresis Nocturne Treated?

The first and most important step in the treatment of Enuresis Nocturna is to motivate the child and the family for treatment. In order to achieve this, it is necessary to establish a warm relationship with the child, to provide understanding and support from the family, to give confidence that the problem will be solved and to eliminate the guilt in the child.

Care should be taken to ensure that the child does not perceive this problem as belonging only to him/her. In cases that may arise during treatment, blaming and punitive behaviors should be avoided. It should be kept in mind that any behavior to the contrary may lead to problems such as loss of self-confidence, behavioral disorders and anxiety in the child.

In general, treatment can be considered in 3 stages;

a) Behavioral therapy,

b) Medication

c) A combination of both options is applied.

In Behavioral Treatment; Rewarding, motivation and a bell system that rings when the child wakes up by ringing during bedwetting, which we call “alarm treatment”, are used. It requires the participation of the family and a long and persistent treatment. There is no harm and side effects.

Alarm Therapy; also called “Wake Up Alarm Therapy”. Conditioning treatments are applied together with an improved alarm device.

Alarm therapy uses a device that sounds an alarm when the child wets the diaper. The alarm aims to wake the child up and go to the toilet. At first, the child wakes up when the child wets, but over time, a conditioned reflex develops in the child and the child starts to wake up without urinating. The main thing to be considered here is that the child wakes up with the alarm, goes to the toilet and completely empties the bladder.

In this method, supporting the child with an approach that will increase his/her self-confidence and with rewards increases the success rate. Alarm treatment lasts approximately 2-3 months. The treatment is terminated after the child is completely dry for 1 month. The success rate is around 80-90% depending on the compliance of the child and family. In case of recurrence, treatment is restarted.

How Does an Alarm Device Work?

An alarm device is a device that can be worn on clothing. It consists of two small parts connected by an interconnecting cable. The sensor is attached to the child's underwear and the alarm device is attached to the top of the child's pajamas close to the ear. The device, which is sensitive to wetness, wakes the child by alarming even with a drop of urine.

 

 

Why Does My Child Not Hear the Alarm Device?

This is normal at the beginning of treatment. The treatment should be persistently continued, as time passes, the brain will perceive this and the child will get up and go to the toilet spontaneously.

Drug treatment; Pills or sublingual tablets given to replace a substance that is missing in these children, and some drugs that change the functioning of the bladder can be used under the control of pediatric surgery. When used correctly, the medicines do not have any significant or dangerous side effects. The advantage of sublingual tablets is that they are easy to use and work very quickly. They are particularly ideal when the child has to sleep outside the home. About two thirds of bedwetting patients can be successfully treated with this type of medication. Some medications also work by reducing the kidney's production of urine at night.

If treated for a sufficient period of time and with the right method, bedwetting will disappear after a period of time that varies in each child. If the treatment is discontinued and a recurrence is encountered immediately, the treatment is continued for a while, either with the same method or by changing the method. If dryness without treatment is achieved after a period of up to several months, there is almost no chance of recurrence.

Is medication alone sufficient?

Medication alone is often insufficient in the treatment of nocturnal enuresis. For the success of the treatment, behavioral therapy should be applied together with drug therapy and even alarm therapy if necessary.

However, drug treatment alone may be sufficient in the inadequacy of the hormone called vasopressin, which regulates the urine production of the kidney. Because the release of this hormone in the body increases at night, the kidney produces less urine, the bladder fills later and there is less need to urinate.

Should Lifestyle and Eating Habits be Changed in Children with Enuresis Nocturna?

Nutrition and fluid intake should be regulated in children with urinary incontinence. 250 ml of fluid intake should be provided 6-7 times during the day (may vary according to age), and fluid intake should be restricted 2 hours before bedtime in the evening. Tea, coffee and carbonated drinks should not be given after dinner. The child should be helped to go to the toilet at 3-hour intervals during the day, if there is a constipation problem, a treatment should be applied, the child should be taken to the toilet by waking up before going to bed and 2 hours after going to bed, easy access to the toilet at night should be provided, diapers should be avoided, physical activity should be organized and the child should be prevented from staying in a sitting position for a long time, self-confidence should be protected by avoiding punishment. It is more beneficial for the child not to be diapered at night. Because diapering eliminates the child's need to get up at night and negatively affects the treatment process.

What kind of problems does nocturnal enuresis cause if left untreated?

Nocturnal enuresis can lead to more serious problems if not treated in time;

• Loss of self-confidence in the child
• Anger and hopelessness
• Feelings of shame and guilt
• Feelings of failure in school and social life
• Feelings of feeling worthless
• Feeling in psychological and social problems such as withdrawal and isolation from the social environment.

*** The information provided here, the content of the website is designed to inform the visitor, especially families. No information should be considered as advice by visitors and should not lead to any decision or action. Families should definitely have their patient examined by a pediatric surgery specialist, consult with him/her and make a decision by consulting his/her knowledge.