Bed-wetting

Symptoms Of Bedwetting

The main symptom of bedwetting is involuntary urination during sleep. It is considered a medical condition only when it occurs at least twice a week in children older than 5 years of age for at least 3 months. 

The presence of more than “four” episodes of urination in “a week” is termed as “frequent.”

Individuals having lower urinary tract dysfunction may experience the following additional symptoms:

• Pain in the lower urinary tract

• Increased frequency of urination (≥8 times/day)

• Repeated leakage of urine, even during daytime

• A sudden and immediate urge to urinate

• Pain while urinating

• Straining (application of pressure at the abdomen while urinating)

Causes Of Bedwetting

The different proposed theories behind bedwetting are:

1. Increased urine production at night

Typically, the production of urine diminishes at night due to the increased production of a hormone known as ADH (antidiuretic hormone), a natural process in the body.

Some studies have shown that decreased nocturnal ADH production at night might contribute to bedwetting. 

2. Bladder overactivity

The bladder's fullness causes contraction of the muscles, which leads to emptying. Any defect in these muscles can cause bedwetting. Children with bladder overactivity usually also have daytime symptoms such as urgency of urination. 

3. Role of central nervous system

Sleep cycle and urination are both controlled by the brain. Several studies have found some people have frequent arousals with inability to awaken completely. This causes the bladder brain dysfunction which can lead to bedwetting. 

Risk Factors For Bedwetting

1. Age

Bedwetting is mostly observed in children.

2. Gender

Bedwetting is more common in boys when compared to girls. Boys also have also been found to have more severe bedwetting than girls.

3. Family history

Children with one affected parent have a higher chance of developing bedwetting. This risk increases further if both parents suffer from the condition.

4. Fluid intake at bedtime

Excessive intake of certain foods and drinks is associated with increased urine production at night. Some children are more sensitive to this intake. However, this can be easily prevented by avoiding fluid intake before 1-2 hours of going to sleep.

5. Sleep fluctuations

Deep sleepers or children with excessive daytime sleepiness are more prone to bedwetting.

6. Psychological or behavioral disorders

The following psychological or behavioral disorders can increase the risk of bedwetting:

• Attention deficit and hyperactivity disorder

• Autism spectrum disorder

• Oppositional defiant disorder

• Mood disorders 

These disorders cause bedwetting due to associated disturbed sleep patterns.

7. Non-psychological disorders

Some non-psychological conditions can also contribute to bedwetting through different mechanisms. Examples include:

• Constipation

• Obstruction in the urinary system

• Ectopic ureter (a ureter that does not connect properly to the bladder)

• Urinary tract infections

• Cystitis (infection of the urinary bladder)

• Small bladder capacity

• Overactive bladder

• Kidney disorders

• Sickle cell anemia

• Sleep apnea

• Diabetes Mellitus

• Diabetes insipidus

• Anxiety

• Stress

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Diagnosis Of Bedwetting

The diagnosis of bedwetting involves a series of steps based on the presence of other symptoms.

1. Medical history and clinical examination

Obtaining the history and tracking the symptoms are the most important for all children who present with bedwetting. The essential aspects that are considered include:

• Determining the pattern of bedwetting episodes in one night and the number of nights per week

• Asking about the intake of caffeine or other fluids before going to bed

• Determination of the amount of urine

• Raising questions regarding increased thirst, difficulty in urination, urgency, frequency, daytime incontinence, abnormal urinary stream, and constipation

• Obtaining a family history of involuntary urination

• Determining history of recurrent urinary tract infections 

• Asking about sleep disorders, snoring, or a diagnosis of sleep-disordered breathing

• Knowing about the use of chronic medications

• Screening for psychological or behavioral disturbances, including attention deficit and hyperactivity disorder and learning disabilities

• Finding out stressor

2. Physical examination

In some cases, bedwetting can be due to spinal malformations. A back examination can rule these disorders out. Dimples and hairy patches over the back are signs of a disturbed spine at birth.

3. Urine routine and microscopy

A complete urinalysis is the only preferred test in children without other symptoms. The urine is tested for the presence of: 

• Urinary tract infections

• Glycosuria (glucose in urine)

• Proteinuria (protein in urine)

• Hematuria ((blood in urine)

In various cases, blood urea nitrogen (BUN) and creatinine tests are also performed to assess kidney function.

4. Imaging studies

These tests are usually recommended in children who present with multiple other symptoms also, along with bedwetting. It includes:

• Kidney ultrasound (to look for kidney damage)

• KUB ultrasound ( to assess the assesses the condition of your kidneys, ureters, and urinary bladder)

• Spine MRI (to check for spinal malformations)

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Prevention Of Bedwetting

There is no sure shot way to prevent bedwetting. However, several factors that act as a trigger for bedwetting can be minimized by some lifestyle modifications. These include: 

1. Inculcate healthier eating habits in your child

Healthy eating habits help in the prevention of obesity and diabetes, which act as a trigger for developing bedwetting. The following eating habits should be followed: 

• Limit spicy foods, chocolate, artificial sweeteners, and caffeinated beverages as they may cause irritation and inflammation of the bladder.

• To avoid constipation, include high-fiber foods such as whole-grain cereals (such as porridge, brown rice, wholemeal pasta, wholemeal bread, or pulses such as lentils and beans). Aim for at least 25-30 gms of fiber each day. 

• Make them eat fruits and vegetables to keep the process of defecation easy.
  
  

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2. Keep your child hydrated

The lesser intake of water is also associated with constipation and bladder irritation. This can act as a risk factor for developing bedwetting. To prevent dehydration:

• Make them drink at least 6 to 8 glasses of water every day

• Make a habit of frequently sipping water even when they are not feeling thirsty

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The color of the urine helps identify whether the person is drinking an adequate amount of water. A pale yellow urine indicates that the person is adequately hydrated, while a dark yellow urine indicates dehydration.

3. Follow good toilet habits

Bedwetting can be prevented by teaching good toilet habits to your child, which includes:

• Avoiding holding urine for a long period 

• Taking sufficient time to empty the bladder fully

• Sitting in the full crouching squat position while urinating 

• Going to the toilet when the bladder is full

• Using correct posture while passing urine, which involves an upright sitting with elevated feet

Specialist To Visit 

It is believed that bedwetting resolves independently as the child ages. This is somewhat true, but it can be treated and managed in several ways. The problem of bedwetting should not be ignored.

Some of the specialists that can help diagnose and treat bedwetting include:

• General Physician

• Pediatric urologist

• Pediatrician

A general physician will examine your symptoms and initiate treatment.

A pediatrician can be consulted for medical treatment and preventive healthcare services for children and adolescents.

A pediatric urologist is a doctor who specializes in diagnosing and treating diseases of the urinary system in children.

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Treatment Of Bedwetting

The goal of treatment of bed wetting includes: 

• Reducing the total number of enuretic night

• Avoiding enuresis on specific nights in specific locations

• Mitigating the stress of the child 

• Avoiding the recurrence
  
  

Treatment options for monosymptomatic bedwetting include:

1. Behavioral therapy 

In this, children are educated about bedwetting. They are also advised to make specific lifestyle changes, such as limiting fluid intake 1-2 hours before bedtime and timed voiding every 3 to 4 hours.

2. Enuresis alarms

Enuresis alarms are used if behavioral therapy is ineffective. These electronic devices are designed to awaken the child during urination. 

The devices are worn or placed in bed. The device produces a loud noise when it senses an episode of urination. They are proven even more effective than some medications in children with good learning capacity.

3. Medications 

• Desmopressin: It is a synthetic analog of the antidiuretic hormone. It works by decreasing the urine output of the kidneys. 

• Oxybutynin:  Oxybutynin works by relaxing the bladder's smooth muscle. They are mainly shown to be effective in children with an overactive bladder. 

• Polyethylene glycol: It is a stool softener that helps resolve nighttime bedwetting, even in children without constipation. 

• Imipramine: It is an antidepressant that also decreases the episodes of bedwetting through multiple mechanisms. It is mainly used as the second and third line of treatment. 

Home-care For Bedwetting

1. Adjust the intake of fluids

Children should be trained for the intake of fluids. Some specific adjustments surely help in bringing down the episodes of bedwetting. These include:

• Avoiding soda and caffeinated beverages such as tea and coffee

• Keeping the child hydrated

• Having 2/3rd of the fluids during the morning to early afternoon and then the other 1/3rd the remainder of the day

• Avoiding the consumption of any fluid before 1-2 hours of going to bed

2. Practice timed voiding

Practice going to the bathroom regularly instead of waiting for the urge to go. This will prevent the bladder from overfilling and thus reduce the chances of bedwetting. Inculcate a habit of going to the washroom once every 3-4 hours in your child. 

3. Empty bladder before bedtime

It is very important  to empty the bladder right before bedtime. This helps in reducing the episode of bedwetting to a greater extent.

4. Improve sleep hygiene

Maintaining a sleep routine helps improve the symptoms of several sleep-related disorders, including bedwetting. It also helps improve nocturnal bladder control. 

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5. Maintain a diary

The parents should maintain a journal for a few days to record the following activities:

• Any leakage of urine during the daytime

• Frequency of bedwetting

• Ability to reach washroom on time

• Conditions that trigger bedwetting

Complications Of Bedwetting

Bedwetting negatively impacts the quality of life of both child and family. It can lead to:

• Low self esteem

• Mood problems

• Stress 

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Alternative Therapies For Bedwetting

The alternative therapies for bedwetting include:

1. Urotherapy

This involves giving the child behavioral training, which includes limiting fluid intake before bed, enhancing awareness of daytime voiding (the process of removing urine), and voiding before bedtime.

2. Motivational therapy (positive reinforcement)

It involves giving the children prizes or stickers for following the urotherapy guidelines. It is helpful for the children who are motivated to treat their bedwetting. 

This technique has shown a reduction in relapse rate and bedwetting frequency in children between 5 to 7 years of age having mild symptoms ( <7 nights/week)

3. Biofeedback 

The technique records individuals' responses, such as heart rate, muscle tension, brain activity, etc., after stimulation. By analyzing the triggers, it helps alleviate physical and emotional symptoms.

Living With Bedwetting

Bedwetting can have both physical and emotional impacts on a child’s life. It does not resolve immediately with treatment. The journey to dry night is a progression that requires a lot of patience from both the child and the caregiver. 

Role of caregivers -  Managing emotional aspect

Bedwetting can be a frustrating and embarrassing condition for a grown-up child. These children may suffer from poor self-esteem. As per the study, children with chronic bedwetting problems are more likely to develop behavior problems, such as aggressive behavior and attention problems.

The following measures from a parent/caregiver help in managing the emotional fluctuations in a child:

• Reassure and educate the child about bedwetting

• Give answers to every question of the child

• Support the child and let them know that various kids have the same problem

• Try to minimize the number of investigations by preparing well in advance by recording the symptoms well in advance

• Understand the fact that bedwetting is not in control of your child instead of blaming them

• Set a no-teasing rule in the family in which nobody is allowed to tease the child

• Do not punish or reprimand the child, as it can make the feeling of shame even worse

• Reward the child not for dry nights but for adhering to the treatment guidelines

• Ease any anxiety or stress during bedtime by creating a quiet environment. Read a book together, massage the child, or tell the stories