Enuresis in Children

What Is Enuresis?

Enuresis is more commonly known as bed-wetting. Nocturnal enuresis, or bed-wetting at night, is the most common type of elimination disorder. Daytime wetting is called diurnal enuresis. Some children experience either or a combination of both.

This behavior may or may not be purposeful. The condition is not diagnosed unless the child is 5 years or older.

What Are the Symptoms of Enuresis?

The main symptoms of enuresis include:

  • Repeated bed-wetting
  • Wetting in the clothes
  • Wetting at least twice a week for approximately three months

What Causes Enuresis?

Many factors may be involved in the development of enuresis. Involuntary, or non-intentional, release of urine may result from:

Voluntary, or intentional, enuresis may be associated with other mental disorders, including behavior disorders or emotional disorders such as anxiety. Enuresis also appears to run in families, which suggests that a tendency for the disorder may be inherited (passed on from parent to child, particularly on the father's side). In addition, toilet training that was forced or started when the child was too young may be a factor in the development of the disorder, although there is little research to make conclusions about the role of toilet training and the development of enuresis.

Children with enuresis are often described as heavy sleepers who fail to awaken at the urinary urge to void or when their bladders are full.

How Common Is Enuresis?

Enuresis is a common childhood problem. Estimates suggest that 7% of boys and 3% of girls age 5 have enuresis. These numbers drop to 3% of boys and 2% of girls by age 10. Most children outgrow this problem by the time they become teens, with only about 1% of males and less than 1% of females having the disorder at age 18.

How Is Enuresis Diagnosed?

First, the doctor will take a medical history and perform a physical exam to rule out any medical disorder that may be causing the release of urine, which is called incontinence. Lab tests may also be performed, such as a urinalysis and blood work to measure blood sugar, hormones, and kidney function. Physical conditions that could result in incontinence include diabetes, an infection, or a functional or structural defect causing a blockage in the urinary tract.

Enuresis also may be associated with certain medicines that can cause confusion or changes in behavior as a side effect. If no physical cause is found, the doctor will base a diagnosis of enuresis on the child's symptoms and current behaviors.

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How Is Enuresis Treated?

Treatment may not be needed for mild cases of enuresis, because most children with this condition outgrow it (usually by the time they become teens). Knowing when to begin treatment is difficult, because it is impossible to predict the course of symptoms and when the child will simply outgrow the condition. Some factors to consider when deciding to begin treatment are whether the child's self esteem is affected by the wetting and whether enuresis is causing impairment in functioning, such as causing the child to avoid attending sleepovers with friends.

When treatment is used, therapy aimed at changing behavior is most often recommended. Behavior therapy is effective in more than 75% of patients and may include:

  • Alarms: Using an alarm system that rings when the bed gets wet can help the child learn to respond to bladder sensations at night. The majority of the research on enuresis supports the use of urine alarms as the most effective treatment. Urine alarms are currently the only treatment associated with persistent improvement. The relapse rate is low, generally 5% to 10%, so that once a child's wetting improves, it almost always remains improved.
  • Bladder training: This technique uses regularly scheduled trips to the bathroom timed at increasing intervals to help the child become used to "holding" urine for longer periods. This also helps to stretch the size of the bladder, which is a muscle that responds to exercise. Bladder training is typically used as part of an enuresis treatment program.
  • Rewards: This may include providing a series of small rewards as the child achieves bladder control.

Medications are available to treat enuresis, but they generally are only used if the disorder interferes with the child's functioning and usually are not recommended for children under 6 years of age.

Medications may be used to decrease the amount of urine produced by the kidneys or to help increase the capacity of the bladder or. Drugs commonly used include desmopressin acetate (DDAVP), which affects the kidneys' urine production, and imipramine (Tofranil), an antidepressant which has also been found useful for treating enuresis.

While drugs can be useful for managing the symptoms of enuresis, once they are stopped, the child typically begins wetting again. When choosing medications for children, the side effects and cost need to be considered; the medications may help improve the child's functioning until behavioral treatments begin to work.

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What Is the Outlook for Children With Enuresis?

Most children with enuresis outgrow the disorder by the time they reach their teen years, with a spontaneous cure rate of 12% to 15% per year. Only a small number, about 1%, continues to have a problem into adulthood.

Can Enuresis Be Prevented?

It may not be possible to prevent all cases of enuresis -- particularly those that are related to problems with the child's anatomy -- but getting your child evaluated by a pediatrician as soon as symptoms appear may help reduce the problems associated with the condition. Being positive and patient with a child during toilet training may help prevent the development of negative attitudes about using the toilet.

WebMD Medical Reference Reviewed by Joseph Goldberg, MD on July 30, 2016

Sources

SOURCES:
Thiedke, C. Carolyn, MD, "Nocturnal Enuresis," American Family Physician Vol. 67 #7 April 1, 2003.
Section of Behavior Medicine at the Children's Hospital at the Cleveland Clinic (2005).
Christopherson, E.R., & Purvis, P.C. (2001). "Toileting problems in children." In C.E. Walker& M.C. Roberts (Eds.) The Handbook of Clinical Child Psychology (3rd Ed., pp. 453-469). New York: NY: JohnWiley & Sons. Walker, C.E.,"Elimination disorders: Enuresis and encopresis." In M.C.Roberts (Ed.) Handbook of Pediatric Psychology (3rd Ed, 2001 pp.546-560). New York, NY: Guilford Press

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