Bedwetting
Encyclopedia
Nocturnal enuresis, commonly called bedwetting, is involuntary urination
while asleep
after the age at which bladder
control usually occurs. Nocturnal enuresis is considered primary (PNE) when a child has not yet had a prolonged period of being dry. Secondary nocturnal enuresis (SNE) is when a child or adult begins wetting again after having stayed dry.
Bedwetting is the most common childhood urologic complaint and one of the most common pediatric-health issues. Most bedwetting, however, is just a developmental delay—not an emotional problem or physical illness. Only a small percentage (5% to 10%) of bedwetting cases are caused by specific medical situations. Bedwetting is frequently associated with a family history
of the condition.
Most girls can stay dry by age six and most boys stay dry by age seven. By ten years old, 95% of children are dry at night. Studies place adult bedwetting rates at between 0.5% to 2.3%.
Treatments range from behavioral-based
options such as bedwetting alarm
s, to medication such as hormone replacement, and even surgery such as urethral enlargement. Since most bedwetting is simply a developmental delay, most treatment plans aim to protect or improve self-esteem
. Bedwetting children and adults can suffer emotional stress or psychological injury if they feel shamed by the condition. Treatment guidelines recommend that the physician counsel the parents, warning about psychological damage caused by pressure, shaming, or punishment for a condition children cannot control.
that reduces urine
production at night. The second is the ability to wake up when the bladder
is full. Children usually achieve nighttime dryness by developing one or both of these abilities. There appear to be some hereditary factors in how and when these develop.
The first ability is a hormone
cycle that reduces the body's urine production. At about sunset each day, the body releases a minute burst of antidiuretic hormone
(also known as arginine vasopressin or AVP). This hormone burst reduces the kidney
's urine output well into the night so that the bladder does not get full until morning. This hormone cycle is not present at birth. Many children develop it between the ages of two and six years old, others between six and the end of puberty
, and some not at all.
The second ability that helps people stay dry is waking when the bladder is full. This ability develops in the same age range as the vasopressin hormone, but is separate from that hormone cycle.
Most children develop the ability to stay dry as they grow older. The typical development process begins with one- and two-year-old children developing larger bladders and beginning to sense bladder fullness. Two- and three-year-old children begin to stay dry during the day. Four- and five-year-olds develop an adult pattern of urinary control and begin to stay dry at night.
Doctors frequently consider bedwetting as a self-limiting problem, since most children will outgrow it. Children 5 to 9 years old have a spontaneous cure rate of 14% per year. Adolescents 10 to 18 years old have a spontaneous cure rate of 16% per year.
Approximate bedwetting rates are:
As can be seen from the numbers above, a portion of bedwetting children will not outgrow the problem. Adult rates of bedwetting show little change due to spontaneous cure. Persons who are still enuretic at age 18 are likely to deal with bedwetting throughout their lives.
Studies of bedwetting in adults have found varying rates. The most quoted study in this area was done in the Netherlands. It found a 0.5% rate for 18- to 64-year-olds. A Hong Kong study, however, found a much higher rate. The Hong Kong researchers found a bedwetting rate of 2.3% in 16- to 40-year-olds.
Medical guidelines vary on when a child is old enough to stay dry. Common medical definitions allow doctors to diagnose PNE beginning at between 4 to 5 years old. This type of classification is frequently used by insurance companies. It defines PNE as, "persistent bedwetting in the absence of any urologic, medical or neurological anomaly in a child beyond the age when over 75% of children are normally dry."
Some researchers, however, recommend a different starting age range. This guidance says that bedwetting can be considered a clinical problem if the child regularly wets the bed after turning seven years old. D'Alessandro refines this to bedwetting more than twice a month after six years old for girls and seven years old for boys.
's DSM-IV, defining nocturnal enuresis as repeated urination into bed or clothes, occurring twice per week for at least three consecutive months in a child of at least 5 years of age and not due to either a drug side effect
or a medical condition. Even if the case does not meet these criteria, the DSM-IV definition allows psychologists to diagnose nocturnal enuresis if the wetting causes the patient clinically significant distress.
These first two items are the most common factors in bedwetting, but current medical technology offers no easy testing for either cause. There is no test to prove that bedwetting is only a developmental delay, and genetic testing offers little or no benefit.
As a result, doctors work to rule out other causes. The following causes are less common, but are easier to prove and more clearly treated:
Children questioned in one study ranked bedwetting as the third most stressful life event, after parental divorce and parental fighting. Adolescents in the same study ranked bedwetting as tied for second with parental fighting.
Bedwetting children face problems ranging from being teased by siblings, being punished by parents, and being afraid that friends will find out.
Psychologists report that the amount of psychological harm depends on whether the bedwetting harms self-esteem or development of social skills. Key factors are:
As mentioned below, current studies show that it is very rare for a child to intentionally wet the bed as a method of acting out.
in The Canon of Medicine
:
Psychological theory through the 1960s placed much greater focus on the possibility that a bedwetting child might be acting out, purposefully striking back against parents by soiling linens and bedding. (More recent research and medical literature states that this is very rare.)
In the United States, about 25% of enuretic children are punished for wetting the bed. In Hong Kong, 57% of enuretic children are punished for wetting. Parents with only a grade-school level education punish bedwetting children at twice the rate of high-school- and college-educated parents.
Despite these stressful effects, doctors emphasize that parents should react patiently and supportively.
abnormalities, infection
, or diabetes. Physicians also treat bedwetting when it may harm the child's self-esteem
or relationships with family/friends. Only a small percentage of bedwetting is caused by a specific medical condition, so most treatment is prompted by concern for the child's emotional welfare. Behavioral treatment of bedwetting overall tends to show increased self esteem for children
Parents become concerned much earlier than doctors. A study in 1980 asked parents and physicians the age that children should stay dry at night. The average parent response was 2.75 years old, while the average physician response was 5.13 years old.
Punishment is not effective and can interfere with treatment.
, a set of three behavioral characteristics described by John Macdonald
in 1963. The other two characteristics were firestarting and animal abuse. Macdonald suggested that there was an association between a person displaying all three characteristics, then later displaying sociopathic
criminal behavior.
Research has found that, however, that enuresis is not associated with sociopathic behavior. Enuresis is an “unconscious, involuntary, and nonviolent act and therefore linking it to violent crime is more problematic than doing so with animal cruelty or firesetting".
Bedwetting can be connected to emotional or physical trauma. Trauma can trigger a return to bedwetting (secondary enuresis) in both children and adults. In addition, caregivers cause some level of emotional trauma when they punish or shame a bedwetting child.
This leads to a difficult distinction: it is not the bedwetting that increases the chance of criminal behavior, but the trauma. For example, parental cruelty can result in "homicidal proneness".
Urination
Urination, also known as micturition, voiding, peeing, weeing, pissing, and more rarely, emiction, is the ejection of urine from the urinary bladder through the urethra to the outside of the body. In healthy humans the process of urination is under voluntary control...
while asleep
Sleep
Sleep is a naturally recurring state characterized by reduced or absent consciousness, relatively suspended sensory activity, and inactivity of nearly all voluntary muscles. It is distinguished from quiet wakefulness by a decreased ability to react to stimuli, and is more easily reversible than...
after the age at which bladder
Bladder
Bladder usually refers to an anatomical hollow organBladder may also refer to:-Biology:* Urinary bladder in humans** Urinary bladder ** Bladder control; see Urinary incontinence** Artificial urinary bladder, in humans...
control usually occurs. Nocturnal enuresis is considered primary (PNE) when a child has not yet had a prolonged period of being dry. Secondary nocturnal enuresis (SNE) is when a child or adult begins wetting again after having stayed dry.
Bedwetting is the most common childhood urologic complaint and one of the most common pediatric-health issues. Most bedwetting, however, is just a developmental delay—not an emotional problem or physical illness. Only a small percentage (5% to 10%) of bedwetting cases are caused by specific medical situations. Bedwetting is frequently associated with a family history
Family history (medicine)
In medicine, a family history consists of information about disorders from which the direct blood relatives of the patient have suffered. Genealogy typically includes very little of the medical history of the family, but the medical history could be considered a specific subset of the total history...
of the condition.
Most girls can stay dry by age six and most boys stay dry by age seven. By ten years old, 95% of children are dry at night. Studies place adult bedwetting rates at between 0.5% to 2.3%.
Treatments range from behavioral-based
Behaviour therapy
Behaviour therapy, or behavior therapy is an approach to psychotherapy based on learning theory which aims to treat psychopathology through techniques designed to reinforce desired and eliminate undesired behaviours.-History:...
options such as bedwetting alarm
Bedwetting alarm
A bedwetting alarm is an electronic device used as a treatment option for nocturnal enuresis. The alarm activates when the wearer urinates. Alarms come in several different styles: wearable alarms, wireless alarms, and pad-type alarms...
s, to medication such as hormone replacement, and even surgery such as urethral enlargement. Since most bedwetting is simply a developmental delay, most treatment plans aim to protect or improve self-esteem
Self-esteem
Self-esteem is a term in psychology to reflect a person's overall evaluation or appraisal of his or her own worth. Self-esteem encompasses beliefs and emotions such as triumph, despair, pride and shame: some would distinguish how 'the self-concept is what we think about the self; self-esteem, the...
. Bedwetting children and adults can suffer emotional stress or psychological injury if they feel shamed by the condition. Treatment guidelines recommend that the physician counsel the parents, warning about psychological damage caused by pressure, shaming, or punishment for a condition children cannot control.
Normal processes of staying dry
Two physical functions prevent bedwetting. The first is a hormoneHormone
A hormone is a chemical released by a cell or a gland in one part of the body that sends out messages that affect cells in other parts of the organism. Only a small amount of hormone is required to alter cell metabolism. In essence, it is a chemical messenger that transports a signal from one...
that reduces urine
Urine
Urine is a typically sterile liquid by-product of the body that is secreted by the kidneys through a process called urination and excreted through the urethra. Cellular metabolism generates numerous by-products, many rich in nitrogen, that require elimination from the bloodstream...
production at night. The second is the ability to wake up when the bladder
Bladder
Bladder usually refers to an anatomical hollow organBladder may also refer to:-Biology:* Urinary bladder in humans** Urinary bladder ** Bladder control; see Urinary incontinence** Artificial urinary bladder, in humans...
is full. Children usually achieve nighttime dryness by developing one or both of these abilities. There appear to be some hereditary factors in how and when these develop.
The first ability is a hormone
Hormone
A hormone is a chemical released by a cell or a gland in one part of the body that sends out messages that affect cells in other parts of the organism. Only a small amount of hormone is required to alter cell metabolism. In essence, it is a chemical messenger that transports a signal from one...
cycle that reduces the body's urine production. At about sunset each day, the body releases a minute burst of antidiuretic hormone
Vasopressin
Arginine vasopressin , also known as vasopressin, argipressin or antidiuretic hormone , is a neurohypophysial hormone found in most mammals, including humans. Vasopressin is a peptide hormone that controls the reabsorption of molecules in the tubules of the kidneys by affecting the tissue's...
(also known as arginine vasopressin or AVP). This hormone burst reduces the kidney
Kidney
The kidneys, organs with several functions, serve essential regulatory roles in most animals, including vertebrates and some invertebrates. They are essential in the urinary system and also serve homeostatic functions such as the regulation of electrolytes, maintenance of acid–base balance, and...
's urine output well into the night so that the bladder does not get full until morning. This hormone cycle is not present at birth. Many children develop it between the ages of two and six years old, others between six and the end of puberty
Puberty
Puberty is the process of physical changes by which a child's body matures into an adult body capable of reproduction, as initiated by hormonal signals from the brain to the gonads; the ovaries in a girl, the testes in a boy...
, and some not at all.
The second ability that helps people stay dry is waking when the bladder is full. This ability develops in the same age range as the vasopressin hormone, but is separate from that hormone cycle.
Most children develop the ability to stay dry as they grow older. The typical development process begins with one- and two-year-old children developing larger bladders and beginning to sense bladder fullness. Two- and three-year-old children begin to stay dry during the day. Four- and five-year-olds develop an adult pattern of urinary control and begin to stay dry at night.
Frequency of bedwetting (epidemiology)
Most girls can stay dry at night by age six and most boys stay dry by age seven. Boys are three times more likely to wet the bed than girls.Doctors frequently consider bedwetting as a self-limiting problem, since most children will outgrow it. Children 5 to 9 years old have a spontaneous cure rate of 14% per year. Adolescents 10 to 18 years old have a spontaneous cure rate of 16% per year.
Approximate bedwetting rates are:
- Age 5: 20%
- Age 6: 10–15%
- Age 7: 7%
- Age 10: 5%
- Age 15: 1–2%
- Age 18–64: 0.5–1%
As can be seen from the numbers above, a portion of bedwetting children will not outgrow the problem. Adult rates of bedwetting show little change due to spontaneous cure. Persons who are still enuretic at age 18 are likely to deal with bedwetting throughout their lives.
Studies of bedwetting in adults have found varying rates. The most quoted study in this area was done in the Netherlands. It found a 0.5% rate for 18- to 64-year-olds. A Hong Kong study, however, found a much higher rate. The Hong Kong researchers found a bedwetting rate of 2.3% in 16- to 40-year-olds.
Medical definitions: primary vs. secondary enuresis
The medical name for bedwetting is nocturnal enuresis. The condition is divided into two types: primary nocturnal enuresis (PNE) and secondary nocturnal enuresis.Primary nocturnal enuresis (PNE)
Primary nocturnal enuresis (PNE) is the most common form of bedwetting. Bedwetting counts as a disorder once a child is old enough to stay dry, but continues either to average at least two wet nights a week with no long periods of dryness or to not sleep dry without being taken to the toilet by another person.Medical guidelines vary on when a child is old enough to stay dry. Common medical definitions allow doctors to diagnose PNE beginning at between 4 to 5 years old. This type of classification is frequently used by insurance companies. It defines PNE as, "persistent bedwetting in the absence of any urologic, medical or neurological anomaly in a child beyond the age when over 75% of children are normally dry."
Some researchers, however, recommend a different starting age range. This guidance says that bedwetting can be considered a clinical problem if the child regularly wets the bed after turning seven years old. D'Alessandro refines this to bedwetting more than twice a month after six years old for girls and seven years old for boys.
Secondary nocturnal enuresis
Secondary enuresis occurs after a patient goes through an extended period of dryness at night (roughly six months or more) and then reverts to nighttime wetting. Secondary enuresis can be caused by emotional stress or a medical condition, such as a bladder infection.U.S. psychological definition
Psychologists may use a definition from the American Psychiatric AssociationAmerican Psychiatric Association
The American Psychiatric Association is the main professional organization of psychiatrists and trainee psychiatrists in the United States, and the most influential worldwide. Its some 38,000 members are mainly American but some are international...
's DSM-IV, defining nocturnal enuresis as repeated urination into bed or clothes, occurring twice per week for at least three consecutive months in a child of at least 5 years of age and not due to either a drug side effect
Adverse drug reaction
An adverse drug reaction is an expression that describes harm associated with the use of given medications at a normal dosage. ADRs may occur following a single dose or prolonged administration of a drug or result from the combination of two or more drugs...
or a medical condition. Even if the case does not meet these criteria, the DSM-IV definition allows psychologists to diagnose nocturnal enuresis if the wetting causes the patient clinically significant distress.
Causes of and increased risks for bedwetting
The following list summarizes bedwetting's known causes and risk factors. Enuretic patients frequently have more than one cause or risk factor from the items listed below.Most common causes
Most cases of bedwetting are PNE-type, which has two related most common causes- Neurological-developmental delay
This is the most common cause of bedwetting. Most bedwetting children are simply delayed in developing the ability to stay dry and have no other developmental issues. Studies suggest that bedwetting may be due to a nervous system that is slow to process the feeling of a full bladder.
- Genetics
Bedwetting has a strong genetic component. Children whose parents were not enuretic have only a 15% incidence of bedwetting. When one or both parents were bedwetters, the rates jump to 44% and 77% respectively. Genetic research shows that bedwetting is associated with the genes on chromosomes 13q and 12q (possibly 5 and 22 also).
These first two items are the most common factors in bedwetting, but current medical technology offers no easy testing for either cause. There is no test to prove that bedwetting is only a developmental delay, and genetic testing offers little or no benefit.
As a result, doctors work to rule out other causes. The following causes are less common, but are easier to prove and more clearly treated:
- Alcohol consumption
Drinking alcoholEthanolEthanol, also called ethyl alcohol, pure alcohol, grain alcohol, or drinking alcohol, is a volatile, flammable, colorless liquid. It is a psychoactive drug and one of the oldest recreational drugs. Best known as the type of alcohol found in alcoholic beverages, it is also used in thermometers, as a...
increases urineUrineUrine is a typically sterile liquid by-product of the body that is secreted by the kidneys through a process called urination and excreted through the urethra. Cellular metabolism generates numerous by-products, many rich in nitrogen, that require elimination from the bloodstream...
production. - Attention deficit hyperactivity disorder (ADHD)
Children with ADHD are 2.7 times more likely to have bedwetting issues. - Caffeine
CaffeineCaffeineCaffeine is a bitter, white crystalline xanthine alkaloid that acts as a stimulant drug. Caffeine is found in varying quantities in the seeds, leaves, and fruit of some plants, where it acts as a natural pesticide that paralyzes and kills certain insects feeding on the plants...
increases urineUrineUrine is a typically sterile liquid by-product of the body that is secreted by the kidneys through a process called urination and excreted through the urethra. Cellular metabolism generates numerous by-products, many rich in nitrogen, that require elimination from the bloodstream...
production. - Constipation
Chronic constipationConstipationConstipation refers to bowel movements that are infrequent or hard to pass. Constipation is a common cause of painful defecation...
can cause bedwetting. When the bowels are full, it can put pressure on the bladderBladderBladder usually refers to an anatomical hollow organBladder may also refer to:-Biology:* Urinary bladder in humans** Urinary bladder ** Bladder control; see Urinary incontinence** Artificial urinary bladder, in humans...
. - Infection/disease
Infections and disease are more strongly connected with secondary nocturnal enuresis and with daytime wettingDaytime WettingEnuresis is defined as involuntary voiding of urine beyond the age of anticipated control. Diurnal enuresis is daytime wetting, nocturnal enuresis is nighttime wetting. Both of these conditions can occur at the same time, however, many children with nighttime wetting will not have wetting during...
. Less than 5% of all bedwetting cases are caused by infection or disease, the most common of which is a urinary tract infectionUrinary tract infectionA urinary tract infection is a bacterial infection that affects any part of the urinary tract. Symptoms include frequent feeling and/or need to urinate, pain during urination, and cloudy urine. The main causal agent is Escherichia coli...
. - Insufficient anti-diuretic hormone (ADH) production
A portion of bedwetting children do not produce enough of the anti-diuretic hormone. As explained above, the body normally increases ADHVasopressinArginine vasopressin , also known as vasopressin, argipressin or antidiuretic hormone , is a neurohypophysial hormone found in most mammals, including humans. Vasopressin is a peptide hormone that controls the reabsorption of molecules in the tubules of the kidneys by affecting the tissue's...
hormone levels at night, signalling the kidneys to produce less urine. The diurnal change may not be seen until about age 10. - More severe neurological-developmental issues
Patients with mental handicaps have a higher rate of bedwetting problems. One study of seven-year-olds showed that "handicapped and mentally retarded children," had a bedwetting rate almost three times higher than non-handicapped children (26.6% vs. 9.5%, respectively). - Physical abnormalities
Less than 10% of enuretics have urinary tract abnormalities, such as a smaller than normal bladderBladderBladder usually refers to an anatomical hollow organBladder may also refer to:-Biology:* Urinary bladder in humans** Urinary bladder ** Bladder control; see Urinary incontinence** Artificial urinary bladder, in humans...
. Current data does support increased bladder tone in some enuretics, which functionally would decrease bladder capacity. - Psychological
Psychological issues (e.g., death in the family, sexual abuseSexual abuseSexual abuse, also referred to as molestation, is the forcing of undesired sexual behavior by one person upon another. When that force is immediate, of short duration, or infrequent, it is called sexual assault. The offender is referred to as a sexual abuser or molester...
, extreme bullying) are established as a cause of secondary nocturnal enuresis (a return to bedwetting), but are very rarely a cause of PNE-type bedwetting. Bedwetting can also be a symptom of a pediatric neuropsychological disorder called PANDAS. When enuresis is caused by a psychological or neuropsychological disorder, the bedwetting is considered a symptom of the disorder. Enuresis has a psychological diagnosis code (see previous section), but it is not considered a psychological condition itself. (See section on psychological/social impact, below) - Sleep apnea
Sleep apneaSleep apneaSleep apnea is a sleep disorder characterized by abnormal pauses in breathing or instances of abnormally low breathing, during sleep. Each pause in breathing, called an apnea, can last from a few seconds to minutes, and may occur 5 to 30 times or more an hour. Similarly, each abnormally low...
stemming from an upper airwayAirwayThe pulmonary airway comprises those parts of the respiratory system through which air flows, conceptually beginning at the nose and mouth, and terminating in the alveoli...
obstruction has been associated with bedwetting. SnoringSnoringSnoring is the vibration of respiratory structures and the resulting sound, due to obstructed air movement during breathing while sleeping. In some cases the sound may be soft, but in other cases, it can be loud and unpleasant...
and enlarged tonsils or adenoids are a sign of potential sleep apneaSleep apneaSleep apnea is a sleep disorder characterized by abnormal pauses in breathing or instances of abnormally low breathing, during sleep. Each pause in breathing, called an apnea, can last from a few seconds to minutes, and may occur 5 to 30 times or more an hour. Similarly, each abnormally low...
problems. - Sleepwalking
SleepwalkingSleepwalkingSleepwalking, also known as somnambulism, is a sleep disorder belonging to the parasomnia family. Sleepwalkers arise from the slow wave sleep stage in a state of low consciousness and perform activities that are usually performed during a state of full consciousness...
can lead to bedwetting. During sleepwalking, the sleepwalker may think he/she is in another room. When the sleepwalker urinatesUrinationUrination, also known as micturition, voiding, peeing, weeing, pissing, and more rarely, emiction, is the ejection of urine from the urinary bladder through the urethra to the outside of the body. In healthy humans the process of urination is under voluntary control...
during a sleepwalking episode, he/she usually thinks they are in the bathroom, and therefore urinate where they think the toilet should be. Cases of this have included opening a closet and urinating in it; urinating on the sofa and simply urinating in the middle of the room. - Stress
Stress is not a cause of primary nocturnal enuresis (PNE), but is well established as a cause of returning to bedwetting (secondary nocturnal enuresis). Researchers studying children who have yet to stay dry find "no relationship to social background, life stresses, family constellation, or number of residencies." On the other hand, stress is a cause of people who return to wetting the bed. Researchers find that moving to a new town, parent conflict or divorce, arrival of a new baby, or loss of a loved one or pet can cause insecurity, contributing to returning bedwetting.
Unconfirmed, controversial, or mixed causes
- Heavy sleeping
Many parents report that their bedwetting children are heavy sleepers. Research in this area has produced some contradictory results. Studies show that children wet the bed during all phases of sleep, not just the deepest (stage four, or stages three and four). A recent study, however, showed that enuretic children were harder to wake up. Some literature does show a possible connection between sleep disorders and ADHVasopressinArginine vasopressin , also known as vasopressin, argipressin or antidiuretic hormone , is a neurohypophysial hormone found in most mammals, including humans. Vasopressin is a peptide hormone that controls the reabsorption of molecules in the tubules of the kidneys by affecting the tissue's...
production. Insufficient ADH might make it more difficult to transition from light sleep to being awake. - Food allergies
For some patients, food allergiesFood allergyA food allergy is an adverse immune response to a food protein. They are distinct from other adverse responses to food, such as food intolerance, pharmacological reactions, and toxin-mediated reactions....
may be part of the cause. This link is not well established, requiring further researchResearchResearch can be defined as the scientific search for knowledge, or as any systematic investigation, to establish novel facts, solve new or existing problems, prove new ideas, or develop new theories, usually using a scientific method...
. - Improper toilet training
This is another disputed cause of bedwetting. This theory was more widely supported in the last century and is still cited by some authors today. Some say bedwetting can be caused by improper toilet trainingToilet trainingToilet training, or potty training, is the process of training a young child to use the toilet for urination and defecation, though training may start with a smaller toilet bowl-shaped device...
, either by starting the training when the child is too young or by being too forceful. Recent research has shown more mixed results and a connection to toilet training has not been proven or disproven. - Dandelions
Anecdotal reports and folk wisdom say children who handle dandelions can end up wetting the bed. Dandelions are reputed to be a potent diuretic. English folk names for the plant are "peebeds" and "pissabeds". In French dandelions are called pissenlit, which means "urinate in bed"; likewise "piscialletto", an Italian folkname, and "meacamas" in Spanish.
Psychological-social impact
A review of medical literature shows doctors consistently stressing that a bedwetting child is not at fault for the situation. Many medical studies state that the psychological impacts of bedwetting are more important than the physical considerations. "It is often the child's and family member's reaction to bedwetting that determines whether it is a problem or not."Impact on self-esteem
Whether bedwetting causes low self-esteem remains a subject of debate, but several studies have found that self-esteem improved with management of the condition.Children questioned in one study ranked bedwetting as the third most stressful life event, after parental divorce and parental fighting. Adolescents in the same study ranked bedwetting as tied for second with parental fighting.
Bedwetting children face problems ranging from being teased by siblings, being punished by parents, and being afraid that friends will find out.
Psychologists report that the amount of psychological harm depends on whether the bedwetting harms self-esteem or development of social skills. Key factors are:
- How much the bedwetting limits social activities like sleep-overs and campouts
- The degree of the social ostracism by peers
- Anger, punishment, and rejection by caregivers
- The number of failed treatment attempts
- How long the child has been wetting
Behavioral impact
Studies show that bedwetting children are more likely to have behavioral problems. For children who have developmental problems, the behavioral problems and the bedwetting are frequently part of/caused by the developmental issues. For bedwetting children without other developmental issues, these behavioral issues can result from self-esteem issues and stress caused by the wetting.As mentioned below, current studies show that it is very rare for a child to intentionally wet the bed as a method of acting out.
Historical psychological perspective on bedwetting
An early psychological perspective on bedwetting was given in 1025 by AvicennaAvicenna
Abū ʿAlī al-Ḥusayn ibn ʿAbd Allāh ibn Sīnā , commonly known as Ibn Sīnā or by his Latinized name Avicenna, was a Persian polymath, who wrote almost 450 treatises on a wide range of subjects, of which around 240 have survived...
in The Canon of Medicine
The Canon of Medicine
The Canon of Medicine is an encyclopedia of Galenic medicine in five books compiled by Ibn Sīnā and completed in 1025. It presents a clear and organized summary of all the medical knowledge of the time...
:
Psychological theory through the 1960s placed much greater focus on the possibility that a bedwetting child might be acting out, purposefully striking back against parents by soiling linens and bedding. (More recent research and medical literature states that this is very rare.)
Punishment for bedwetting: effects and rates
Medical literature states and studies show that punishing or shaming a child for bedwetting will frequently make the situation worse. Doctors describe a downward cycle where a child punished for bedwetting feels shame and a loss of self-confidence. This can cause increased bedwetting incidents, leading to more punishment and shaming.In the United States, about 25% of enuretic children are punished for wetting the bed. In Hong Kong, 57% of enuretic children are punished for wetting. Parents with only a grade-school level education punish bedwetting children at twice the rate of high-school- and college-educated parents.
Impact on families
Parents and family members are frequently stressed by a child's bedwetting. Soiled linens and clothing cause additional laundry. Wetting episodes can cause lost sleep if the child wakes and/or cries, waking the parents. A European study estimated that a family with a child who wets nightly will pay about $1,000 a year for additional laundry, extra sheets, disposable absorbent garments such as diapers, and mattress replacement.Despite these stressful effects, doctors emphasize that parents should react patiently and supportively.
Treatment and management options
There are a number of treatment and condition management options for bedwetting. The following options apply when the bedwetting is not caused by a specifically identifiable medical condition such as a bladder abnormality or diabetes.When treatment is recommended
Doctors consider treatment when there is a specific medical condition such as bladderBladder
Bladder usually refers to an anatomical hollow organBladder may also refer to:-Biology:* Urinary bladder in humans** Urinary bladder ** Bladder control; see Urinary incontinence** Artificial urinary bladder, in humans...
abnormalities, infection
Infection
An infection is the colonization of a host organism by parasite species. Infecting parasites seek to use the host's resources to reproduce, often resulting in disease...
, or diabetes. Physicians also treat bedwetting when it may harm the child's self-esteem
Self-esteem
Self-esteem is a term in psychology to reflect a person's overall evaluation or appraisal of his or her own worth. Self-esteem encompasses beliefs and emotions such as triumph, despair, pride and shame: some would distinguish how 'the self-concept is what we think about the self; self-esteem, the...
or relationships with family/friends. Only a small percentage of bedwetting is caused by a specific medical condition, so most treatment is prompted by concern for the child's emotional welfare. Behavioral treatment of bedwetting overall tends to show increased self esteem for children
Parents become concerned much earlier than doctors. A study in 1980 asked parents and physicians the age that children should stay dry at night. The average parent response was 2.75 years old, while the average physician response was 5.13 years old.
Punishment is not effective and can interfere with treatment.
Treatment options with high success rates
- Waiting
Almost all children will outgrow bedwetting. For this reason, urologists and pediatricians frequently recommend delaying treatment until the child is at least six or seven years old. Physicians may begin treatment earlier if they perceive the condition is damaging the child's self-esteem and/or relationships with family/friends.
- Bedwetting alarms
Physicians also frequently suggest bedwetting alarmBedwetting alarmA bedwetting alarm is an electronic device used as a treatment option for nocturnal enuresis. The alarm activates when the wearer urinates. Alarms come in several different styles: wearable alarms, wireless alarms, and pad-type alarms...
s which sound a loud tone when they sense moisture. This can help conditionClassical conditioningClassical conditioning is a form of conditioning that was first demonstrated by Ivan Pavlov...
the child to wake at the sensation of a full bladderUrinary bladderThe urinary bladder is the organ that collects urine excreted by the kidneys before disposal by urination. A hollow muscular, and distensible organ, the bladder sits on the pelvic floor...
. These alarms are considered effective, with study participants being 13 times more likely to become dry at night. There is a 29% to 69% relapse rate, however, so the treatment may need to be repeated. - DDAVP (desmopressin)
DesmopressinDesmopressinDesmopressin is a synthetic replacement for vasopressin, the hormone that reduces urine production. It may be taken nasally, intravenously, or as a tablet...
tablets are a synthetic replacement for antidiuretic hormoneVasopressinArginine vasopressin , also known as vasopressin, argipressin or antidiuretic hormone , is a neurohypophysial hormone found in most mammals, including humans. Vasopressin is a peptide hormone that controls the reabsorption of molecules in the tubules of the kidneys by affecting the tissue's...
, the hormone that reduces urine production during sleep. Desmopressin is usually used in the form of desmopressin acetate, DDAVP. Patients taking DDAVP are 4.5 times more likely to stay dry than those taking a placebo. The drug replaces the hormone for that night with no cumulative effect.
US drug regulators have banned using desmopressin nasal sprays for treating bedwetting, but say that desmopressin pills are still considered a safe bedwetting treatment for otherwise healthy patients. The regulators reviewed the drug after two adult nasal spray users died from hyponatremiaHyponatremiaHyponatremia is an electrolyte disturbance in which the sodium concentration in the serum is lower than normal. In the vast majority of cases, hyponatremia occurs as a result of excess body water diluting the serum sodium and is not due to sodium deficiency. Sodium is the dominant extracellular...
, an imbalance of sodium levels in the body.
- Tricyclic antidepressants
Tricyclic antidepressantTricyclic antidepressantTricyclic antidepressants are heterocyclic chemical compounds used primarily as antidepressants. The TCAs were first discovered in the early 1950s and were subsequently introduced later in the decade; they are named after their chemical structure, which contains three rings of atoms...
prescription drugPrescription drugA prescription medication is a licensed medicine that is regulated by legislation to require a medical prescription before it can be obtained. The term is used to distinguish it from over-the-counter drugs which can be obtained without a prescription...
s with anti-muscarinic properties have been proven successful in treating bedwetting, but also have an increased risk of side effects, including death from overdose. These drugs include amitriptylineAmitriptylineAmitriptyline is a tricyclic antidepressant . It is the most widely used TCA and has at least equal efficacy against depression as the newer class of SSRIs...
, imipramineImipramineImipramine , also known as melipramine, is an antidepressant medication, a tricyclic antidepressant of the dibenzazepine group...
and nortriptylineNortriptylineNortriptyline is a second-generation tricyclic antidepressant marketed as the hydrochloride salt under the trade names Sensoval, Aventyl, Pamelor, Norpress, Allegron, Noritren and Nortrilen. It is used in the treatment of major depression and childhood nocturnal enuresis...
. Studies find that patients using these drugs are 4.2 times as likely to stay dry as those taking a placeboPlaceboA placebo is a simulated or otherwise medically ineffectual treatment for a disease or other medical condition intended to deceive the recipient...
. The relapse rates after stopping the medicines are close to 50%.
Condition management options
- Absorbent Underwear
Absorbent underwear can reduce embarrassment for bedwetters and make cleanup easier for caregivers. These products are known as training pants when used for younger children, and as absorbent underwear when marketed for older children and adults. A major benefit is the reduced stress on both the bedwetter and caregivers. Absorbent underwear can be especially beneficial for bedwetting children wishing to attend sleepovers or campouts, reducing emotional problems caused by social isolation and/or embarrassment in front of peers. Extended diaper usage may interfere with learning to stay dry at night, at least in adults with severe disabilities.
- Waterproof mattress pads are used in some cases to ease clean-up of bedwetting incidents, however they only protect the mattress, and the sheets, bedding or sleeping partner may be soiled.
Unproven/ineffective treatment options
- Dry bed training
Dry bed training consists of a strict schedule of waking the child at night, attempting to condition the child into waking by himself/herself. Studies show this training is ineffective by itself and does not increase the success rate when used in conjunction with a bedwetting alarm. - Star chart
A star chart allows a child and parents to track dry nights, as a record and/or as part of a reward program. This can be done either alone or with other treatments. There is no research to show effectiveness, either in reducing bedwetting or in helping self-esteem. Some psychologists, however, recommend star charts as a way to celebrate successes and help a child's self-esteem.
Macdonald triad
Research has shown that bedwetting does not indicate a greater possiblity of being a sociopath, as long as caregivers do not cause trauma by shaming or punishing a bedwetting child. Bedwetting was part of the Macdonald triadMacdonald triad
The Macdonald triad is a set of three behavioral characteristics that are associated with sociopathic behavior. The triad was first identified by J.M...
, a set of three behavioral characteristics described by John Macdonald
John Macdonald (psychiatrist)
John Marshall Macdonald was a forensic psychiatrist most renowned for his discovery of the Macdonald triad of sociopathic traits and his profiling of serial killers. He published approximately a dozen books in his field.- Bibliography :*The murderer and his victim...
in 1963. The other two characteristics were firestarting and animal abuse. Macdonald suggested that there was an association between a person displaying all three characteristics, then later displaying sociopathic
Psychopathy
Psychopathy is a mental disorder characterized primarily by a lack of empathy and remorse, shallow emotions, egocentricity, and deceptiveness. Psychopaths are highly prone to antisocial behavior and abusive treatment of others, and are very disproportionately responsible for violent crime...
criminal behavior.
Research has found that, however, that enuresis is not associated with sociopathic behavior. Enuresis is an “unconscious, involuntary, and nonviolent act and therefore linking it to violent crime is more problematic than doing so with animal cruelty or firesetting".
Bedwetting can be connected to emotional or physical trauma. Trauma can trigger a return to bedwetting (secondary enuresis) in both children and adults. In addition, caregivers cause some level of emotional trauma when they punish or shame a bedwetting child.
This leads to a difficult distinction: it is not the bedwetting that increases the chance of criminal behavior, but the trauma. For example, parental cruelty can result in "homicidal proneness".