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Bedwetting in childhood: epidemiology, pathophysiology, and treatment

Enuresis, as defined by the International Children's Continence Society, is the occurrence of urinary incontinence during sleep.1,2 Bedwetting (i.e. occurs at least twice a week) is a common childhood condition affecting approximately 5–10% of children aged between 5 and 7 years.3–6 The prevalence of bedwetting decreases with age, but approximately 1% of bedwetters continue to do so in adulthood.7,8 Bedwetting is twice as common in boys as in girls; for example in the UK, the prevalence of bedwetting at least 3 times a week ranges from 5–10% in 9-year-old girls to 15–22% in 7-year-old boys.8

The pathophysiology of enuresis is complex and involves the central nervous system (several neurotransmitters and receptors), circadian rhythm (sleep and diuresis), and bladder dysfunction.4 Most often, enuresis results from a high arousal threshold (i.e. the child does not awaken to void when the bladder is full) combined with either nocturnal polyuria (i.e. over-production of urine at night) or nocturnal detrusor overactivity (and, therefore, reduced bladder capacity), or both.4,6

Impact of nocturnal enuresis on the child and family
 

The impact of bedwetting on a child and family is often underestimated and trivialised,8 yet bedwetting has a significant influence on a child’s cognitive functioning and psychosocial well-being, with negative consequences for daytime functioning (including school performance), self-esteem, and interactions with peers.4,7,9,10 Anxiety about bedwetting may exclude the child from group activities (e.g. sleepovers, school trips) and discourage parents from taking the child on long journeys (e.g. flights, long drives) to visit friends and family or to take a holiday.4,7,9

For parents of an enuretic child, the stress and frustration of dealing with the impact of bedwetting (e.g. changing bed sheets, bathing the child) may lead to intolerance and punitive behaviour.3–5,8 Although more than 50% of enuretic children or their parents are significantly concerned about the impact of bedwetting on their life,3 many parents are reluctant to consult a healthcare professional about the problem and delay doing so for approximately 1–3 years.5,9 This reluctance to seek help may be partly due to a lack of awareness about the causes of enuresis and availability of treatment. Indeed, many parents try lifestyle changes (e.g. waking the child to void and restricting fluid intake before bedtime) before seeking medical help.3,5,9

Prompt diagnosis and treatment are key
 

Bedwetting has long been considered a simple condition that resolves spontaneously, but this is not necessarily the case.4,7 Untreated, nocturnal enuresis may have adverse effects on neuropsychological functioning in the developing child.4 It is therefore important that affected families can discuss the problem with a healthcare professional without feeling embarrassed or guilty.11

Successful treatment of enuresis relieves the emotional burden on the child and improves the child’s daytime functioning, including social and school performance.12 Treatment can also prolong the crucial period of undisturbed sleep.12

To find out more about available and future treatment options, visit the Publications section of the Bedwetting Resource Centre.

Guidelines are available to help healthcare professionals diagnose and treat bedwetting.4,6,8,11,13,14 In many cases, monosymptomatic enuresis (i.e. that occurring with no other lower urinary tract symptoms and no history of bladder dysfunction) can be effectively treated by education about its causes and management, with advice on eating, drinking, and toileting habits; a suitable treatment can be prescribed on the basis of an appropriate evaluation, perhaps with a voiding diary.4

Depending on the preference and motivation of the parents and child, first-line treatment may consist of an enuresis alarm or desmopressin (or both).4,6 Desmopressin is a synthetic analogue of the antidiuretic pituitary hormone vasopressin, lack of which is thought to underlie nocturnal polyuria.4,6 Desmopressin has an anti-diuretic action that reduces urine production and increases urine concentration; it inhibits bladder contractions and enhances arousability.8 If treatment with desmopressin fails, an anticholinergic drug may be tried.6,8,15

For more treatment guidelines, visit the Bedwetting Resource Centre’s Guidelines section. Other useful information about nocturnal enuresis can be found in the Practical Tools section of the Bedwetting Resource Centre.

About World Bedwetting Day
 

To raise awareness among the public and healthcare professionals that bedwetting is a common medical condition that can and should be treated, the International Children’s Continence Society (ICCS) and the European Society of Paediatric Urologists (ESPU) launched the first World Bedwetting Day in 2015.11 In 2016, World Bedwetting Day is Tuesday 24 May, and thereafter it will be held annually on the last Tuesday of May. World Bedwetting Day is supported by the World Bedwetting Day Steering Committee, a working group led by the ICCS and the ESPU and comprising patient and professional groups from around the world.

The theme of World Bedwetting Day – ‘Time to Take Action’ – is an encouragement to healthcare professionals to do more to diagnose and treat nocturnal enuresis in children.

The initiative is supported by an unrestricted educational grant from Ferring Pharmaceuticals.

For more information please visit www.worldbedwettingday.com.

References
 

1. Austin PF, Bauer SB, Bower W, et al. The standardization of terminology of lower urinary tract function in children and adolescents: update report from the Standardization Committee of the International Children’s Continence Society. J Urol. 2014;191:1863-5.e13.

2. Austin PF, Bauer SB, Bower W, et al. The standardization of terminology of lower urinary tract function in children and adolescents: Update report from the standardization committee of the International Children’s Continence Society. Neurourol Urodyn. 2016;35:471-81.

3. Lee SD, Sohn DW, Lee JZ, Park NC, Chung MK. An epidemiological study of enuresis in Korean children. BJU Int. 2000;85:869-73.

4. Vande Walle J, Rittig S, Bauer S, et al. Practical consensus guidelines for the management of enuresis. Eur J Pediatr. 2012;171:971-83.

5. Schlomer B, Rodriguez E, Weiss D, Copp H. Parental beliefs about nocturnal enuresis causes, treatments, and the need to seek professional medical care. J Pediatr Urol. 2013;9:1043-8.

6. Nevéus T. Nocturnal enuresis-theoretic background and practical guidelines. Pediatr Nephrol Berl Ger. 2011;26:1207-14.

7. NHS Choices. Bedwetting. Available from www.nhs.uk/Conditions/Bedwetting/Pages/Introduction.aspx. Published 14 April 2015. Accessed 9 May 2016.

8. Nathan D, Balain J, Evans J. Nocturnal enuresis guideline. Available from www.nuh.nhs.uk/handlers/downloads.ashx?id=61094. Published February 2014. Accessed 9 May 2016.

9. Joinson C, Heron J, Butler R, et al. A United Kingdom population-based study of intellectual capacities in children with and without soiling, daytime wetting, and bed-wetting. Pediatrics. 2007;120:e308-16.

10. Theunis M, Van Hoecke E, Paesbrugge S, Hoebeke P, Vande Walle J. Self-image and performance in children with nocturnal enuresis. Eur Urol. 2002;41:660-7; discussion 667.

11. Hjalmas K, Arnold T, Bower W, et al. Nocturnal enuresis: an international evidence based management strategy. J Urol. 2004;171:2545-61.

12. Van Herzeele C, Dhondt K, Roels SP, et al. Desmopressin (melt) therapy in children with monosymptomatic nocturnal enuresis and nocturnal polyuria results in improved neuropsychological functioning and sleep. Pediatr Nephrol Berl Ger. April 2016.

13. Vande Walle J, Rittig S, Bauer S, Eggert P, Marschall-Kehrel D, Tekgul S. Erratum to: Practical consensus guidelines for the management of enuresis. Eur J Pediatr. 2012;171:1005.

14. Vande Walle J, Rittig S, Bauer S, Eggert P, Marschall-Kehrel D, Tekgul S. Erratum to: Practical consensus guidelines for the management of enuresis. Eur J Pediatr. 2013;172:285.

15. Tu ND, Baskin LS. Nocturnal enuresis in children: management. UpToDate®. Available from www.uptodate.com/contents/nocturnal-enuresis-in-children-management?topicKey=PEDS%2F2863&elapsedTimeMs=10&view=print&displayedView=full. Published 2 March 2016. Accessed 9 May 2016.


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Consensus Guidelines

Practical consensus guidelines for the management of enuresis. 
Evaluation and management of enuresis, a common condition, is not a priority in training programs for medical doctors (MDs), despite being a common condition.