Bedwetting: cause of peeing in bed and unlearning bedwetting

Bedwetting (nocturnal enuresis) is a common problem. How can you stop bedwetting in children? Most children are dry at night when they are about 6 or 7 years old. Both parents and children become somewhat dismayed when bedwetting continues into school age. Yet in the Netherlands, more than 100,000 children over the age of 6 regularly suffer from bedwetting. It turns out that the timing of toilet training is partly hereditary. Bedwetting is difficult: it requires extra laundry and older children can become ashamed of it. Parents should realize that bedwetting does not happen intentionally. The child who wets the bed needs support and reassurance from the parents. Bedwetting is easily treatable and a child can unlearn it with good support. Various devices, treatments and techniques have been developed to keep bedwetters dry at night.

  • What is bedwetting?
  • When does bedwetting occur?
  • Cause of bedwetting
  • Forms of bedwetting
  • Primary bedwetting
  • Secondary bedwetting
  • Urinary tract infection
  • Diabetes
  • Structural or anatomical abnormality
  • Neurological problems
  • Emotional problems
  • Obstructive sleep apnea syndrome (OSAS)
  • Pinworms
  • Excessive drinking
  • Symptoms of bedwetting
  • How common is bedwetting?
  • How to stop bedwetting in children: tips and training
  • Calmness and patience
  • Do not wear diapers from age 3
  • Motivation
  • Preventively wake up / get out of bed
  • Calendar method
  • Motivation method
  • Bedwetting alarm
  • Bladder training ( retention control training )
  • Medicines
  • Call in your GP
  • Prognosis

 

What is bedwetting?

The medical term for bedwetting is nocturnal enuresis . Enuresis means involuntary urination or bladder emptying and nocturna stands for nighttime. Most children make the transition to nighttime toilet training at the age of 4 to 5, but there are also children who start a little later. If a child becomes toilet trained at a later age, it often turns out that one of the parents was not involved early. The moment at which a child becomes toilet-trained is partly determined by genetics. Bedwetting is part of life and is only seen as a problem when the children are older than five or six years old.
Insecurity and shame
It can be very annoying to have to wash wet sheets and pajamas again and again. It can also be difficult for the child itself , especially if he or she is older. The bedwetter can become very insecure and ashamed of it. Especially when the immediate environment reacts negatively to the urinary problems. Bedwetting can also have a negative impact on social life. The older bedwetter becomes ashamed of it and does not dare to stay with friends for fear of nighttime ‘accidents’. School camps are totally a problem; the child is afraid that others will find out and squeeze him or her with it. The older the bedwetter is, the more important this aspect plays a role. These may be reasons to give the natural learning process a helping hand from the age of 6.

When does bedwetting occur?

Nocturnal enuresis is diagnosed when a child aged 5 or 6 years wets the bed at least twice a week at night during the last three months or when a child aged 7 years or older wets the bed at night at least once a month. .¹ A distinction is made between primary and secondary nocturnal enuresis. Primary nocturnal enuresis is present from birth and secondary nocturnal enuresis represents the situation in which a child wets the bed again after a period of at least six months of toilet training.

Cause of bedwetting

Halfway through the second year of life, the child’s autonomic and voluntary nervous system has developed to such an extent that it senses that the bladder is full and that it needs to urinate. Children need to learn to control their bladder. Controlling the pelvic floor muscles is also necessary for toilet development and this is a maturation process. In principle, all conditions for toilet training are present from about the age of four. It is partly a learning process and for some children toilet training is easier than for others. Children with delayed development take longer than average.
Familial occurrence
Nocturnal enuresis has a familial occurrence; In a large number of children, the parents also suffered from nocturnal enuresis as children. There also appears to be a genetic component. Many children with nocturnal enuresis have not yet learned to be aware of a full bladder and an urge to urinate at night. When a full bladder is present, a signal is sent to the brain. Children must learn to pick up this signal at night, so that they wake up during sleep. During the day the child is much more aware of this process. That is why a child is usually toilet trained earlier during the day than at night. The main cause of nocturnal enuresis is an inadequate wake-up response to a full bladder.² The idea that bedwetting children sleep too deeply is based on a misunderstanding. A child also does not wet the bed because he or she drank too much in the evening.
Factors that play a role
It is difficult to say why a child wets the bed at night. These often concern normal children from normal families. It is important to keep in mind that the age of dryness shows variation in normal development. Just as children learn to crawl and walk at different ages, they also become dry at night at different ages. Factors that can play a role in bedwetting are the following:

  • Constipation. Hard stools in the rectum can put pressure on the bladder.
  • Emotional factors. Bedwetting often increases with tension and anxiety. For example, when parents divorce, when a family member or pet dies or when they are bullied at school or in the neighborhood.
  • Urinary tract infection. This is a common cause of bedwetting in children who were previously toilet trained (secondary nocturnal enuresis).
  • In some cases, improper toilet training is the cause. Positive stimuli (and not punishment or threats of punishment) promote toilet training.

A deficiency of antidiuretic hormone (ADH) does not appear to be a significant causal factor in bedwetting.

Forms of bedwetting

Two types of bedwetting are distinguished: primary and secondary. Primary bedwetting refers to bedwetting that has persisted without interruption since childhood. A child with primary bedwetting has never been dry for a long time at night. Secondary bedwetting is bedwetting that starts again after the child has been dry at night for a long period of time (at least six months).

Primary bedwetting

In general, primary bedwetting probably indicates immaturity of the nervous system. A child who wets the bed does not recognize the feeling of a full bladder during sleep and therefore does not wake up during sleep to go to the toilet. The cause is likely due to one or a combination of the following:

  • The child cannot hold urine all night long.
  • The child does not wake up when his or her bladder is full. Some children have a smaller bladder volume than their peers.
  • The child produces a large amount of urine during the evening and night hours.
  • The child has poor toilet habits during the day. Many children ignore the urge to delay urination as long as possible.

 

Secondary bedwetting

Secondary bedwetting can be a sign of an underlying medical or emotional problem. The child with secondary bedwetting is much more likely to have other symptoms, such as pants-wetting. Common causes of secondary bedwetting include:

Urinary tract infection

A urinary tract infection can cause bladder irritation, lower abdominal pain or soreness, irritation or burning when urinating (dysuria), an increased urge to urinate and frequent urination. A urinary tract infection in children can in turn indicate another problem, such as an anatomical abnormality.

Diabetes

People with type 1 diabetes have high levels of sugar (glucose) in their blood. The body increases urine production due to excessive blood glucose levels. Frequent urination is a common symptom of diabetes.

Structural or anatomical abnormality

An abnormality in the organs, muscles or nerves involved in urination can cause urinary incontinence or other urinary problems including bedwetting.

Neurological problems

Abnormalities in the nervous system, or injuries or disorders of the nervous system, can affect urination.

Emotional problems

A stressful home situation, such as living with parents who are constantly fighting each other or where abuse occurs, can lead to children wetting the bed. Major changes, such as starting school for the first time, having a new brother or sister, or moving to a new home, are other stressors that can also trigger bedwetting. Children who are physically or sexually abused sometimes also start wetting the bed.

Obstructive sleep apnea syndrome (OSAS)

Obstructive sleep apnea syndrome (OSAS) is a sleep-related breathing disorder in which your body stops breathing during sleep. OSAS can be associated with bedwetting.

Adult pinworms / Source: Public domain, Wikimedia Commons (PD)

Pinworms

Pinworms (enterobiasis) are small worms that can appear in the feces. Children can sometimes start to wet the bed due to a worm infection. Pinworms can irritate the urethra, which can lead to bedwetting.

Excessive drinking

Excessive drinking increases urine production and predisposes a child to bedwetting. Sometimes tea, coffee and energy drinks/carbonated drinks also cause bedwetting.

Symptoms of bedwetting

Bedwetters wet the bed during sleep. This leads to soaked sheets and pajamas. This can be accompanied by feelings of shame and guilt. Bedwetting can lead to low self-esteem. Secondary bedwetting may be accompanied by other symptoms depending on the underlying cause.

How common is bedwetting?

Figures on the prevalence of nocturnal enuresis vary widely. This depends on the research method used, the population studied and the definition used. A study with children between 4 and 16 years old, with the definition ‘wet two or more nights per month in the past six months’, shows the following picture. The prevalence in boys aged 4 to 7 years was 12% and in girls aged 4 to 7 years 8%. In 8 to 11 year olds, the prevalence had fallen to 7 and 4% respectively.³
Boys suffer from nocturnal enuresis more often than girls. It also lasts longer in boys. Nocturnal enuresis occurs approximately twice as often in children of Turkish or Moroccan descent than in children of Dutch descent. No good explanation for this has been found so far.

How to stop bedwetting in children: tips and training

Calmness and patience

The child who wets the bed is best treated with calmness and a lot of patience, even though it is very annoying to have to wash wet sheets and pajamas and change the bed again and again. Punishing or threatening punishment is counterproductive. Bedwetting does not happen on purpose. Keep in mind that children who wet the bed have not yet learned to become aware of the urge to urinate at night. Continue to approach the child in a positive and friendly manner, but explain that the intention is for the bed to remain dry. So don’t say that bedwetting is not a problem, because then the need to stay dry disappears. Praise the child if he/she stayed dry overnight. It may be useful to have the child help change the bed as soon as he or she is able to do so. In this way, he/she becomes more involved in the process of getting through the night dry.

Do not wear diapers from age 3

Do not allow children older than 3 years to wear diapers; a child wearing a diaper may experience bedwetting as a matter of course. Make sure you have a good mattress protector. It is neither wise nor useful to let the child drink less in the evening; it does not lead to faster drying. However, it is a good habit to let the child go to the toilet before going to sleep. Caffeinated drinks have a stimulating effect on urine production. These are therefore not recommended for the evening.

Motivation

Over the years, all kinds of methods have been devised to help children get rid of bedwetting. Experience shows that the child must be at least 6 years old to tackle the problem. But the most important key to success is that the child is motivated. Furthermore, it is advisable to continue with a chosen method consistently for several months. The most important methods to stop bedwetting are:

Preventively wake up / get out of bed

This method is used by many parents/guardians (for children up to 6 years old). It is agreed in advance with the child that he/she will be woken up at a specific time. The child is woken up quietly at the indicated time, after which the child is allowed to walk to the toilet to urinate. Do not wake the child more than once per night. If it turns out that the child is already wet when he/she is admitted, make sure that he/she is woken up the next night fifteen minutes earlier than the night before. Continue this until the time is found when the child is still dry. Remember that the child is not woken up earlier than an hour and a half after falling asleep. If the child remains dry for several nights in a row, do not wake him/her up again. This way you can see whether it remains dry without recording. The objection raised against this method is that the child does not learn to wake up when the bladder is full.

Calendar method

This is a method in which the child is rewarded. In practice it appears to work well. It is suitable for children up to 8 years old. The parent or caregiver makes a calendar sheet with the child with one box per day. When the child wakes up dry in the morning, he/she can color, draw or sticker one box. However, if the child has wet the bed, no box is colored in. After ten boxes the child is rewarded. The reward and the number of days it must be dry are agreed in advance with the child. This reward provides an extra incentive for the child to stay dry. If this method does not work well, you should not continue with it for too long. Continuing fruitlessly is frustrating and demotivating, for both parent and child.

Motivation method

The motivation method is applied to older children (up to 12 years old). Encourage the child to stay dry by giving him a present (a so-called ‘motivator’) when he is dry.

Bedwetting alarm

The bedwetting alarm is an effective method to get rid of bedwetting. The method has been tested and the success rate is approximately 70%. Using the bedwetting alarm, the child learns to wake up when the bladder gives a signal that it is full. This is done using special pants that contain a moisture sensor, which is connected to a bedwetting alarm. When the child loses the first drops of urine, the bedwetting alarm goes off. The child is promptly awakened and the urine is reflexively held. The alarm can be turned off, after which he/she finishes urinating in the toilet. The system is very sensitive. Even one drop will ring a bell. The method can be applied to children from the age of 5.

Bladder training ( retention control training )

There are children who have to urinate more than eight times during the day. Then it could be that they have a somewhat tight bladder. A tight bladder fills quickly, even at night. By holding the urine a little longer during the day. the child can also stay dry a little longer at night. There is some debate about the effect of this method.

Medicines

Drug therapy can reduce nocturnal urine production. They are preferably not used for a long period of time, but they can provide a solution if the child is staying over or participating in a summer or school camp.

Call in your GP

If you suspect a physical abnormality or underlying condition such as a urinary tract infection, always consult your GP.

Prognosis

Most children outgrow bedwetting when they are about 7 years old. At this age, bladder control is stronger and more fully developed. Lifestyle changes , medical treatment, and support from family and friends can help children and adults overcome bedwetting.
Notes:

  1. Dr. JAH Eekhof, Dr. A. Knuistingh Neven, Dr. W. Opstelten: Minor ailments in children. Elsevier Healthcare, Maarssen, second edition 2009, p.570.
  2. Ibid, p.571.
  3. Verhulst FC, Van der Lee JH, Akkerhuis GW, Sanders-Woudstra JA, Donkhorst ID. The prevalence of enuresis in children aged 4-16 years: an epidemiological study. Ned Tijdschr Geneeskd 1985;129:2260-3.

 

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