BED WETTING – NOCTURNAL ENEURESIS
Dr. Vivek M. Rege
Pediatric Surgeon & Pediatric Urologist
B J Wadia Hospital For Children, Hurkisondas Hospital, Wockhardt Hospital, Mumbai
This is a common condition occurring in some children. Bedwetting at night during sleep in a child above the age of 4 years is considered abnormal and called Nocturnal Eneuresis. Originally it was always thought that the cause is psychological but today it is known that there may be more than one reason for this anomaly.
There are 2 classifications of this condition. The first is Primary and Secondary nocturnal eneuresis. Primary nocturnal eneuresis is when the child has been bed wetting since younger days and continues to do so even after 4 years. Secondary nocturnal eneuresis is when the child had stopped bedwetting for a continuous period of at least 6 months and again begins bed wetting. This is important for the possible cause and also the treatment of this condition. The second classification has also 2 types, one is Isolated nocturnal eneuresis – here the bedwetting is the only problem in micturition in the child. The other type is nocturnal eneuresis with dysfunctional voiding symptoms- here , besides having bedwetting, the child has other daytime complaints like frequency, urgency, hesitancy in passing urine. Again, the importance is in the cause and the therapy to be recommended for that particular child.
Why does a child have nocturnal eneuresis? There may be multiple reasons like – a small functional capacity of the urinary bladder – the amount of urine that a bladder can hold without discomfort to the child or the child having to evacuate the bladder for relief; a delay in maturation of the development of the bladder growth, the nerves to and from the bladder; deep sleeper with difficulty in arousing the child from sleep, thus causing the child to pass urine in deep sleep unaware of the problem; abnormal intermittent contractions of the bladder muscle causing evacuation of the bladder before it is full; or improper secretion of a hormone in the body at night. This hormone decreases the volume of urine excreted at night, and less filling of the bladder, if there is a deficiency of this hormone, the kidneys throw out a lot of urine at night that fills the bladder and urine is passed out at night. There is a very strong hereditary role in transmission of the condition. There is a very high chance of occurrence in a child with both parents who were nocturnal eneuretics, lessor in those with one parent , and about 15% in a child whose parents were normal too. Race may also have a role to play.
Such a child must be shown to a properly trained doctor if bed wetting continues beyond the age of 4 years. A detailed history and a thorough examination followed by relevant investigations are a must to get to the root cause of the condition. In some children a whole lot of investigations are required, in others very few need be done.
Treatment is begun after taking the child into full confidence ensuring full cooperation and involvement. Parents must realize that getting angry or ridiculing the child alone or in front of relatives or friends is the worst thing to do. No child purposely likes bedwetting, and thus understanding, empathy and emotional support is most important for getting early and excellent results. Treatments are of different types like: behavior modification; bio feedback; use of alarms; selective and supervised use of drugs and a prolonged but regular follow up for 3 years at least. Begin with simple things like stop drinking water or liquids about 3 hours before going to bed. Child is advised to pass urine completely during the day with increased frequency like 6 times or so. Pass urine fully just before bed. Use of an alarm clock to wake the child 4 hours after going to bed and make the child pass urine in the bathroom daily for a few months till the child is able to get up on his/her own. Use of the hormone drug – Desmopressin in selected cases will decrease the volume of urine formed at night and avoid wet nights. This drug is continued for long periods with gradual tapering off. This drug can be given thru a nasal spray and the dose needs to be adjusted. Children who have an unstable bladders, that contracts intermittently drugs like Oxybutynin help in correction and normalization of the bladder function. A note of caution here is that proving this abnormality requires a thorough Urodynamic study on the child before starting the therapy and a follow up is essential. The child being actively involved in each step of the therapy and the result acts as an incentive for a rapid improvement and rise in self esteem of the child. The improvement will be sustained with a regular follow up and pep talks to the child from time to time – to keep it up. The therapy of this condition depends on understanding, and a total involvement of the patient, doctor and the parents to give the best results.
Last Updated: 27th January 2009