Bed-wetting! One of the concerns often brought to the Paediatricians by mothers!
It seems next to the issue of teething and poor eating, concerns about bed-wetting ranks as the third most common questions mothers ask the Paediatricians.
Dr Adaobi Solarin, Consultant Paediatric Nephrologist addresses the issue of bed-wetting in children in a recent Group Discussion on Ask The Paediatricians Group recently. The essential highlights of that discourse are summarised in this article.
Bladder only does two things. It likes to fill up with pee and store it for you until you are ready to go to the toilet. This is what the bladder should do most of the time. The Bladder fills first with urine and when the bladder is half full, there is a first desire to pass urine (micturate) but most people will through the brain inhibits the process until they are at the right place and time to pass urine. There is a sphincter or tap that control the release of urine when the person is ready by relaxing so the urine can flow out. When the person is ready, the bladder will empty. The tap at the bottom has to open nicely and the muscle in the bladder squeezes all the pee out so none is left behind.
Bedwetting is also called ENURESIS when it happens at night. Enuresis means recurrent, spontaneous urination during sleep in children aged at least 5 yrs. of age. By age 5 yrs. a child is normally able to avoid at will and to postpone voiding in a socially acceptable manner.
It is a common disorder that affects 15 – 20% of 5 yr old kids and 5 – 10% of 7yr olds. There is a higher prevalence in boys than in girls by a ratio of 2:1. It is a hereditary disorder that runs in some families with an autosomal dominant pattern of inheritance. If either parent had enuresis the relative risk for the child to have enuresis is 7.8; if both parents had enuresis the relative risk is 16. Children with developmental delay, mental retardation, Attention deficit hyperactivity disorder (ADHD) and minor neurological dysfunction have a higher prevalence of bed-wetting compared to other children.
Apart from hereditary, it can occur as a result of three major mechanisms:
- Nocturnal Polyuria (too much urine in the bladder at night)
- Detrusor overactivity (the bladder muscle working too much)
- Increased arousal thresholds ( a problem at the brain that does not make the child wake up on time) Common disturbance at brainstem level.
Enuresis or Bed-wetting can be classified in many ways.
Primary Enuresis: no specific cause in a child who has not been dry for less than 6 months
Secondary Enuresis: due to other diseases in a child who has been previously dry for at least 6 months.
Monosymptomatic Enuresis: Enuresis without any other Lower Urinary Tract symptoms (LUT)
Non-monosymptomatic Enuresis: Enuresis with other LUT symptoms, e.g. daytime incontinence, urgency, frequency, weak stream, straining
The secondary Causes of Enuresis include Urinary tract infection, Constipation, Pinworm infection, Diabetes Mellitus, Diabetes Insipidus, Psychological stress and Chronic Renal failure.
HOW DO DOCTORS HANDLE CHILDREN WHO HAVE ENURESIS (BED-WETTING)
In managing a child with enuresis, the first thing doctors do is to ask questions. Some of these questions that are important you will be asked include the family history of bedwetting; has the child always bed-wet or there is a preceding dry period; nocturia – every night or occasionally, the child’s drinking habits and sleeping patterns.
After the questions, the child will be examined physically. This includes the Ear, Nose and Throat (ENT) examination for adenotonsillar hypertrophy; Abdominal palpation for renal masses and faecal mass; the external genitalia (phimosis, hypospadias); the spine for deformation, pigmentation, hair growth and neurological examination. Finally, Urine is tested with a dipstick for the presence of sugar, protein and white blood cells that may help rule out Diabetes mellitus, renal disease and urinary tract infection.
TREATMENT OF ENURESIS
• Primary mono-symptomatic enuresis resolves with time.
• Medication is rarely indicated in children younger than 6 yrs of age.
• The first step is to educate the child and family.
• Before primary nocturnal enuresis is treated, daytime symptoms must be actively identified and managed.
• Secondary causes like urinary tract infection must be investigated and managed appropriately.
GENERAL MEASURES (for Parents)
- Bladder retraining
- Regular fluid intake: 30ml of water/kg each day, mostly at school
- Minimise evening fluid and solute intake
- Timed regular voiding: voiding regularly, At least two or three times during school hours
- Correct toilet position: Relax the pelvic floor muscles
- Treat constipation: Fluids, higher fibre intake
- Encourage physical activities
TREATMENT
When general measures do not lead to resolution of symptoms, then the child should be seen by the Paediatric Nephrologist, the Paediatrician with expertise in managing kidney and urinary problems in children.
Some of the modes of treatment used by the Nephrologists include the use of alarms and medications such as Desmopressin and imipramine. These medications must be prescribed by your doctors and you must be conversant with their potential side effects.
All children with daytime wetting (not the wets during an afternoon nap but otherwise dry) MUST see their paediatrician for appropriate evaluation and referral to the nephrologist.
In conclusion, most bed-wetting with no cause will resolve with general measures. Bed-wetting that are due to other causes will resolve with treatment of the underlying causes. If there is no improvement with simple and general measures, it is important to see a Paediatric nephrologist for further evaluation and treatment.