Bed-Wetting in Children

Cause

Almost all children who wet the bed do not do so intentionally. Most likely, several things are involved when a child older than age 5 continues to wet the bed. Possible causes of primary nocturnal enuresis include:

• Delayed development. Children with a less mature nervous system may not be as able to sense when the bladder is full.
• Small bladder capacity. Having a smaller-than-normal bladder may make some children more prone to wet the bed.
• Too little antidiuretic hormone (ADH). Levels of antidiuretic hormone (ADH), a brain chemical that signals the kidneys to release less water, normally rise at night. Some children who wet their beds may not produce more ADH at night.
• Sound sleeping. Many parents note that their child who wets the bed is a deep sleeper. These children usually wet the bed less often as their sleep patterns mature.
• Psychological and social factors. Bed-wetting does not appear to be a direct result of emotional problems. In fact, bed-wetting may be the cause of some emotional problems for children. But children living in stressful home situations or in institutions may be more likely to wet the bed.

Some of these things may be inherited. A child is at increased risk for wetting the bed if one or both parents has a history of bed-wetting as a child.

Most cases of primary nocturnal enuresis are not caused by any medical condition. But secondary nocturnal enuresis, which is bed-wetting that occurs after a period of staying dry, is more likely to be related to a medical condition. Examples of physical causes include a kidney or bladder infection (urinary tract infection) or birth defects that affect the urinary tract. Emotional stress, such as may result from the birth of a brother or sister, can also be something that triggers bed-wetting.

Symptoms

Bed-wetting is not a disease, so it has no symptoms. For a child who has never had nighttime bladder control for more than 3 months, overcoming this problem is usually a matter of normal development.

If a child has other symptoms, such as crying or complaining of pain when urinating, sudden strong urges to urinate, or increased thirst, bed-wetting may be a symptom of some other medical condition. Call the doctor if your child has any of these symptoms.

What Happens

Bed-wetting is common in young children. Children grow and develop at different rates, and bladder control is achieved at an individual pace. Usually, daytime bladder control occurs before nighttime control.

Children may wet the bed several times during the night, and they may not wake up after wetting.

Primary nocturnal enuresis —bed-wetting that continues past the age that most children have nighttime bladder control—will usually stop over time without treatment. If a medical condition is causing the bed-wetting, treating the condition may stop the wetting.

Treatment often does not completely stop bed-wetting, but it may reduce how often it occurs. Although bed-wetting may return when treatment is stopped, repeating or combining treatments may have longer-lasting results.

Sometimes bed-wetting is related to emotional stress. Bed-wetting usually stops when the stress is relieved or managed.

The emotional responses to bed-wetting can impact the relationship with your child. If you or your child is having difficulty with handling bed-wetting, you may wish to find out about treatment options.

Some children who wet the bed also experience accidental daytime wetting. When wetting occurs during both the day and night, usually the things related to the daytime wetting are explored first.

What Increases Your Risk

Children who develop at a slower rate than other children during the first 3 years of life have an increased likelihood of wetting the bed. Boys tend to develop more slowly, so they are more likely than girls to wet the bed.

A child may inherit the tendency to wet the bed.

When To Call

Call your doctor if:

• Your child has signs of a bladder or kidney infection such as:
  • Cloudy or pink urine or bloodstains on underclothes.
  • Urinating more often than usual.
  • Crying or complaining when urinating.
  • Back pain.
  • Belly pain.
  • Fever.
• Your child age 4 or older is wetting the bed and is leaking stool. The child may have stool blocking the intestines, caused by having constipation over a period of time.
• Your child wets the bed more often while you are using home treatment for bed-wetting.
• Your child age 5 or older has never had bladder control for more than 3 months in a row after trying home treatment, and it is causing problems at school or in the child's relationships with family and friends.
• Your child who has had bladder control for at least 3 months has begun to wet the bed, and this has happened more than a few times.

Watchful waiting

Watchful waiting is okay if bed-wetting is not affecting how your child is doing with schoolwork or getting along with peers or family. Most children develop complete bladder control even without treatment. Home treatment may be all that is needed to help the child learn bladder control.

Watchful waiting may not be a good choice if bed-wetting starts after a child has had bladder control for a period of time. Look for possible stresses that might be causing the bed-wetting. Bed-wetting may stop when your child's stress is relieved or managed. If it doesn't, your child should see a doctor.

Exams and Tests

Any child beyond age 6 or 7 who continues to wet the bed may need to be evaluated by a doctor. The evaluation should include a urinalysis.

A medical history and a physical exam are also part of a medical evaluation of bed-wetting. If you are having your child evaluated for bed-wetting, keep a diary for a week or two before your visit. Write down when wettings occur and how much urine is released.

In some cases, further testing may be needed. Tests may include:

• A urine culture to find out if your child has a bladder or kidney infection.
• Psychological testing, if emotional stress is suspected.

If a child has uncontrollable wetting both at night and in the day, other tests may need to be done.

Treatment Overview

Most children gain bladder control over time without any treatment. Bed-wetting that continues past the age that most children have nighttime bladder control—typically at 5 or 6 years of age—also will usually stop over time without treatment. If not, home treatment may be all that is needed to help a child stop wetting the bed. For more information, see the Home Treatment section of this topic.

If home treatment is unsuccessful, if the child and parents need assistance, or if the bed-wetting may be caused by a medical condition, medical treatment may be helpful. Medical treatment may help your child wet the bed less often or help him or her wake up to use the toilet more often.

Treatment for bed-wetting is based on the:

• Child's age. Some treatments work better than others for children of a specific age group.
• Child's and parents' attitudes about the bed-wetting. If gaining bladder control is seen as a normal process, it is usually easier for the child to stop bed-wetting.
• Home situation. If the child shares a bedroom with other children, certain techniques to arouse the child, such as some moisture alarms, may not be practical.

Treatment for bed-wetting may include:

• Motivational therapy. This method involves parents encouraging and reinforcing a child's sense of control over bed-wetting.
• Moisture alarms, which detect wetness in the child's underpants during sleep and sound an alarm to wake the child.
• Desmopressin and tricyclic antidepressants. These medicines increase the amount of urine that the bladder can hold or decrease the amount of urine released by the kidneys.

Treatment may be helpful if bed-wetting seems to be affecting your child's self-esteem or affecting how your child is doing with schoolwork or getting along with his or her peers.

The best solution may be a combination of treatments. Below are some suggestions for treatment options according to the age of your child.

• Ages 5 to 8: Help your child understand that wetting the bed is a normal part of growing up. Encouragement and praise may be all that is needed to help your child wake up before wetting. Praise and reward your child for the steps he or she takes to have dry nights. And have your child take an active role in cleaning up after wetting.
• Ages 8 to 11: If your child still wets the bed, a moisture alarm may be a successful treatment option. Also, a medicine such as desmopressin can be helpful for occasional overnight events such as camp or sleepovers.
• Ages 12 and older: There can be significant emotional effects if bed-wetting persists at this age, so treatment can be more aggressive. If consistent use of moisture alarms does not work, the doctor may suggest medicine and/or counseling.

For more information, see:

What about treatment for daytime wetting?

Accidental daytime wetting may be a normal part of a child's development, or it may point to a medical condition. Talk to your child's doctor if your child has daytime wetting.

What to think about

Treatment for bed-wetting is usually not a cure. The goal is to reduce the number of times the child wets the bed and to manage the wetting until it goes away on its own.

Some children who finish a treatment and have dry nights for a while will start to wet the bed again. Repeating treatment, especially with a moisture alarm, usually helps bring back dry nights.

Counseling (psychotherapy) may be helpful for the child who has secondary enuresis or for bed-wetting that is caused by emotional stress. Psychotherapy involves talking with a trained counselor. The counselor helps the child identify and deal with the emotional stress that may be causing him or her to have accidental wettings. The goal is to reduce or help manage the stress or to prevent stress from occurring.

Prevention

Learning to use the toilet is a natural process that occurs when children are old enough to control their bladder muscles and to know when they are about to wet. It is normal for young children to have accidental bed-wettings while they are learning to control their bladders.

If you are teaching your child to use the toilet, be patient. Some children are slower than others in gaining complete bladder control. Stay positive and encouraging, and learn about the normal development of bladder control. For more information, see the topic Toilet Training.

You can help prevent or reduce bed-wetting by limiting your child's fluid intake in the evenings. Do not give any drinks containing caffeine, such as cola or tea. Also, remind your child at bedtime that he or she should get up at night to use the bathroom if needed.

Self-Care

Most children gain bladder control over time without any treatment. A child should first be allowed to overcome bed-wetting on his or her own. But home treatment may help a child to wet the bed less frequently.

You can help manage your child's bed-wetting:

• Monitor your child's consumption of liquids. As a rule of thumb, children should be encouraged to consume 40% of their total daily liquids in the morning, 40% in the afternoon, and 20% in the evening. Talk with the doctor about how much fluid your child needs.
• Have your child avoid caffeine. Caffeine is a diuretic, which means that it promotes the excretion of urine. Foods such as chocolate and beverages such as colas and tea may contain caffeine.
• Have your child use the toilet before going to bed.
• Remind your child to get up during the night to go to the bathroom. It may help to keep a night-light near or potty chair beside the bed.
• Let your child help solve the problem, if he or she is older than 4.
• Praise and reward your child for taking steps to have more dry nights. Involve your child in planning the reward system. You may want to use a calendar and put stars or stickers on the days that your child does not wet the bed. You know your child. If you think a reward system will help your child, then try it. If you think it may make your child feel worse, then do not use a reward system.
• Encourage your child to take responsibility for changing clothes and linens after a bed-wetting accident. For example, use washable sleeping bags as bedding so your child can easily replace one that is wet with one that is dry.
• Add 0.5 cup (125 mL) of vinegar to the wash water to get rid of the urine odor in clothing and bed linens.

If your child wets the bed, don't blame yourself or the other parent. Don't punish, blame, or embarrass your child. Your child is neither consciously nor unconsciously choosing to wet the bed. Give your child understanding, encouragement, love, and positive support.

• Be patient about changing the bed linens. Don't act offended by the smell of urine.
• Do not wake the child up at different times during the night to go to the bathroom unless it is part of a systematic treatment that the child has agreed to.
• Do not make the child feel bad. Shaming or punishing the child may make the problem worse.
• If you think your child may be feeling emotional stress, talk with a health professional about whether counseling may be helpful.

Medicines

Medicines that either increase the amount of urine that the bladder can hold (bladder capacity) or decrease the amount of urine released by the kidneys may be used to treat bed-wetting. These prescription medicines may be used to control bed-wetting for a little while. They don't completely stop it.

• Medicines work well to control accidental wetting for short periods of time, such as when children are on overnight trips or at camp.
• Your doctor may suggest them for bed-wetting that is related to a stressful event, such as divorce or the birth of a sibling.
• Sometimes medicines are used along with other treatments or for children who have not been able to control bed-wetting with other treatments. Medicines can help to encourage and motivate a child who is having trouble with other treatments by letting the child feel what it is like to have dry nights.

Medicine choices

• Desmopressin for Bed-Wetting (DDAVP)
• Tricyclic Antidepressants (TCAs) for Bed-Wetting (such as desipramine or imipramine)

In a few cases, when a small bladder capacity or overactive bladder is thought to be the cause of bed-wetting, oxybutynin (such as Ditropan or Oxytrol) may be used to treat bed-wetting, especially when the child also has daytime accidental wettings.

Other Treatment

You may hear of other ways to help children who wet the bed. But not all of these treatments have good evidence that they help. Talk to your doctor before you spend time and money on these other treatments. Ask about the risks and benefits. Examples include:

• Acupuncture.
• Bladder-stretching exercises that teach the child to hold urine for longer periods of time.
• Dry-bed training, which consists of following a strict schedule for waking the child up at night until he or she learns to wake up alone when needed.
• Hypnosis.
• Waking your child and taking him or her to the toilet a few times each night, or having your older child wake himself or herself a few times each night to use the toilet.

It's not a good idea to have your child wear diapers or pull-ups at night on a regular basis. Using diapers can get in the way of proven treatments (such as motivational therapy and moisture alarms) that require a child to get up at night.