Helping Adolescents Overcome Bed-Wetting

Involuntary urination at night – known as nocturnal enuresis or bed-wetting – is a common problem among young children, especially those six and under. Bed-wetting can continue into adolescence. According to The International Children’s Continence Society (ICCS), bed-wetting affects 5 to 10 percent of children below the age of 10 and a few percent of older children and teenagers as well.

It’s important for pediatric nurses to understand nocturnal enuresis and how to help patients and families, who may feel frustrated about nighttime bed-wetting. “Although bed-wetting is not physically harmful to children, it can be embarrassing and lower their self-esteem,” says Rebecca Cesa, MSN, RN, a certified pediatric nurse practitioner at Cleveland Clinic. “Children who are bothered by bed-wetting wake up wet and feel as if they have already failed for the day.”

What are the causes?

Unfortunately, medical practitioners can’t always pinpoint the exact cause of nocturnal enuresis. In adolescents with normal bladder control, nerves in the bladder wall relay messages to the brain when the bladder is full. The brain, in turn, sends messages back to the bladder to prevent it from emptying before the child is ready to go to the bathroom. Adolescents with nocturnal enuresis, however, involuntarily urinate at night.

Some causes of bed-wetting include:

• Deep sleep – “Almost all parents of children who wet the bed will say that their child is a deep sleeper,” says Cesa. “The child is unable to receive the signal from their bladder that it is ‘time to go.’”
• Nightly fluid intake – Children who consume most of their fluid intake in the evening before bed may experience bed-wetting.
• Genetics – Adolescents with a family history of nocturnal enuresis are more inclined to be bed-wetters.
• Bladder problems – Sometimes the child’s bladder is irritated and the muscles contract or spasm, which prevents the bladder from holding urine. Other children may have small bladders and simply can’t hold a large volume of urine.
• Hormonal issues – The antidiuretic hormone (ADH) causes the body to produce less urine at night. However, some adolescents don’t make sufficient ADH: Their bodies produce too much urine while they are sleeping.
• Medical conditions – A host of medical conditions can cause bed-wetting, including constipation, diabetes, sleep apnea and urinary tract infections.

How do we treat it?

“The first and most important step to treatment is a motivated child,” says Cesa. “If the child is not bothered by bed-wetting, then it may be hard to get him or her on board with a treatment plan.”

Here are some other treatment options:

• Work on communication between the brain and bladder. Timed voiding every two hours during the day and a potty watch alerting the child to use the bathroom may be helpful with this. In addition, use a nighttime bed-wetting alarm every night for eight to 12 weeks.
• Try fluid shifting. This tricks the body into making most of its urine during the day. Children should drink as much water as they can between the time they wake up and dinner. After dinner, they should consume only a small amount of fluid and have nothing to drink two hours before bed.
• Eliminate bladder irritants. Remove food and drink from the child’s diet that may irritate the bladder and contribute to bed-wetting. Items should be eliminated for two weeks and then reintroduced one at time every three to four days. Watch for return of or increased bed-wetting. Some items to eliminate include caffeine, carbonation, citrus, chocolate and red dye. Children should only drink water, white milk and naturally colored juices.
• Treat constipation. Constipation causes bladder irritation and pressure, which helps contribute to bed-wetting. Encourage parents to make sure their children have a daily soft bowel movement.
• Encourage double voiding. Ask children to double void at bedtime. “I usually recommend that they void before they start their bedtime routine – washing their face, showering and brushing their teeth. Then they should void again right before they get in bed,” says Cesa.
• Prescribe medication. There are three commonly used medications for managing bed-wetting. These medications do not correct the problem, and once they are stopped, bed-wetting may resume.
  • DDAVP® (desmopressin) is a synthetic replacement for vasopressin and reduces the amount of urine produced at night by the kidneys.
  • Ditropan® (oxybutynin) is an anticholinergic, which relaxes the bladder and allows for more storage of urine.
  • Tofranil® (imipramine) is an antidepressant that works by changing the child’s sleep and wakening pattern, allowing more storage of urine and reducing the amount of urine produced.

What not to do

It’s important when you are working with a bed-wetting patient to stress to parents things they should not do – tactics that may actually undermine efforts to stop nocturnal enuresis and demoralize the child. First, parents should never punish the child. “Bed-wetting is not the child, nor the parents’ fault,” says Cesa. “Children should not be punished or penalized for episodes of bed-wetting.”

Secondly, don’t intermittently wake the child. “Some parents will set an alarm and wake the child at timed intervals throughout the night,” says Cesa. “This does not work for two reasons. First, you don’t know if this is a time when the child’s bladder is full and would be signaling them that is it time to void. Only wake them when the bed-wetting alarm alerts. Second, interrupting sleep leads to sleep deprivation. When children are sleep deprived they tend to sleep much deeper and are harder to wake when alerted by bed-wetting alarms or when their bladder signals them to void.”

Finally, don’t ignore daytime symptoms. “If a child has any daytime urinary symptoms – incontinence, leaking, urgency – these should be addressed and corrected first,” says Cesa.

By following this advice, you can help many patients successfully stop nocturnal enuresis, which is gratifying to children, their families and you as a healthcare professional. “Helping children conquer bed-wetting and seeing how much it has improved their quality of life is one of the reasons I come to work every day!” says Cesa.