Oh no! it’s happened again

By Prasanna Panditharatne

Bedwetting is not uncommon, though children and parents often feel that they are the only ones with the problem because the condition is simply not talked about, or if it is, it is usually with hushed voices and a sense of shame. The medical term for bedwetting is 'nocturnal enuresis' and if a child starts to wet the bed after a lengthy period of dryness, this is called secondary enuresis; however, the assessment and treatment are the same for both.

Why do some children wet the bed and others don't? There is no simple 'catch all' reason why it occurs, it could be that an older member of the family used to wet the bed, and the child has simply inherited the tendency, or a child might start to wet the bed during times of worry or stress. The causes of bedwetting are best understood as being the result of one or more of the following:

• A lack of the naturally occurring hormone vasopressin (AVP). This hormone is released during sleep and reduces the amount of urine produced through the night. A lack of this hormone results in the production of daytime amounts of urine, which quite simply cause the bladder to fill quickly and overflow. There are no tests available to confirm that a lack of vasopressin is causing the bedwetting, but there are a few signs which point towards this, including wetting soon after sleep, consistently large puddles in the bed and weak urine concentration in the mornings.

• Bladder overactivity affects about 30% of children who wet the bed. It is caused by the bladder wall muscles contracting before the bladder is full and causing it to empty. Symptoms include the need to use the toilet urgently and frequently through the day, small wet patches on underwear during the day, a small bladder capacity and waking up immediately after wetting during the night.

• Many children who wet the bed do not wake to the signal that the bladder is full and needs emptying. The crucial factor in this instance is not how deeply the child sleeps but how easily they can wake from sleep.

What can a parent do to help?

It is very important to appreciate that the problem is outside the child's control, so no blame is attached to bedwetting accidents. The following suggestions may help: encourage them to drink regularly through the day (6-8 cups)- this is important because regular drinking of water-based fluids helps the bladder to hold more. There is no need to stop the child drinking before going to bed but it may be worthwhile limiting it to one drink during the hour before bed; empty the bladder before going to bed and then once again before to going to sleep; easy access to the toilet, leave a light on if the child is concerned about the dark or provide a potty in the child's bedroom; praise the child for any dry nights.

Some parents 'lift' ( take the child to the toilet in the night, without necessarily waking up the child) the child during the night which may result in a dry bed, but does not help the process of learning to wake up and react to the sensation of a full bladder. If a parent wishes to continue to 'lift', ensure the child is fully awake and the time is varied from night to night.

A child's biggest worry is that their bedwetting will be made public, so sleepovers or school trips are a particular concern. However, practical steps can be taken to ensure nights away with confidence. For example, it is always worthwhile talking to the trip organiser to ensure that they are aware of the situation and can provide discreet assistance. This may mean waking the child early to deal with wet beds or clothes in private.

Should parents seek medical intervention?

If the bedwetting persists, or if it is causing concern to the child or family, a health professional can enable access to the most suitable treatment to identify any related problems such as a urinary infection, assess the child's pattern of bedwetting, check that the child is not constipated, and develop a programme of treatment. Moreover, bedwetting can start to have a negative effect on children's self-esteem and the child will often curtail social activities because of the bedwetting, and it is often at this point (commonly around seven years of age) that the child will urge parents to seek intervention to deal with the problem. If the child is involved in the decision to intervene, the levels of motivation will be high and so will help resolve the bedwetting.

What treatments are available?

Bedwetting alarms can be used from the age of five, but it is important to ensure that the child is motivated and is able to manage the alarm, with prompting from the parent, if the child is difficult to wake. Sometimes it is better to wait until the child is a little older and more able to cope with the intrusive nature of the alarm. The alarm will disturb sleep most nights, for both the parent and the child, until the routine is established and dry nights begin to occur.

There are two types of bedwetting alarms: firstly, the bedside type which lies flat in the bed and the box is placed beside the bed and, secondly, the body-worn alarm which clips to the child's pyjamas around the collarbone area, with a sensor connecting to underwear. With both types of alarm, the noise box sounds when urine touches the sensor, causing the child to wake up. Gradually the child learns to wake earlier and earlier during the process of wetting until they wake solely to the sensation of a full bladder. Alarms can take from about 5-12 weeks to be fully effective, but some children take longer. The use of an alarm for all concerned requires determination and patience.

Medication can be helpful for some children and desmopressin is the most widely prescribed medication for bedwetting. This medication is a synthetic form of the naturally occurring hormone, vasopressin, working in the same way by reducing and concentrating the amount of urine produced overnight. Oxybutinin is sometimes prescribed for children who have symptoms of urgency during the day. It works by helping the bladder to relax and thus removing the frequent urge to use the toilet.

Many families find that "complementary therapies" provide an alternative perspective on the problem of bedwetting. There hasn't been any conclusive research to indicate the validity of complementary therapy as a cure for bedwetting, but there are numerous positive anecdotal stories of, for example, hypnotherapy, self-help tapes or acupuncture proving successful.

(The writer is a Consultant Psychologist)