Bedwetting

Bedwetting or enuresis is the involuntary passage of urine during sleep for girls over age five years and boys over age six years. By age six years, only ten percent of children have enuresis, and approximately fifteen percent of these individuals attain nighttime dryness each year subsequent to age six. About ninety-nine percent of adolescents are dry by age fifteen, but for the small percentage of adolescents, mainly males, who have bedwetting, this can be a devastating problem. In a study published in 2006, three percent of adolescents ages thirteen to fifteen years reported that they were currently having problems with bedwetting.

Teens with enuresis typically do not have a disease causing the symptoms. Rather, there are two different mechanisms that explain the cause of bedwetting. Most adolescents have developed the pathway between the bladder and brain such that when the bladder is full, the sleeping teen will awaken. It is felt that adolescents with bedwetting do not awaken when the bladder is full. In fact, most of the teens with enuresis are exceedingly deep sleepers who have a high arousal threshold for many different stimuli. And second, many of the teens with bedwetting have a small bladder so that it will fill with urine sooner than those teens with a larger capacity bladder. Most teens should have a bladder with a capacity of twelve to sixteen ounces. Therefore, when the bladder is full in adolescents with the tendency to wet the bed, it will involuntarily discharge the urine while the teen is asleep.

Generally, psychological issues in adolescents are not a cause of enuresis. Some disease states can lead to increased production of urine, and these include diabetes mellitus, diabetes insipidus and sickle cell anemia. Most adolescents, however, will awaken from the sensation of a full bladder. However, a teen that has been drinking excessive amounts of alcohol may have increased urine production due to the diuretic effects of alcohol. And also, the teen may be in a state where he or she may not awaken due to the soporific effects of alcohol.

Enuresis may run in some families. This is thought to be inherited through an autosomal dominant pattern where fifty percent of the children of a parent with a history of enuresis will develop bedwetting. The marker for enuresis has been identified on chromosome 13q. Of course, other adolescents wet the bed on the basis of their own development rather than through a genetic mechanism.

Enuresis is characterized by the involuntary release of urine during sleep. Most of the teens will not have involuntary urine release when they are awake. There are no associated symptoms such as burning on urination or frequency of urination. If there is an underlying disease such as diabetes mellitus, there will be other symptoms due to the diabetic state. These symptoms could include weight loss, fatigue, craving for fluids and increased volume of urine passed during the daytime and nighttime hours.

When an adolescent presents to his or her clinician with enuresis, a complete history and physical examination should be performed. A history to delineate symptoms suggestive of sleep disorder, substance abuse or diabetic state should be obtained. The physical examination should be general and also have a particular focus on the abdominal and genital regions. Every teen with enuresis should have a urinalysis to rule out diabetes mellitus, diabetes insipidus and screen for infection. Radiological or other imaging studies are not routinely performed unless there are signs suggestive of urinary tract obstruction or a neurological problem with the bladder. A primary care clinician such as a pediatrician or specialist in adolescent medicine is capable of conducting the evaluation for enuresis.

Without treatment, most adolescents will stop bedwetting. However, being wet at night can be a significant crimp in a teen’s social life. The following are suggestions to help teens stop bedwetting:

• Decrease the amount of fluid taken by mouth in the two hours prior to going to bed
• One should urinate before going to bed
• The teen should set the alarm clock to ring during the night so that he or she can empty your bladder
• Adolescents can strengthen and enlarge their bladders by holding their urine during the day for increasing lengths of time

There are other options for the teen with bedwetting. Small, portable, inexpensive alarms help awaken teens to the sensation of a full bladder. They typically have a moisture sensor that is placed near the teen’s urethra so that the first drops of involuntarily passed urine will activate the alarm. The alarm can either be a sound or stimulation that quickly awakens the teen. The teen then voluntarily empties his or her bladder. There are some problems with the alarms. Some teens simply sleep through the entire alarm and the household awakens. And alarms do require lots of self-motivation to use them. They are not appropriate to use when the teen is sleeping over a friend’s house or is in over night camp. Some researchers have found that up to seventy percent of enuretics can be trained to be dry using an alarm system.

The other modality of treatment for enuretic adolescents is medication. Two drugs have been studied fairly extensively. Imipramine hydrochloride is a tricyclic antidepressant that has been used extensively for years. Adolescents with enuresis are not necessarily emotionally depressed. Imipramine acts on the bladder to increase its capacity. Some also believe it acts to develop the teen’s ability to awaken when the bladder signals it is filled to capacity. Success rates range from ten percent to sixty percent depending on the studies, although there are lots of relapses after a teen discontinues the use of imipramine. At high doses, the medication can be quite toxic, so it should be kept away from children.

Desmopressin is a hormone that reduces urine production by increasing water retention and urine concentration. It is administered as a spray into the nose at bedtime. About twenty-five percent of the patients become dry on this medication, but close to one hundred percent relapse once the medication is stopped. It is appropriate for the teen that wishes to participate in a sleepover or in overnight camp.

Teens who wet at night should be responsible for changing the sheets. Also, dry pajamas should be readily available. Some teens use towels or a rubber sheet underneath them to avoid the hassle of changing sheets in the middle of the night.

Most causes of bedwetting are genetic or through a developmental mechanism and cannot be prevented. However, bladder-strengthening exercises that include holding in urine for increasing lengths of time during the day will build up bladder capacity and bladder muscle strength. These exercises could be appropriate for preadolescent children.

Related topics:

Alcohol, antidepressants, diabetes, growth and development, kidney disorders, sleep, sleepovers