Retired Professor of Paediatrics and Neonatal Medicine, Imperial College School of Medicine, University of London
What is bed wetting?
Enuresis or bed wetting is the involuntary passage of urine beyond the age of anticipated control that is usually 5-6 years. 15-20% of children 5 years of age wet their beds. Nearly 5% of 10 year olds will wet, and 1% of adolescents and adults continue to wet. It is twice as common in boys as in girls. Bedwetting also seems to run in families.
What are the types of wetting problems?
Primary enuresis means that the child has been wet from the beginning, whereas secondary enuresis means that the child had been dry earlier and has now started wetting. The latter condition could be due to urinary infection, diseases like diabetes, structural abnormalities in the urinary passages or stressful situations at school or at home like divorce, demanding parents or the arrival of a sibling.
What are the symptoms?
Commonly, wetting at night is the only symptom, but some children also have frequent urination during the daytime with occasional wetting. It has been seen that children who are constipated are more likely to have enuresis.
What investigations are needed?
The doctor first takes a detailed history and examines the child to exclude structural abnormalities that may be the cause of bed-wetting. In case a doubt persists after examination, the doctor will order a urine test to exclude urinary infection. An ultrasound scan may be done to evaluate the urinary system for structural abnormalities. Rarely, special tests may be asked for, like intravenous pyelography (IVP) that is a special X-ray test after an injection into the vein, or cystometry in which the pressures inside the urinary bladder are measured.
What is the treatment?
The good thing is that a large number of children stop wetting as they grow up. But during the time that they are wetting, the social costs are enormous. These children need all the support and compassion from their parents and the care givers. Other methods that often help include:
Behaviour modification techniques such as rewarding the child for remaining dry at night. The rewards may increase in value with each passing dry night. It is inappropriate to punish the child for a wet night. In fact, punishment worsens the situation.
Fluid intake should be limited from the evening so that the child produces less urine. Sometimes this regime may be harsh to enforce on children.
The use of alarm devices is beneficial. These alarms use a pad inserted into the child's underwear, so that as soon as the pad gets wet an alarm bell rings waking the child up before the bladder empties completely. This conditions the voiding mechanism in several children. Unfortunately, good quality alarms are not available in India.
Counselling of the child and the family may be necessary in case an underlying emotional or interpersonal problem is suspected.
In older children, and in those who fail to respond to the above methods of treatment, medicines may be prescribed. Imipramine is a commonly used drug that is normally prescribed for the treatment of depression in adults. It helps correct bedwetting in about 30% of children and needs to be given for 4-6 months. The side effects of imipramine include sleepiness and mood changes. Another medicine called desmopressin, that is a derivative of the hormone vasopressin also helps in about 30% cases. This drug is given as a spray into the nose. This latter drug is expensive.
Most successful treatment programmes require a multifaceted approach. Often a combination of techniques gives better results. In case of relapse after stopping treatment, the regimen may need to be started all over again. Success in treatment depends on a motivated child and dedicated and compassionate parents.