What is Bed Wetting (Enuresis)? Causes and Treatment

Urinary incontinence is a common problem in children. Approximately 15 percent of five-year-old children have difficulty holding urine. The majority of these children experience enuresis nocturna, that is, bedwetting at night. While the rate of urinary incontinence in six-year-old children drops to 13 percent, this rate is 10 percent in 7-year-old children. As age increases, the incidence of urinary incontinence decreases. For people aged 15 and over, the rate drops to 1-2%.

What is Bed Wetting (Enuresis)?

Many people ask doctors the question of what enuresis means, which is a common condition in our country. The word enuresis means bedwetting. Bedwetting problem at night is enuresis nocturna, and bedwetting both day and night is enuresis diurna. Enuresis is divided into two: monosymptomatic or non-monosymptomatic. Monosymptomatic enuresis is the absence of any symptoms in the lower urinary tract or deterioration in bladder function other than bedwetting. Monosymptomatic enuresis types are divided into primary and secondary. Primary monosymptomatic enuresis is the more common type and is a constant bedwetting problem. Secondary is the onset of urinary incontinence following a period of no bedwetting for at least six months. In case of non-monosymptomatic enuresis, the following symptoms may be observed in addition to bedwetting:

• A persistent increase (8 or more times per day) or decrease (3 or fewer times per day) in urination frequency
• Daytime urinary incontinence
• Sudden feeling of tightness
• Difficulty initiating urination
• Using abdominal pressure to initiate or maintain urination
• weak urine stream
• Urination occurs intermittently rather than all at once
• Feeling of not emptying the bladder completely
• Dripping after urination
• Pain in the genital area or lower urinary tract

Bladder dysfunction (complex enuresis) is seen in some patients with non-monosymptomatic enuresis, and symptoms occur not only at night but also during the day in these patients. It is usually accompanied by symptoms such as a sudden feeling of urgency during the daytime or a change in urination frequency.

Why Does Bedwetting (Enuresis) Occur?

Normally, the functioning of the bladder is based on the complex relationship between the autonomic and somatic nerves in which the brain stem, midbrain, meninges (cortex) and a part of the spinal cord are involved. While autonomic nerves control involuntary movements, somatic nerves ensure the contraction and relaxation movements of voluntary muscles. This coordinated relationship within the nervous system plays an important role in keeping the urine in the bladder and in allowing the urine to come out by contracting the muscles in the bladder wall (detrusor muscle) when the pressure in the bladder increases. Since this coordination has not yet occurred during birth, contraction cannot be controlled when the bladder is full and urination occurs uncontrollably. In the first three years of life, the capacity of the bladder increases disproportionately compared to body surface area. By age four, most children pee five to six times a day. The development of the bladder control mechanism occurs over time. At first, children become aware that the bladder is full, and then the ability to prevent contraction of the bladder wall muscle develops. As a result, the coordination between the sphincter muscles and detrusor muscles, which prevent urine from leaving the bladder, is learned. The use of these abilities during the day usually occurs by the age of four.

Night bladder control is usually learned months or years later and is not expected to occur until the age of five to seven. The fact that this development process in the bladder is not completed immediately causes bedwetting problems related to urinary incontinence during the day. This is usually due to bladder dysfunction, overactive bladder, underactive bladder, recurrent urinary tract infections, and in some cases, vesicoureteral reflux (urine moving up from the bladder).

Causes of Bedwetting (Enuresis)
Bedwetting problem can occur due to many reasons. It may occur in conditions related to nervous system development, such as autism spectrum disorder and attention deficit hyperactivity disorder. Additionally, psychological abnormalities are among the non-organic causes of enuresis. In other words, no definitive relationship has yet been found as to why psychological problems cause enuresis. Known organic causes of bedwetting problem are examined under two headings:

• Renal/Urological Causes: Bladder dysfunction, urinary tract infection, chronic kidney disease, ectopic ureter in women (upper urinary tract that connects the kidney to somewhere other than the bladder).
• Other Underlying Medical Conditions: Constipation, sickle cell disease, seizures, diabetes, diabetes insipidus, obstructive sleep apnea, pinworms, primary polydipsia (voluntary excessive drinking).

Bedwetting (Enuresis) Treatment

Initial treatment of enuresis consists of correction of accompanying conditions, setting goals and expectations, providing advice and education, and motivational therapy.

• Correction of accompanying conditions: It should be started at the same time as enuresis treatment. Concomitant conditions may affect the course of the problem and response to treatment. Therefore, underlying factors should be determined in patients with secondary enuresis. Conditions such as constipation, sleep apnea (snoring), attention deficit hyperactivity disorder should be treated.
• Determining goals and expectations: Goals such as preventing wetting problems in special situations such as sleepovers, reducing the number of bedwetting at night, and avoiding recurrence should be determined. In addition, it is necessary to reduce the impact of bedwetting on the family and child.
• Providing advice and education: Any questions that come to mind before and after starting treatment should be asked to the physician. Compliance with the advice and training given to patients and their families during the treatment process has a significant impact on the treatment process.
• Motivation therapy: It is necessary to provide the necessary motivation to monitor bedwetting during the treatment process. Providing motivation is an initially effective method, especially for children between the ages of five and seven who do not have a problem with bedwetting every night. Studies have shown that applying a reward system, such as giving stickers and collecting stickers and giving certain rewards to ensure motivation, contributes positively to the treatment.

In the alarm treatment method used in children who have enuresis and have difficulty waking up, the alarm starts to sound as soon as the child leaks urine. In this way, bedwetting problem can be treated with the development of the conditioning reflex. The drug called desmopressin, used in the treatment of enuresis, plays an active role in the treatment by reducing the amount of urine. This medicine, which is in pill or nasal spray form, is used before going to bed at night. Additionally, desmopressin, which dissolves under the tongue, is also effective in treatment.

How to Prevent Leaking?

Early diagnosis is very important to prevent the problem of enuresis. In patients diagnosed early, treatment is started quickly and positive results are obtained for the bedwetting problem. In addition, a supportive approach is necessary because bedwetting causes self-confidence problems, especially in children. It is important for children to learn that this problem is a common condition and that the problem can be overcome in terms of treatment. In addition to emotional support, taking some precautions is effective in preventing bedwetting in children:

• Limiting fluid intake in the evening: Caffeine-containing drinks such as tea and carbonated drinks should not be given, especially in the two hours before bedtime.
• Children should be given the habit of going to the toilet before going to bed.
• Instead of focusing on not wetting the bed at night, children should be encouraged to use the toilet at night. In this way, the habit of going to the toilet every night should be gained.
• Children need to have easy access to the toilet. It is important to place night lights between the bed and the toilet and to avoid obstacles on the way to the toilet. If necessary, a portable toilet should be used.
• Although the use of absorbent diapers at night is recommended by some doctors, it is sometimes not recommended. Therefore, its use can be decided by consulting a physician.
• Children’s bowel movements should also be observed. In case of constipation, difficulty in emptying the bladder effectively and completely may occur. Therefore, it is necessary to consult a physician when complaining of constipation.

Enuresis is also seen in adults. Restricting fluid intake in the evening and making it a habit to go to the toilet before going to bed at night is effective in preventing bedwetting problems in adults.

It is possible to get more effective results when bedwetting (enuresis) treatment is started early. People who want to get more information about enuresis and its treatment should definitely consult their health institutions. We wish you healthy days.