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{{short description|Involuntary urination while asleep}}
{{SignSymptom infobox |
{{cs1 config|name-list-style=vanc|display-authors=6}}
Name = Enuresis |
{{For|the Chris Brown song|Wet the Bed}}
ICD10 = R32-N341-N399|
{{Infobox medical condition (new)
ICD9 = {{ICD9|788.36}} |
| name = Nocturnal enuresis
| image = Wet bed again.jpg
| caption = Urine mark on bedding caused by a nocturnal enuresis episode.
| pronounce =
| field = [[Pediatrics]], [[Psychology]], [[Urology]]
| synonyms = Nighttime urinary incontinence, sleepwetting, bedwetting
| symptoms =
| complications =
| onset =
| duration =
| types =
| causes =
| risks =
| diagnosis =
| differential =
| prevention =
| treatment =
| medication =
| prognosis =
| frequency =
| deaths =
}}
<!-- Definition -->
'''Bedwetting''' (or '''nocturnal enuresis''' or '''sleepwetting''') is involuntary [[urination]] while [[sleep|asleep]]. It is the normal state of affairs in [[infancy]], but can be a source of embarrassment when it persists into school age or the teen years.
 
'''Nocturnal enuresis''' ('''NE'''), also informally called '''bedwetting''', is [[urinary incontinence|involuntary urination]] while [[sleep|asleep]] after the age at which [[bladder]] control usually begins.<ref>{{Cite journal |last=Fischer |first=Emil |date=May 1860 |title=Cases from the Surgical Clinic of the Philadelphia Hospital: Service of Professor Gross |journal=The North American Medico-chirurgical Review |volume=4 |number=3 |page=455 |pmid=38079927 |pmc=10344007}}</ref> Bedwetting in children and adults can result in emotional stress.<ref name=NIH2017Def/> Complications can include [[urinary tract infections]].<ref name=NIH2017Def>{{cite web|title=Definition & Facts for Bladder Control Problems & Bedwetting in Children|url=https://www.niddk.nih.gov/health-information/urologic-diseases/bladder-control-problems-bedwetting-children/definition-facts|website=National Institute of Diabetes and Digestive and Kidney Diseases|access-date=25 October 2017|date=September 2017|url-status=live|archive-url=https://web.archive.org/web/20171025073642/https://www.niddk.nih.gov/health-information/urologic-diseases/bladder-control-problems-bedwetting-children/definition-facts|archive-date=25 October 2017}}</ref><ref>{{Cite book|last1=Lallemand|first1=François|title=A Practical Treatise on the Causes, Symptoms, and Treatment of Spermatorrhoea|last2=McDougall|first2=Henry J|publisher=Blanchard and Lea|year=1853|editor-last=McDougall|editor-first=Henry J.|___location=Harvard University|page=231}}</ref><ref>{{Cite book|last=Cooper|first=Samuel|title=The first lines of the practice of surgery|publisher=Richard Phillips|year=1807|___location=the University of California|page=456}}</ref><ref>{{Cite book |last=Navy |first=United States |title=Medical News Letter |year=1954 |pages=18}}</ref>
Primary enuresis is when the child has never been dry at night or would not sleep dry without being taken to the toilet by another person or has some dry nights but continues to average at least two wet nights a week with no long periods of dryness. Secondary enuresis occurs when a child goes through an extended period of dryness and begins to experience night-time wetting again. Secondary enuresis is often (though by no means always) caused by emotional stress.
 
<!-- Cause -->
==Regulation in the organism==
Most bedwetting is a [[Specific developmental disorder|developmental delay]]—not an emotional problem or physical illness. Only a small percentage (5 to 10%) of bedwetting cases have a specific medical cause.<ref name="johnson">{{cite web|url=http://www.duj.com/Johnson.html|title=Nocturnal Enuresis|website=www.duj.com|access-date=2008-02-02|last=Johnson |first=Mary |archive-url = https://web.archive.org/web/20080122063339/http://www.duj.com/Johnson.html <!-- Bot retrieved archive --> |archive-date = 2008-01-22}}</ref> Bedwetting is commonly associated with a [[Family history (medicine)|family history]] of the condition.<ref>{{cite web| title = Bedwetting| publisher = The Royal Children's Hospital Melbourne | url = https://www.rch.org.au/kidsinfo/fact_sheets/Bedwetting/| access-date = 2009-10-20| url-status = live | archive-url = https://web.archive.org/web/20081226144048/http://www.rch.org.au/kidsinfo/factsheets.cfm?doc_id=3716| archive-date = 2008-12-26}}</ref> Nocturnal [[enuresis]] is considered ''primary'' when a child has not yet had a prolonged period of being dry. ''Secondary'' nocturnal enuresis is when a child or adult begins wetting again after having stayed dry.
Children usually achieve nighttime dryness by developing one or both of two abilities. There appear to be some hereditary factors in how and when these develop.
 
<!-- Treatment -->
*One is a hormone cycle in which a minute burst of [[antidiuretic hormone]] happens daily at about sunset reducing kidney output of urine well into the night so the bladder doesn't get full until morning. This hormone cycle is not present at birth. Many children develop it between the ages of two and six, others between six and the end of puberty, and some not at all.
Treatments range from [[Behaviour therapy|behavioral therapy]], such as [[bedwetting alarm]]s, to medication,<ref>{{Cite journal |last=Trousseau |first=Armand |date=1882 |title=Clinical Medicine |journal=Clinical Medicine Lectures Delivered at the Hôtel-Dieu, Paris |publisher=P. Blakiston, Son |volume=2 |page=304}}</ref><ref>{{Cite journal |last=Adee |first=D. |date=1843 |title=The Retrospect of Practical Medicine and Surgery |journal=Being a Half-yearly Journal Containing a Retrospective View of Every Discovery and Practical Improvement in the Medical Sciences |volume=1-4 |page=73}}</ref> such as [[Hormone replacement therapy|hormone replacement]], and even surgery such as [[urethral dilatation]]. Since most bedwetting is simply a developmental delay, most treatment plans aim to protect or improve [[self-esteem]].<ref name="johnson" /> Treatment guidelines recommend that the physician counsel the parents,<ref>{{Cite journal| vauthors = Cook DE, Monro IS, West DH |date=1945|title=Standard Catalog for Public Libraries: 1941-1945 supplement to the 1940 edition|journal=Standard Catalog for Public Libraries: Supplement... 1941-, H.W. Wilson Company|publisher=H. W. Wilson Company, 1945|volume=1|page=18}}</ref> warning about psychological consequences caused by pressure, shaming, or punishment for a condition children cannot control.<ref name="johnson" />
*The other is the ability to awaken before sleepwetting. For some children this is a natural extension of learning to be aware of and control their bladders while awake. For others, a variety of factors suppress or disrupt this awareness when asleep, and they are unlikely to develop it. Taking children to use the toilet while not fully awake can prolong dependence on that by encouraging them to urinate while nearly asleep.
 
<!-- Epidemiology -->
==Prevalence==
Bedwetting is the most common childhood complaint.<ref>{{cite web | url = http://www.hawaii.edu/medicine/pediatrics/pedtext/s13c09.html | title = Case Based Pediatrics For Medical Students and Residents | access-date = 2010-05-28 | last = Paredes| first = Potenciano Reynoso | publisher = Department of Pediatrics, University of Hawaii John A. Burns School of Medicine | url-status = live | archive-url = https://web.archive.org/web/20100530071129/http://www.hawaii.edu/medicine/pediatrics/pedtext/s13c09.html | archive-date = 2010-05-30 }}</ref><ref>{{cite web | url = http://urology.ucla.edu/body.cfm?id=146 | title = Nocturnal Enuresis | access-date = 2010-05-28 | publisher = UCLA Urology | url-status = live | archive-url = https://web.archive.org/web/20100707101513/http://urology.ucla.edu/body.cfm?id=146 | archive-date = 2010-07-07 }}</ref><ref name="pmid11095087">{{cite journal | vauthors = Butler RJ, Holland P | s2cid = 35856153 | title = The three systems: a conceptual way of understanding nocturnal enuresis | journal = Scandinavian Journal of Urology and Nephrology | volume = 34 | issue = 4 | pages = 270–7 | date = August 2000 | pmid = 11095087 | doi = 10.1080/003655900750042022 }}</ref>
Figures commonly cited suggest that enough children sleepwet at age six (perhaps one in three) so that it is within normal expectations and supportive management is appropriate until a child is seven or eight or has the maturity and desire to take an active role in planning and implementing specific treatment. Also, even with no active treatment, about 15% (one in seven) of children who do sleepwet will stop each year through natural development. Some sources indicate that 5-10% of teenage children experience occasional sleepwetting.
 
==TreatmentImpact==
A review of medical literature shows doctors consistently stressing that a bedwetting child is not at fault for the situation. Many medical studies state that the psychological impacts of bedwetting are more important than the physical considerations. "It is often the child's and family members' reaction to bedwetting that determines whether it is a problem or not."<ref name="ifas" />
[[Tricyclic antidepressant]] [[prescription drug]]s with [[anti-muscarinic]] properties (i.e. [[Amitriptyline]], [[Imipramine]] or [[Nortriptyline]]) may be used to treat bedwetting with much success for periods up to 3 months.
 
===Self-esteem===
Another medication, [[Desmopressin]], is a synthetic replacement for the missing burst of [[Vasopressin|antidiuretic hormone]]. Desmopressin is usually used in the form of Desmopressin acetate, DDAVP. Whether used daily or occasionally, DDAVP simply replaces the hormone for that night with no cumulative effect.
Whether bedwetting causes low self-esteem remains a subject of debate, but several studies have found that self-esteem improved with management of the condition.<ref name="nursingcenter">{{cite web|url=http://www.nursingcenter.com/prodev/ce_article.asp?tid=659967|title=Helping Children with Nocturnal Enuresis|website=www.nursingcenter.com|access-date=2008-02-03|last=Berry|first=Amanda |url-status=live|archive-url=https://web.archive.org/web/20080121094022/http://www.nursingcenter.com/prodev/ce_article.asp?tid=659967|archive-date=2008-01-21}}</ref>
 
Children questioned in one study ranked bedwetting as the third most stressful life event, after "parental war of words", divorce and parental fighting. Adolescents in the same study ranked bedwetting as tied for second with parental fighting.<ref name="nursingcenter" />
Some psychologists and experts recommend the use of night-time training devices such as a [[bedwetting alarm]] to help [[condition]] the child first to wake up at the sensation of moisture and then at the sensation of a full [[Urinary bladder|bladder]]. Success with alarms is increased and relapses reduced when combined in programs which may include bladder muscle exercises, dietary changes, mental imagery, stress reduction, and other supportive activities.
 
Bedwetters face problems ranging from being teased by siblings, being punished by parents, the embarrassment of still having to wear diapers, and being afraid that friends will find out.
Using absorbent products such as [[diaper]]s or padded night-time pants usually helps bedwetting children feel less embarrassed about their accidents. Although these products will not treat or cure bedwetting, they make it easier for children and their families to deal with the issue.
 
Psychologists report that the amount of psychological harm depends on whether the bedwetting harms self-esteem or development of social skills. Key factors are:<ref name="psychtoday">{{cite web|url=http://psychologytoday.com/conditions/enuresis.html|title=Psychology Today's Diagnosis Dictionary: Enuresis|website=Psychology Today|access-date=2008-02-02}}{{Dead link|date=March 2024 |bot=InternetArchiveBot |fix-attempted=yes }}</ref>{{ums|date=January 2018}}
The use of diapers or disposable training pants without any other treatment is not considered unusual until about 6 to 10 years of age. After that point, other treatments may be used with or without absorbent products, such as the aforementioned medication or alarm systems. Occasional bedwetting such as once a month to once a year is normal for a child between 4 and 16 and nothing to get alarmed at.
* How much the bedwetting limits social activities like sleep-overs and campouts
* The degree of the social ostracism by peers
* (Perceived) Anger, punishment, refusal and rejection by caregivers along with subsequent guilt
* The number of failed treatment attempts
* How long the child has been wetting
 
===Behavioral impact===
There is however, a growing number of voices against the use of such products, because some parents feel that they can hinder, rather than help the process of assisting with bedwetting; since some children appear to treat them and indeed use them, as a substitute diaper.
Studies indicate that children with behavioral problems are more likely to wet their beds. For children who have developmental problems, the behavioral problems and the bedwetting are frequently part of/caused by the developmental issues. For bedwetting children without other developmental issues, these behavioral issues can result from self-esteem issues and stress caused by the wetting.<ref name="psychtoday" />{{ums|date=January 2018}}
 
As mentioned below, current studies show that it is very rare for a child to intentionally wet the bed as a method of acting out.{{citation needed|date=April 2021}}
Experts generally agree that parents' understanding that sleepwetting is not the child’s fault strongly increases the child's willingness to help deal with it. Although historically, physical punishment such as spanking was the normal method of incentivizing older children to stop sleep wetting, anti-spanking advocates have discouraged any corporal punishment for this purpose. Punishments including restrictions, teasing, or shaming, whether actual or threatened, are counterproductive. Encouragement of self reliance allows for the child's own natural and native development to acquire the ability to sleep dry on his or her own terms.
 
===Punishment for bedwetting===
==Myths and Common Misconceptions about Bedwetting==
Medical literature states, and studies show, that punishing or shaming a child for bedwetting will frequently make the situation worse. It is best described as a downward cycle, where a child punished for bedwetting feels shame and a loss of self-confidence. This can cause increased bedwetting incidents, leading to more punishment and shaming.<ref name="UFlorida">{{cite web|url=http://edis.ifas.ufl.edu/HE794|title=Bedwetting|access-date=2009-09-12|url-status=live|archive-url=https://web.archive.org/web/20090922115037/http://edis.ifas.ufl.edu/HE794|archive-date=2009-09-22}}</ref>
*You have to wait for your child to outgrow bedwetting.
Although 15 percent of bedwetting children stop wetting on their own each year, that means 85 percent will still be wetting this time next year. Because there are now safe, effective techniques to help your child eliminate bedwetting, there is no reason that you have to wait for years for bedwetting to stop spontaneously. When your family has become frustrated with laundry and begins making excuses for sleepovers, it is time for intervention. Your child should be around 6 before you start.
 
In the United States, about 25% of enuretic children are punished for wetting the bed.<ref name="jdiseases">{{cite journal | vauthors = Haque M, Ellerstein NS, Gundy JH, Shelov SP, Weiss JC, McIntire MS, Olness KN, Jones DJ, Heagarty MC, Starfield BH | title = Parental perceptions of enuresis. A collaborative study | journal = American Journal of Diseases of Children | volume = 135 | issue = 9 | pages = 809–11 | date = September 1981 | pmid = 7282655 | doi = 10.1001/archpedi.1981.02130330021007 }}</ref> In Hong Kong, 57% of enuretic children are punished for wetting.<ref>{{cite journal|url=http://www.hkjpaed.org/details.asp?id=85&show=1234|title=Primary Nocturnal Enuresis: Patient Attitudes and Parental Perceptions|journal=Hong Kong Journal of Paediatrics |series=New Series|year=2004 |volume=9 |pages=54–58|access-date=2008-02-03|url-status=live|archive-url=https://web.archive.org/web/20080121230523/http://www.hkjpaed.org/details.asp?id=85&show=1234|archive-date=2008-01-21}}</ref> Parents with only a grade-school level education punish bedwetting children at twice the rate of high-school- and college-educated parents.<ref name="jdiseases" />
*Most children with bedwetting have mental or physical problems.
Only three in 100 children with primary nocturnal enuresis have a physical or urologic cause for it. Psychological problems as a cause of primary bedwetting are not common. Even children with emotional challenges can respond to treatment for bedwetting.
 
In [[Korea]] and in small parts of [[Japan]], there is a folk tradition whereby bedwetters are made to wear a [[winnowing basket]] on their head and sent to ask their neighbors for [[salt]]. This is motivated in part by a desire to publicly embarrass the child into compliance, as neighbors would recognize why the child was knocking on their door.<ref>{{Cite journal |last=Noh |first=Seonghwan |date=April 2021 |title=한국 오줌싸개 치유에 대한 비교민속학적 고찰 |trans-title=Korean Bedwetter and East Asian Folklore |url=https://www.dbpia.co.kr/Journal/articleDetail?nodeId=NODE10568118 |journal=비교민속학 |trans-journal=Comparative Folklore |language=ko |volume=73 |pages=45–88 |issn=1598-1010 |doi=10.38078/ACF.2021.4.73.45 |s2cid=238041634|url-access=subscription }}</ref>
*If a child is a sound sleeper, a bedwetting alarm won't work for him/her.
It is true that children with bedwetting may have a higher threshold for loud noise than other children. Initially the alarm is for the parents-so they can help wake the child and accompany him/her to the bathroom. Over time, the child begins to associate the noise with stopping the flow of urine and going to the toilet. Gradually, he/she will learn to control her muscles in response to a full bladder instead of relaxing them as he/she has done in the past.
 
===Families===
*If the child doesn't tell her parents he/she is bothered by his/her bedwetting, he/she probably doesn't care if she is wet.
Parents and family members are frequently stressed by a child's bedwetting. Soiled linens and clothing cause additional laundry. Wetting episodes can cause lost sleep if the child wakes and/or cries, waking the parents. A European study estimated that a family with a child who wets nightly will pay about $1,000 a year for additional laundry, extra sheets, diapers, and mattress replacement.<ref name="nursingcenter" />
No child wants to wake up in a wet bed. As children reach school age and realize their peers don't wear disposable pants or worry about waking to a wet bed, their self-esteem and social independence are affected. By middle school, their age-appropriate activities are sharply curtailed. All children would rather be dry, and if given ways to control this, are very cooperative with treatments and the use of bedwetting alarms.
 
Despite these stressful effects, doctors emphasize that parents should react patiently and supportively.<ref>{{cite web |url=http://www.kidshealth.org/parent/general/sleep/enuresis.html|title=Bedwetting|website=www.kidshealth.org|access-date=2008-02-03|url-status=live|archive-url=https://web.archive.org/web/20080202125727/http://www.kidshealth.org/parent/general/sleep/enuresis.html|archive-date=2008-02-02}}</ref>
*Bedwetting is nothing more than a pesky problem that will eventually go away.
Perhaps, but with effective treatment available, why wait until your child outgrows it? Financially, enuresis impacts families. One or two extra loads of laundry each day can cost as much as $700 each year. Disposable pants can easily add up to $300 a year. Medications for bedwetting can cost $4 per tablet, and even $25 prescription drug co-pays add up over time.
 
===Sociopathy===
Emotionally, enuresis impacts families. Overnight arrangements are cumbersome-taking along waterproof sheets, disposable pants, extra clothing, etc. Hiding enuresis from other family members and friends is painful. Peers and siblings can be cruel, teasing or humiliating the affected child. Parents must make every effort to prevent teasing from siblings. Remind siblings that they may have challenges in certain aspects of their lives, too. Bedwetting is not done on purpose. Your family works together to overcome challenges.
{{Update|inaccurate=yes|date=December 2021}}
Bedwetting does ''not'' indicate a greater possibility of being a [[Psychopathy#Sociopathy|sociopath]], as long as caregivers do not cause trauma by shaming or punishing a bedwetting child. Bedwetting was part of the [[Macdonald triad]], a set of three behavioral characteristics described by [[John Macdonald (psychiatrist)|John Macdonald]] in 1963.<ref>{{cite journal |vauthors=Macdonald JM |year=1963 |title=The threat to kill |journal=Am J Psychiatry |volume=120 |issue=2| pages=125–130 |doi=10.1176/ajp.120.2.125}}</ref> The other two characteristics were [[firestarting]] and [[animal abuse]]. Macdonald suggested that there was an association between a person displaying all three characteristics, then later displaying [[Psychopathy|sociopathic]] criminal behavior.<ref>{{Cite journal |last1=Parfitt |first1=Charlotte Hannah |last2=Alleyne |first2=Emma |author-link2=Emma Alleyne |date=April 2020 |title=Not the Sum of Its Parts: A Critical Review of the MacDonald Triad |url=https://kar.kent.ac.uk/66782/1/Parfitt%20%26%20Alleyne%20%28in%20press%29.pdf |journal=Trauma, Violence & Abuse |volume=21 |issue=2 |pages=300–310 |doi=10.1177/1524838018764164 |issn=1552-8324 |pmid=29631500 |s2cid=206738131}}</ref>
 
Up to 60% of multiple murderers, according to some estimates, wet their beds post-adolescence.<ref>{{cite book| first = Helen | last = Gavin |title=Criminological and Forensic Psychology|page=120|year=2013}}</ref>
*My child is alone in having this problem.
If a parent, grandparent, aunt or uncle with a history of bedwetting can share their memories with your child, it will help her see that she is not so different. Learning that an adult she respects and admires was similarly affected may help. Also remind your child that, in a class of 25 8-year-olds, at least one or two other children wet the bed.
 
Enuresis is an "unconscious, involuntary [...] act".<ref>{{cite book|last=Hickey|first=Eric |title=Serial Murderers and their Victims |year=2010 |publisher=Wadsworth, Cengage Learning|___location=Belmont, CA|isbn=978-4-9560081-4-3|page=101}}</ref>
*Bedwetting occurred because I left him in disposable pants too long. Most children are day toilet trained between ages 2 and 4. There are generally three types of children when it comes to nighttime dryness:
**Those who become spontaneously dry at night.
**Those who begin with an occasional dry night, progress to more dry nights than wet ones and achieve complete dryness without intervention, usually by 6. Parents of these children should assist them in removing their disposable pants immediately after wakening in the morning and urinating in the toilet. Disposable pants can be discontinued as dry nights prevail.
**Those who have had very few, if any, dry nights in their lives. These children may wet no matter where they are, how much their fluids are restricted or even if their parents take them to the toilet during the night. Using disposable pants in this group can decrease parent frustration until a treatment program is in place.
 
Bedwetting can be connected to past emotions and identity. Children under substantial stress, particularly in their home environment, frequently engage in bedwetting, in order to alleviate the stress produced by their surroundings.{{citation needed|date=April 2021}} Trauma can also trigger a return to bedwetting (secondary enuresis) in both children and adults.
*Parents should restrict privileges or punish their children so they will become dry quicker.
Remember, your child does not consciously control her bedwetting. Punishing your child for an activity that she has no control over is counterproductive. Dealing with the wetting in a supportive manner, such as having your child help make her bed or carry her bedding to and from the washer should be viewed as sharing in household tasks, not as punishment.
 
It is not bedwetting that increases the chance of criminal behavior, but the associated trauma.<ref>{{Cite journal|date=1919|title=The Journal of Delinquency, Volumes 4-5|journal=The Journal of Delinquency|publisher=California Bureau of Juvenile Research, Whittier State School, Department of Research|volume=4-5|pages=41–55}}</ref> Parental cruelty can result in "homicidal proneness".<ref>{{cite book|title=Encyclopedia of Violence |last=Dicanio|first=Margaret |publisher=iUniverse|year=2004|isbn=0-595-31652-2}}</ref>
*Puberty will end bedwetting.
It's true that the number of children with bedwetting decreases with age, but even 1 percent of 18-year-olds continue to have bedwetting. Puberty does not cure bedwetting, and there is no reason that you should wait until your child approaches this age before you attempt treatment.
 
==Causes==
*Medication is a sure cure for bedwetting.
The [[etiology]] of NE is not fully understood, although there are three common causes: excessive urine volume, poor sleep arousal, and bladder contractions. Differentiation of cause is mainly based on patient history and fluid charts completed by the parent or carer to inform management options.<ref name="Nocturnal enuresis in children">{{cite journal|last1=Magura|first1=Ratidzai |title=Nocturnal enuresis in children|journal=The Pharmaceutical Journal|date=2015-01-05|volume=294|issue=7843/4 |doi=10.1211/pj.2015.20067378|url=http://digital.library.wisc.edu/1793/40627|url-access=subscription}}</ref><ref>{{Cite journal|last=Hallgren|first=Bertil|date=1956|title=Enuresis|journal=Acta Psychiatrica Scandinavica|volume=31|issue=4|pages=405–436|doi=10.1111/j.1600-0447.1956.tb09699.x|s2cid=221430598}}</ref>
Although medications such as DDAVP (desmopressin) or Ditropan (oxybutynin) work well as an adjunct to therapy and in instances where a child has to be dry (camps or overnight visits), use of medication alone rarely helps a child permanently overcome bedwetting. When the medication is stopped, the wetting returns in 80 to 90 percent of those treated. Medication can help to buy time in some families who are not ready to use a bedwetting alarm. Children who use alarms are nine times more likely to become dry and stay dry than those who use medication alone.(36)
 
Bedwetting has a strong genetic component. Children whose parents were not enuretic have only a 15% incidence of bedwetting. When one or both parents were bedwetters, the rates jump to 44% and 77% respectively.<ref name="pracparm">{{cite journal | vauthors = Fritz G, Rockney R, Bernet W, Arnold V, Beitchman J, Benson RS, Bukstein O, Kinlan J, McClellan J, Rue D, Shaw JA, Stock S, Kroeger Ptakowski K | title = Practice parameter for the assessment and treatment of children and adolescents with enuresis | journal = Journal of the American Academy of Child and Adolescent Psychiatry | volume = 43 | issue = 12 | pages = 1540–50 | date = December 2004 | pmid = 15564822 | doi = 10.1097/01.chi.0000142196.41215.cc | doi-access = free }}</ref>
==See also==
* [[Urinary incontinence]]
* [[Toilet training]]
 
These first two factors (aetiology and genetic component) are the most common in bedwetting, but current medical technology offers no easy testing for either cause. There is no test to prove that bedwetting is only a developmental delay, and [[genetic testing]] offers little or no benefit. As a result, other conditions should be ruled out. The following causes are less common, but are easier to prove and more clearly treated:{{citation needed|date=April 2021}}
==External links==
*[http://www.babyzone.com/baby_toddler_preschooler_health/sleep_young_child/a234 Bedwetting facts by Dr Karen Sadler]
*[http://www.emedicinehealth.com/articles/8783-1.asp eMedicine Health: Bedwetting]
*[http://www.dryatnight.com/ Bedwetting Information from a Proven Nurse Practitioner]
*[http://www.helpstopbedwetting.info Bedwetting Information] - Help for parents
*[http://www.bedwettingsolutions.com BedwettingSolutions.com: Features remedies and advice on bedwetting, as well as myths and causes]
*[http://www.spont.com/sleepwetting.html Sleepwetting Forum]
*[http://www.bed-wetting-info.co.uk Seven step programme from child psychologist]
 
In some bedwetting children there is no increase in ADH (antidiuretic hormone) production, while other children may produce an increased amount of ADH but their response is insufficient.<ref name="Nocturnal enuresis in children"/><ref>{{cite journal | vauthors = Eggert P, Kühn B | title = Antidiuretic hormone regulation in patients with primary nocturnal enuresis | journal = Archives of Disease in Childhood | volume = 73 | issue = 6 | pages = 508–11 | date = December 1995 | pmid = 8546506 | pmc = 1511443 | doi = 10.1136/adc.73.6.508 }}</ref>
[[Category:Childhood psychiatric disorders]]
* People with reported bedwetting issues are 2.7 times more likely to be diagnosed with [[attention deficit hyperactivity disorder]].<ref name="cks.library.nhs.uk" />
[[Category:Sleep disorders]]
* [[Caffeine]] increases [[urine]] production.<ref>{{cite web |url=https://www.nlm.nih.gov/medlineplus/ency/article/003144.htm |title=MedlinePlus Medical Encyclopedia: Urination – bed wetting |publisher=www.nlm.nih.gov|access-date=2008-02-02|url-status=dead |archive-date=2007-06-09|archive-url=https://web.archive.org/web/20070609144009/http://www.nlm.nih.gov/medlineplus/ency/article/003144.htm}}</ref>
* Chronic [[constipation]] can cause bed wetting.<ref>{{Cite journal|last=Medical Association|first=Texas|date=1910|title=Texas State Journal of Medicine, Volume 5, Issue 12|journal=Texas State Journal of Medicine|publisher=Texas Medical Association., 1910|volume=5|issue=12|page=433}}</ref> When the [[bowels]] are full, it can put pressure on the [[bladder]].<ref>{{cite web |url=http://www.hawaii.edu/medicine/pediatrics/pedtext/s13c09.html|title=Case Based Pediatrics For Medical Students and Residents |publisher=Department of Pediatrics, University of Hawaii John A. Burns School of Medicine|access-date=2008-02-02|last=Reynoso Paredes |first=Potenciano |url-status=live|archive-url=https://web.archive.org/web/20080120165022/http://www.hawaii.edu/medicine/pediatrics/pedtext/s13c09.html|archive-date=2008-01-20}}</ref> Often such children defecate normally, yet they retain a significant mass of material in the bowel which causes bedwetting.<ref>{{cite web |url=http://www.wakehealth.edu/Urology/Pediatric/Bedwetting-Can-be-Due-to-Hidden-Constipation-Research-Shows.htm|title=Bedwetting and Constipation|website=www.wakehealth.edu|access-date=22 February 2018|url-status=live|archive-url=https://web.archive.org/web/20180222104900/http://www.wakehealth.edu/Urology/Pediatric/Bedwetting-Can-be-Due-to-Hidden-Constipation-Research-Shows.htm|archive-date=22 February 2018}}</ref>
* Infections and disease are more strongly connected with [[#Secondary nocturnal enuresis|''secondary'' nocturnal enuresis]] and with [[daytime wetting]]. Less than 5% of all bedwetting cases are caused by infection or disease, the most common of which is a [[urinary tract infection]].<ref name="cks.library.nhs.uk">{{cite web|url=http://cks.library.nhs.uk/enuresis_nocturnal/in_depth/background_information|title=CKS: Enuresis — nocturnal – In depth – Background information|publisher=National Library for Health, National Health Service|access-date=2008-02-02|archive-url=https://web.archive.org/web/20071010011938/http://cks.library.nhs.uk/enuresis_nocturnal/in_depth/background_information|archive-date=2007-10-10}}</ref>
* Patients with more severe neurological-developmental issues have a higher rate of bedwetting problems. One study of seven-year-olds showed that "handicapped and [[intellectual disability|intellectually disabled]] children" had a bedwetting rate almost three times higher than "non-handicapped children" (26.6% vs. 9.5%, respectively).<ref>{{cite journal | vauthors = Järvelin MR, Vikeväinen-Tervonen L, Moilanen I, Huttunen NP | title = Enuresis in seven-year-old children | journal = Acta Paediatrica Scandinavica | volume = 77 | issue = 1 | pages = 148–53 | date = January 1988 | pmid = 3369293 | doi = 10.1111/j.1651-2227.1988.tb10614.x | s2cid = 34177052 }}</ref>
* Psychological issues (e.g., death in the family, [[sexual abuse]], extreme [[bullying]]) are established as a cause of [[#Secondary nocturnal enuresis|secondary nocturnal enuresis]] (a return to bedwetting), but are very rarely a cause of [[#Primary nocturnal enuresis|PNE-type bedwetting]].<ref name="pracparm" /><ref>{{cite journal | vauthors = Butler RJ | title = Childhood nocturnal enuresis: developing a conceptual framework | journal = Clinical Psychology Review | volume = 24 | issue = 8 | pages = 909–31 | date = December 2004 | pmid = 15533278 | doi = 10.1016/j.cpr.2004.07.001 }}</ref> Bedwetting can also be a symptom of a pediatric neuropsychological disorder called [[PANDAS]].<ref>{{cite web | url = http://www.nimh.nih.gov/health/publications/pandas/pandas-frequently-asked-questions-about-pediatric-autoimmune-neuropsychiatric-disorders-associated-with-streptococcal-infections.shtml | title = PANDAS: Frequently Asked Questions about Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections | access-date = 2010-06-01 | publisher = NIMH | url-status = dead | archive-url = https://web.archive.org/web/20100527174457/http://www.nimh.nih.gov/health/publications/pandas/pandas-frequently-asked-questions-about-pediatric-autoimmune-neuropsychiatric-disorders-associated-with-streptococcal-infections.shtml | archive-date = 2010-05-27 }}</ref>
* [[Sleep apnea]] stemming from an upper [[airway]] obstruction<ref>{{Cite journal|last=Lewis|first=Daniel|date=1909|title=Medical Review of Reviews Volume 15|journal=Medical Review of Reviews|publisher=Austin Flint Association, Incorporated|volume=15|page=748}}</ref> has been associated with bedwetting. [[Snoring]] and enlarged [[tonsils]] or [[adenoids]] are a sign of potential sleep apnea problems.<ref name="pracparm" />
* [[Sleepwalking]] can lead to bedwetting. During sleepwalking, the sleepwalker may think they are in another room. When the sleepwalker urinates during a sleepwalking episode, they usually think they are in the bathroom, and therefore urinate where they think the toilet should be. Cases of this have included opening a closet and urinating in it; urinating on the sofa, and simply urinating in the middle of the room.{{Citation needed|reason=Is this phenomenon mentioned anywhere?|date=November 2022}}
* Stress is a cause of people who return to wetting the bed. Researchers find that moving to a new town, parent conflict or divorce, arrival of a new baby, or loss of a loved one or pet can cause insecurity, contributing to returning bedwetting.<ref name="ifas" />
* [[Type 1 diabetes mellitus]] can first present as nocturnal enuresis. It is classically associated with polyuria, polydipsia, and polyphagia; weight loss, lethargy, and diaper candidiasis may also be present in those with new-onset disease.
* [[Alcohol intoxication]] is a leading cause for nocturnal enuresis among adults. Alcohol suppresses the production of anti diuretic hormones and irritates the detrusor muscle in the bladder. These factors, paired with the large amount of fluid ingested, particularly during binge drinking sessions or when paired with caffeinated drinks, can lead to episodes of nocturnal enuresis.<ref>{{cite web | url=https://health.clevelandclinic.org/adults-booze-bedwetting-heres-happens/ | title=Adults + Booze = Bedwetting? Here's Why It Happens to You | date=27 July 2020 }}</ref>
 
===Unconfirmed===
[[de:Enuresis]]
* [[Food allergy|Food allergies]] may be part of the cause for some patients. This link is not well established, requiring further research.<ref>{{cite journal | vauthors = Mungan NA, Seckiner I, Yesilli C, Akduman B, Tekin IO | s2cid = 33708606 | title = Nocturnal enuresis and allergy | journal = Scandinavian Journal of Urology and Nephrology | volume = 39 | issue = 3 | pages = 237–41 | year = 2005 | pmid = 16118098 | doi = 10.1080/00365590510007739 }}</ref><ref>{{cite web|url=http://healthinfo.cedars-sinai.edu/library/healthguide/en-us/Cam/topic.asp?hwid=hn-1006005|title=Allergies and Sensitivities|publisher=Cedars-Sinai Health System|access-date=2008-02-02|archive-url=https://web.archive.org/web/20080515203038/http://healthinfo.cedars-sinai.edu/library/healthguide/en-us/Cam/topic.asp?hwid=hn-1006005|archive-date=2008-05-15}}</ref>
[[es:Enuresis nocturna]]
* Improper toilet training is another disputed cause of bedwetting. This theory was more widely supported in the last century and is still cited by some authors today. Some say bedwetting can be caused by improper [[toilet training]],<ref>{{cite journal | vauthors = Mowrer OH, Mowrer WM | title = Enuresis—a method for its study and treatment. | journal = American Journal of Orthopsychiatry | date = July 1938 | volume = 8 | issue = 3 | pages = 436–459 | doi = 10.1111/j.1939-0025.1938.tb06395.x }}</ref> either by starting the training when the child is too young or by being too forceful. Recent research has shown more mixed results and a connection to toilet training has not been proven or disproven.<ref>{{cite web |url=http://uimc.discoveryhospital.com/main.php?id=2863 |title=Enuresis |publisher=University of Illinois Medical Center:Health Library |access-date=2008-02-02 |archive-url=https://web.archive.org/web/20080126052155/http://uimc.discoveryhospital.com/main.php?id=2863 |archive-date=2008-01-26 }}</ref> According to the American Academy of Pediatrics, more child abuse occurs during potty training than in any other developmental stage.{{citation needed|date=March 2022}}
[[fr:Énurésie]]
* [[Dandelion]]s are reputed to be a potent diuretic, and anecdotal reports and folk wisdom say children who handle them can end up wetting the bed.<ref>{{cite news|url=http://www.cbc.ca/news/background/living-green/dandelions.html|title=Dandelions:time to throw in the trowel|access-date=2007-07-10|work=CBC News|date=2007-06-13|url-status=live|archive-url=https://web.archive.org/web/20070717153346/http://www.cbc.ca/news/background/living-green/dandelions.html|archive-date=2007-07-17}}</ref> English folk names for the plant are "peebeds" and "pissabeds".<ref>{{cite web|url=http://www.answers.com/topic/dandelions-1|title=English folklore|website=[[Answers.com]]|url-status=live|archive-url=https://web.archive.org/web/20090615022413/http://www.answers.com/topic/dandelions-1|archive-date=2009-06-15}}</ref> In French the dandelion is called ''pissenlit'', which means "piss in bed"; likewise "piscialletto", an Italian folkname, and "meacamas" in Spanish.<ref>{{cite web |title=Benefits of herbal tea |archive-url=https://web.archive.org/web/20080106134125/http://www.herbalteatips.com/Benefits.php |archive-date=2008-01-06|url=http://www.herbalteatips.com/Benefits.php}}</ref>
[[nl:Enurese]]
 
[[no:Sengevæting]]
==Mechanism==
[[ja:夜尿症]]
Two physical functions prevent bedwetting. The first is a [[hormone]] that reduces [[urine]] production at night. The second is the ability to wake up when the [[bladder]] is full. Children usually achieve nighttime dryness by developing one or both of these abilities. There appear to be some [[hereditary]] factors in how and when these develop.<ref>{{Cite journal|last1=von Gontard|first1=A.|last2=Schaumburg|first2=H.|last3=Hollmann|first3=E.|last4=Eiberg|first4=H.|last5=Rittig|first5=S.|date=December 2001|title=The genetics of enuresis: a review |journal=The Journal of Urology|volume=166|issue=6|pages=2438–2443|doi=10.1097/00005392-200112000-00117|issn=0022-5347|pmid=11696807}}</ref>
[[pt:Incontinência urinária]]
 
The first ability is a [[hormone]] cycle that reduces the body's urine production. At about sunset each day, the body releases a minute burst of [[vasopressin|antidiuretic hormone]] (also known as arginine vasopressin or AVP). This hormone burst reduces the [[kidney]]'s urine output well into the night so that the bladder does not get full until morning. This hormone cycle is not present at birth. Many children develop it between the ages of two and six years old, others between six and the end of [[puberty]], and some not at all.<ref>{{Cite journal|date=2005–2012|title=Management of primary nocturnal enuresis|journal=Paediatrics & Child Health|volume=10|issue=10|pages=611–614|doi=10.1093/pch/10.10.611|issn=1205-7088|pmc=2722619|pmid=19668675|last1=Feldman|first1=M.}}</ref>
 
The second ability that helps people stay dry is waking when the bladder is full. This ability develops in the same age range as the vasopressin hormone, but is separate from that hormone cycle.
 
The typical development process begins with one- and two-year-old children developing larger bladders and beginning to sense bladder fullness. Two- and three-year-old children begin to stay dry during the day. Four- and five-year-olds develop an adult pattern of urinary control and begin to stay dry at night.<ref name="johnson" />
 
==Diagnosis==
 
Thorough history regarding frequency of bedwetting, any period of dryness in between, associated daytime symptoms, constipation, and encopresis should be sought.
 
===Voiding diary===
* People are asked to observe, record and measure when and how much their child voids and drinks, as well as associated symptoms. A voiding diary in the form of a frequency volume chart records voided volume along with the time of each micturition for at least 24 hours. The frequency volume chart is enough for patients with complaints of nocturia and frequency only. If other symptoms are also present then a detailed bladder diary must be maintained. In a bladder diary, times of micturition and voided volume, incontinence episodes, pad usage, and other information such as fluid intake, the degree of urgency, and the degree of incontinence are recorded.<ref>{{cite journal |vauthors=Wang CC, Chen JJ, Peng CH, Huang CH, Wang CL |year=2008 |title=Use of a voiding diary in the evaluation of overactive bladder and nocturia |url=http://www.tcs.org.tw/issue/Folder/2_2Suppl/05-V2suppl%201-PP%209-11.pdf |journal=Incontinence & Pelvic Floor Dysfunction |volume=2 |pages=9–11}}</ref>
 
===Physical examination===
* Each child should be examined physically at least once at the beginning of treatment. A full pediatric and neurological exam is recommended.<ref>{{cite book | vauthors = Von Gontard A | chapter = Enuresis | veditors = Rey JM | title = IACAPAP e-Textbook of Child and Adolescent Mental Health. | ___location = Geneva | publisher = International Association for Child and Adolescent Psychiatry and Allied Professions | date = 2012 }}</ref> Measurement of blood pressure is important to rule out any renal pathology. External genitalia and lumbosacral spine should be examined thoroughly. A spinal defect, such as a dimple, hair tuft, or skin discoloration, might be visible in approximately 50% of patients with an intraspinal lesion. Thorough neurologic examination of the lower extremities, including gait, muscle power, tone, sensation, reflexes, and plantar responses should be done during first visit.
 
===Classification===
Nocturnal urinary continence is dependent on three factors: 1) nocturnal urine production, 2) nocturnal bladder function and 3) sleep and arousal mechanisms. Any child will experience nocturnal enuresis if more urine is produced than can be contained in the bladder or if the detrusor is hyperactive, provided that he or she is not awakened by the imminent bladder contraction.<ref>{{cite journal | vauthors = Nevéus T | title = Nocturnal enuresis-theoretic background and practical guidelines | journal = Pediatric Nephrology | volume = 26 | issue = 8 | pages = 1207–14 | date = August 2011 | pmid = 21267599 | pmc = 3119803 | doi = 10.1007/s00467-011-1762-8 }}</ref>
 
====Primary nocturnal enuresis====
Primary nocturnal enuresis is the most common form of bedwetting. Bedwetting becomes a disorder when it persists after the age at which bladder control usually occurs (4–7 years), and is either resulting in an average of at least two wet nights a week with no long periods of dryness or not able to sleep dry without being taken to the toilet by another person.
 
New studies show that anti-psychotic drugs can have a side effect of causing enuresis.<ref>{{cite journal | vauthors = Barnes TR, Drake MJ, Paton C | title = Nocturnal enuresis with antipsychotic medication | journal = The British Journal of Psychiatry | volume = 200 | issue = 1 | pages = 7–9 | date = January 2012 | pmid = 22215862 | doi = 10.1192/bjp.bp.111.095737 | doi-access = free }}</ref>
 
It has been shown that diet impacts enuresis in children. [[Constipation]] from a poor diet can result in impacted stool in the colon putting undue pressure on the bladder creating loss of bladder control ([[overflow incontinence]]).<ref>{{cite web|url=http://urology.ucsf.edu/patient-care/children/urinary-incontinence/nocturnal-enuresis|title=Nocturnal Enuresis|work=ucsf.edu|url-status=live|archive-url=https://web.archive.org/web/20140517132629/http://urology.ucsf.edu/patient-care/children/urinary-incontinence/nocturnal-enuresis|archive-date=2014-05-17}}</ref>
 
Some researchers, however, recommend a different starting age range. This guidance says that bedwetting can be considered a clinical problem if the child regularly wets the bed after turning 7 years old.<ref name="ifas">{{cite web | first1 = Heidi Liss | last1 = Radunovich | first2 = Garret D. | last2 = Evans |url=http://edis.ifas.ufl.edu/HE794|title=Bedwetting|publisher=University of Florida IFAS Extension|access-date=2008-02-02 |url-status=live|archive-url=https://web.archive.org/web/20080119185645/http://edis.ifas.ufl.edu/HE794|archive-date=2008-01-19}}</ref>
 
====Secondary nocturnal enuresis====
Secondary enuresis occurs ''after'' a patient goes through an extended period of dryness at night (six months or more) and then ''reverts'' to night-time wetting. Secondary enuresis can be caused by emotional stress or a medical condition, such as a bladder infection.<ref>{{cite web|url=http://pedclerk.bsd.uchicago.edu/enuresis.html|title=Enuresis|publisher=University of Chicago Pritzker School of Medicine|access-date=2008-02-02|archive-url=https://web.archive.org/web/20080206103432/http://pedclerk.bsd.uchicago.edu/enuresis.html|archive-date=2008-02-06}}</ref>
 
====Psychological definition====
Psychologists are usually allowed to diagnose and write a prescription for diapers if nocturnal enuresis causes the patient significant distress.<ref>{{cite journal | vauthors = Mellon MW, McGrath ML | title = Empirically supported treatments in pediatric psychology: nocturnal enuresis | journal = Journal of Pediatric Psychology | volume = 25 | issue = 4 | pages = 193–214; discussion 215–8, 219–24 | date = June 2000 | pmid = 10814687 | doi = 10.1093/jpepsy/25.4.193 | doi-access = free }}</ref> Psychiatists may instead use a definition from the [[DSM-IV]], defining nocturnal enuresis as repeated urination into bed or clothes, occurring twice per week or more for at least three consecutive months in a child of at least 5 years of age and not due to either a [[Side effect|drug side effect]] or a [[medical condition]].
 
==Management==
There are a number of management options for bedwetting. The following options apply when the bedwetting is not caused by a specifically identifiable medical condition such as a bladder abnormality or diabetes. Treatment is recommended when there is a specific medical condition such as [[bladder]] abnormalities, [[infection]], or [[diabetes]]. It is also considered when bedwetting may harm the child's [[self-esteem]] or relationships with family/friends. Only a small percentage of bedwetting is caused by a specific medical condition, so most treatment is prompted by concern for the child's ''emotional'' welfare. Behavioral treatment of bedwetting overall tends to show increased self-esteem for children.<ref>{{Cite journal |doi = 10.1037/h0100319|title = Behavioral treatment for nocturnal enuresis|journal = Journal of Early and Intensive Behavior Intervention|volume = 2|issue = 4|pages = 259–267|year = 2005|last1 = Friman|first1 = Patrick C.|last2 = Jones|first2 = Kevin M. |doi-access = free}}</ref><ref>{{Cite journal |last=Forrest |first=J.E. |date=1880 |editor-last=M.D. |editor-first=T.P. Wilson |editor2-last=M.D. |editor2-first=T.P. Geppert |title=Cincinnati Medical Advance |journal=Cincinnati Medical Advance |publisher=J.E. Forrest |publication-place=Cincinnati Medical Advance |volume=7-8 |pages=347-348}}</ref>
 
Parents become concerned much earlier than doctors. A study in 1980 asked parents and physicians the age that children should stay dry at night. The average parent response was 2.75 years old, while the average physician response was 5.13 years old.<ref>{{cite journal | vauthors = Shelov SP, Gundy J, Weiss JC, McIntire MS, Olness K, Staub HP, Jones DJ, Haque M, Ellerstein NS, Heagarty MC, Starfield B | title = Enuresis: a contrast of attitudes of parents and physicians | journal = Pediatrics | volume = 67 | issue = 5 | pages = 707–10 | date = May 1981 | doi = 10.1542/peds.67.5.707 | pmid = 7255000 | s2cid = 12300964 }}</ref>
 
Punishment is not effective and can interfere with treatment.
 
===Treatment approaches===
Simple behavioral methods are recommended as initial treatment.<ref name="Cald2013">{{cite journal | vauthors = Caldwell PH, Nankivell G, Sureshkumar P | title = Simple behavioural interventions for nocturnal enuresis in children | journal = The Cochrane Database of Systematic Reviews | volume = 7 | issue = 7 | pages = CD003637 | date = July 2013 | pmid = 23881652 | doi = 10.1002/14651858.cd003637.pub3 | doi-access = free }}</ref> Other treatment methods include the following:
* Motivational therapy in nocturnal enuresis mainly involves parent and child education. Guilt should be allayed by providing facts. Fluids should be restricted 2 hours prior to bed. The child should be encouraged to empty the bladder completely prior to going to bed. Positive reinforcement can be initiated by setting up a diary or chart to monitor progress and establishing a system to reward the child for each night that they are dry.<ref>{{Cite journal |last=K. |first=Popler |date=1976 |title=Token reinforcement in the treatment of nocturnal enuresis: A case study and six month follow-up. |url=https://doi.org/10.1016/0005-7916(76)90051-3 |journal=Journal of Behavior Therapy and Experimental Psychiatry |volume=7 |issue=1 |pages=83–84|doi=10.1016/0005-7916(76)90051-3 |url-access=subscription }}</ref> The child should participate in morning cleanup as a natural, nonpunitive consequence of wetting. This method is particularly helpful in younger children (<8 years) and will achieve dryness in 15-20% of the patients.<ref name="ReferenceA">{{cite journal | vauthors = Jain S, Bhatt GC | s2cid = 21887776 | title = Advances in the management of primary monosymptomatic nocturnal enuresis in children | journal = Paediatrics and International Child Health | volume = 36 | issue = 1 | pages = 7–14 | date = February 2016 | pmid = 25936863 | doi = 10.1179/2046905515Y.0000000023 }}</ref><ref>{{cite journal | vauthors = Doleys DM | title = Behavioral treatments for nocturnal enuresis in children: a review of the recent literature | journal = Psychological Bulletin | volume = 84 | issue = 1 | pages = 30–54 | date = January 1977 | pmid = 322182 | doi = 10.1037/0033-2909.84.1.30 }}</ref>
* Waiting:<ref>{{Cite journal|last=Josephus Robinson|first=William|date=1922|title=Married Life and Happiness Or, Love and Comfort in Marriage ...|journal=Married Life and Happiness or, Love and Comfort in Marriage ...|___location=University of Chicago|publisher=Eugenics Publishing Company|volume=4|page=167}}</ref> Almost all children will outgrow bedwetting. For this reason, urologists and pediatricians frequently recommend delaying treatment until the child is at least six or seven years old. Physicians may begin treatment earlier if they perceive the condition is damaging the child's self-esteem and/or relationships with family/friends.<!-- Deleted image removed: [[File:Wearable alarm.gif|thumb|250px|Wearable Bedwetting Alarm]] -->
* Bedwetting alarms: Physicians also frequently suggest [[bedwetting alarm]]s which sound a loud tone when they sense moisture. This can help [[Classical conditioning|condition]] the child to wake at the sensation of a full [[Urinary bladder|bladder]].<ref>{{cite journal | vauthors = Martin B, Kubly D | title = Results of treatment of enuresis by a conditioned response method | journal = Journal of Consulting Psychology | volume = 19 | issue = 1 | pages = 71–3 | date = February 1955 | pmid = 14354096 | doi = 10.1037/h0042300 }}</ref> These alarms are considered more effective than no treatment and may have a lower risk of adverse events than some medical therapies but it is still uncertain if alarms are more effective than other treatments.<ref>{{cite journal | vauthors = Caldwell PH, Codarini M, Stewart F, Hahn D, Sureshkumar P | title = Alarm interventions for nocturnal enuresis in children | journal = The Cochrane Database of Systematic Reviews | volume = 5 | pages = CD002911 | date = May 2020 | issue = 3 | pmid = 32364251 | pmc = 7197139 | doi = 10.1002/14651858.CD002911.pub3 }}</ref> There may be a 29% to 69% relapse rate, so the treatment may need to be repeated.<ref name="bmj">{{cite journal | vauthors = Evans JH | title = Evidence based management of nocturnal enuresis | journal = BMJ | volume = 323 | issue = 7322 | pages = 1167–9 | date = November 2001 | pmid = 11711411 | pmc = 1121645 | doi = 10.1136/bmj.323.7322.1167 }}</ref>
* DDAVP ([[desmopressin]]) tablets are a synthetic replacement for [[Vasopressin|antidiuretic hormone]], the hormone that reduces urine production during sleep. Desmopressin is usually used in the form of desmopressin acetate, DDAVP. Patients taking DDAVP are 4.5 times more likely to stay dry than those taking a placebo.<ref name="bmj" /> The drug replaces the hormone for that night with no cumulative effect. US drug regulators have banned using desmopressin nasal sprays for treating bedwetting since the oral form is considered safer.
* DDAVP is most efficient in children with nocturnal polyuria (nocturnal urine production greater than 130% of expected bladder capacity for age) and normal bladder reservoir function (maximum voided volume greater than 70% of expected bladder capacity for age).<ref>{{cite journal | vauthors = Neveus T, Eggert P, Evans J, Macedo A, Rittig S, Tekgül S, Vande Walle J, Yeung CK, Robson L | title = Evaluation of and treatment for monosymptomatic enuresis: a standardization document from the International Children's Continence Society | journal = The Journal of Urology | volume = 183 | issue = 2 | pages = 441–7 | date = February 2010 | pmid = 20006865 | doi = 10.1016/j.juro.2009.10.043 }}</ref><ref>{{cite journal | vauthors = Janknegt RA, Smans AJ | title = Treatment with desmopressin in severe nocturnal enuresis in childhood | journal = British Journal of Urology | volume = 66 | issue = 5 | pages = 535–7 | date = November 1990 | pmid = 2249126 | doi = 10.1111/j.1464-410X.1990.tb15005.x }}</ref> Other children who are likely candidates for desmopressin treatment are those in whom alarm therapy has failed or those considered unlikely to comply with alarm therapy. It can be very useful for summer camp and sleepovers to prevent enuresis.<ref name="ReferenceA"/>
* Tricyclic antidepressants: [[Tricyclic antidepressant]] [[prescription drug]]s with [[anti-muscarinic]] properties have been proven successful in treating bedwetting, but also have an increased risk of side effects, including death from overdose.<ref>{{cite journal | vauthors = Robson WL | title = Clinical practice. Evaluation and management of enuresis | journal = The New England Journal of Medicine | volume = 360 | issue = 14 | pages = 1429–36 | date = April 2009 | pmid = 19339722 | doi = 10.1056/nejmcp0808009 }}</ref> These drugs include [[amitriptyline]], [[imipramine]] and [[nortriptyline]]. Studies find that patients using these drugs are 4.2 times as likely to stay dry as those taking a [[placebo]].<ref name="bmj" /> The relapse rates after stopping the medicines are close to 50%.
 
===Condition management===
* Diapers: Wearing a [[diaper]] can reduce embarrassment for bedwetters and make cleanup easier for caregivers. These products are known as training pants or diapers when used for younger children, and as absorbent underwear or incontinence briefs when marketed for older children and adults. Some diapers are marketed especially for people with bedwetting. A major benefit is the reduced stress on both the bedwetter and caregivers. Wearing diapers can be especially beneficial for bedwetting children wishing to attend sleepovers or campouts, reducing emotional problems caused by social isolation and/or embarrassment in front of peers. According to a study of one adult with severe disabilities, extended diaper usage may interfere with learning to stay dry.<ref>{{cite web|url=http://seab.envmed.rochester.edu/jaba/articles/2004/jaba-37-01-0097.pdf |title=Extended Diaper Wearing: Effects on Continence in and Out of the Diaper |publisher=Journal of Applied Behavior Analysis |access-date=2008-02-03|archive-url=https://web.archive.org/web/20070628192201/http://seab.envmed.rochester.edu/jaba/articles/2004/jaba-37-01-0097.pdf|archive-date=2007-06-28}}</ref>
 
[[File:Plastic Pants suitable for nocturnal enuresis in larger child or small adult.JPG|thumb|Plastic pants suitable for nocturnal enuresis in larger child or small adult]]
* Waterproof mattress pads are used in some cases to ease clean-up of bedwetting incidents, however they only protect the mattress, and the sheets, bedding or sleeping partner may be soiled.
 
===Unproven===
* Acupuncture: While acupuncture is safe in most adolescents,<ref>{{cite journal | vauthors = Jindal V, Ge A, Mansky PJ | title = Safety and efficacy of acupuncture in children: a review of the evidence | journal = Journal of Pediatric Hematology/Oncology | volume = 30 | issue = 6 | pages = 431–42 | date = June 2008 | pmid = 18525459 | pmc = 2518962 | doi = 10.1097/MPH.0b013e318165b2cc }}</ref> studies done to assess its effectiveness for nocturnal enuresis are of low quality.<ref name="pmid15791606">{{cite journal | vauthors = Bower WF, Diao M, Tang JL, Yeung CK | title = Acupuncture for nocturnal enuresis in children: a systematic review and exploration of rationale | journal = Neurourology and Urodynamics | volume = 24 | issue = 3 | pages = 267–72 | date = 2005 | pmid = 15791606 | doi = 10.1002/nau.20108 | s2cid = 24646177 }}</ref>
* Dry bed training: Dry bed training is frequently waking the child at night.<ref name="yahoohealth">{{cite web|url=http://health.yahoo.com/fitness-resources/dry-bed-training-for-bed-wetting/healthwise--hw211600.html|title=Dry-bed training for bed-wetting|publisher=Yahoo! Health|access-date=2008-02-03|last=Fackler|first=Amy |archive-url=https://web.archive.org/web/20080208110616/http://health.yahoo.com/fitness-resources/dry-bed-training-for-bed-wetting/healthwise--hw211600.html|archive-date=2008-02-08}}</ref><ref>{{Cite journal|last=Wood|first=W.|date=1918|title=Medical Record|journal=Medical Record|volume=94|issue=1–12|page=204}}</ref> Studies show this training is ineffective by itself<ref name="bmjconcise">{{cite journal | vauthors = Makari J, Rushton HG | title = Nocturnal enuresis | journal = American Family Physician | volume = 73 | issue = 9 | pages = 1611–3 | date = May 2006 | pmid = 16719255 | url = http://www.aafp.org/afp/20060501/bmj.html | url-status = live | archive-url = https://web.archive.org/web/20070929083129/http://www.aafp.org/afp/20060501/bmj.html | archive-date = 2007-09-29 }}</ref> and does not increase the success rate when used in conjunction with a bedwetting alarm.<ref name="bmj" />
* Star chart: A star chart allows a child and parents to track dry nights, as a record and/or as part of a reward program. This can be done either alone or with other treatments. There is no research to show effectiveness, either in reducing bedwetting or in helping self-esteem.<ref name="bmj" /> Some psychologists, however, recommend star charts as a way to celebrate successes and help a child's self-esteem.<ref name="yahoohealth" />
 
==Epidemiology==
Doctors frequently consider bedwetting as a self-limiting problem, since most children will outgrow it. Children 5 to 9 years old have a spontaneous cure rate of 14% per year. Adolescents 10 to 17 years old have a spontaneous cure rate of 16% per year.<ref name="BJU">{{cite journal | vauthors = Nappo S, Del Gado R, Chiozza ML, Biraghi M, Ferrara P, Caione P | title = Nocturnal enuresis in the adolescent: a neglected problem | journal = BJU International | volume = 90 | issue = 9 | pages = 912–7 | date = December 2002 | pmid = 12460356 | doi = 10.1046/j.1464-410X.2002.03030.x | publisher = British Journal of Urology | s2cid = 19386118 | doi-access = free }}</ref>
 
As can be seen from the numbers above, a portion of bedwetting children will not outgrow the problem. Adult rates of bedwetting show little change due to spontaneous cure. Persons who are still enuretic at age 17 are likely to deal with bedwetting throughout their lives.<ref name="BJU" />
 
Studies of bedwetting in adults have found varying rates. The most quoted study in this area was done in the Netherlands. It found a 0.5% rate for 20- to 79-year-olds. A Hong Kong study, however, found a much higher rate. The Hong Kong researchers found a bedwetting rate of 2.3% in 16- to 40-year-olds.<ref name="BJU" />
 
==History==
In the first century B.C., at lines 1026–29 of the fourth book of his [[De rerum natura|On the Nature of Things]], [[Lucretius]] gave a high-style description of bed-wetting:<ref>{{cite book|url= https://books.google.com/books?id=QWx1AAAAIAAJ | title=De rerum natura|page=178| isbn=978-0-598-06609-1| last1=Carus| first1=Titus Lucretius| year=1924}}</ref>
 
:"Innocent children<ref>{{cite journal|title=The Bed-Wetters in Lucretius 4.1026|jstor=311321|last1=Brown|first1=Robert D.|journal=Harvard Studies in Classical Philology|year=1994|volume=96|pages=191–196|doi=10.2307/311321|pmid=16437861}}</ref> often, when they are bound up by sleep, believe they are raising up their clothing by a latrine or shallow pot; they pour out the urine from their whole body, and the Babylonian bedding with its magnificent splendor is soaked."
 
An early psychological perspective on bedwetting was given in 1025 by [[Avicenna]] in ''[[The Canon of Medicine]]'':<ref>{{Cite book|title=Sleep Psychiatry| first1 = Alexander Z. | last1 = Golbin | first2 = Howard M. | last2 = Kravitz | first3 = Louis G. | last3 = Keith |publisher=[[Taylor and Francis]]|year=2004|isbn=1-84214-145-7|page=171}}</ref>
:"Urinating in bed is frequently predisposed by deep sleep: when urine begins to flow, its inner nature and hidden will (resembling the will to breathe) drives urine out before the child awakes. When children become stronger and more robust, their sleep is lighter and they stop urinating."
 
Psychological theory through the 1960s placed much greater focus on the possibility that a bedwetting child might be acting out, purposefully striking back against parents by soiling linens and bedding. However, more recent research and medical literature states that this is very rare.<ref name="rwj">{{cite web|url=http://rwjsurgery.umdnj.edu/divisions/Urology/Peds/bedwetting.asp|title=Department of Surgery, UMDNJ-RWJMS|publisher=rwjsurgery.umdnj.edu|access-date=2008-02-03|archive-url=https://web.archive.org/web/20080206095959/http://rwjsurgery.umdnj.edu/divisions/Urology/Peds/bedwetting.asp|archive-date=2008-02-06}}</ref><ref>{{cite web|url=http://children.musc.edu/news/parenting_newsletter/2002_12/|title=Many Older Children Struggle With Bedwetting|publisher=MUSC Children's Hospital|access-date=2008-02-03|archive-url =https://web.archive.org/web/20080206120225/http://children.musc.edu/news/parenting_newsletter/2002_12/<!-- Bot retrieved archive --> |archive-date = 2008-02-06}}</ref>
 
== See also ==
* [[Enuresis]]
* [[Nocturnal emission]]
 
== References ==
{{Reflist}}
 
== External links ==
{{Medical resources
| DiseasesDB = 4326
| ICD10 = {{ICD10|F|98|0|f|90}}, {{ICD10|R|32||r|30}}
| ICD9 = {{ICD9|307.6}}, {{ICD9|788.36}}
| ICDO =
| OMIM =
| MedlinePlus = 003144
| eMedicineSubj = ped
| eMedicineTopic = 689
| MeshID = D053206
}}
 
{{Mental and behavioral disorders|selected = physical}}
{{Urinary system symptoms and signs}}
 
{{Authority control}}
 
[[Category:Childhood]]
[[Category:Mental disorders diagnosed in childhood]]
[[Category:Pediatrics]]
[[Category:Sleep disorders]]
[[Category:Symptoms and signs: Urinary system]]
[[Category:Toilet training]]
[[Category:Urine]]
[[Category:Urology]]
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