Have a good, dry night

One hot summer night when I was about eight, my sister and I had a little slumber party in my parents’ bedroom. It was nice and cool in their room, as we turned up the air conditioning as high as it could go. After a night of playing board games, snacking on popcorn, and drinking lots of soda, we snuggled in our blankets and settled down to sleep. Later in the middle of the night, I got up to go to the bathroom.

I remember trying to “feel” my way through the darkness and tripping by the dresser. When I made it to the toilet, I quickly pulled down my underwear and started to pee. The next thing I knew, I felt something warm creep up my nightshirt. Apparently, my trip to the bathroom was just a dream. And I had peed on the bed.

Panicked, I got up from bed (yes, awake for real this time!) and started to find a way to hide my accident. Because of the commotion I caused, my mom woke up. I cowered in fear of her response because no eight-year-old should wet her bed, right? To my amazement, all she said was that it was an accident and it was okay.

That was the only time I remember wetting the bed.

For many children, though, bedwetting is a common experience. Estimates show that up to seven percent of eight-year-old children still wet their beds. For younger children, estimates go up to 16 percent. It is more prevalent in boys compared to girls and the likelihood of bedwetting decreases as a child gets older.

Bedwetting is known medically as enuresis (en-yur-ee-sis). Some experts also call it as nocturnal enuresis or nighttime incontinence, mainly because it is used to describe the inability to control one’s bladder during sleep even after the age at which this should have been mastered. For many of those who wet the bed, they are able to effectively identify the need to go to the bathroom during the day, but not at night.

Nocturnal enuresis is classified into two subcategories: Primary Nocturnal Enuresis (PNE) and Secondary Nocturnal Enuresis (SNE). PNE pertains to the typical bedwetting behaviors of a child who has not yet had a prolonged period of being dry throughout the night. SNE refers to bedwetting behaviors that occur after a child has stopped wetting the bed for a significant amount of time. This is usually triggered by a stressful period in the child’s life, such as moving homes, experiencing a loss, or having difficulties with school, peers, or family.

Causes of Enuresis

Most of the time, bedwetting is resolved by age three. However, for some children, it takes longer. Although the exact cause of bedwetting is not readily identified, there are a number of possible reasons why it happens.

According to an article by Dr. David Bolong, a leading Pediatric Urologist in the country who treats patients with enuresis, “it should be emphasized that the cause of all forms of enuresis is almost never due to laziness or deliberate willfulness by the child.” It is important for parents and family members to know this, so that they can be patient and understanding toward the child.

On the other hand, enuresis can be explained by several physiologic causes. Bedwetting is said to be a developmental stage children go through because their nervous or urinary systems have not fully matured. Most cases of bedwetting are said to be caused by a slower-than-normal ability to control one’s bladder. “Slow maturation” of the child’s central nervous system may also be a cause. The messages being sent to the brain from the bladder is not sent efficiently, resulting in a child failing to wake from sleep to go to the bathroom. It is also possible that the child has a small bladder.

Some children with this problem are said to be heavy sleepers. Sleep arousal problems are said to be plausible explanations for wetting the bed.

Another possible reason for bedwetting is a hormonal imbalance. Children who do not produce enough of the hormone known as vasopressin, an antidiuretic hormone (ADH), may more likely wet their beds because their bodies are unable to slow down nighttime urine production, thus filling up their bladders more quickly than others.

Bedwetting has been said to have familial or genetic causes. Children with parents who also struggled with bedwetting during childhood are more likely experience it as well. Statistics suggest that if a child has one parent who had problems with bedwetting in the past, he or she will have a 44 percent chance of also becoming a bedwetter. If both parents had the problem, the probability goes up to 77 percent. On the contrary, if the parents had no problems with enuresis, the child only has a 15 percent chance of developing a problem with bedwetting.

Illnesses such as diabetes, urinary tract infections, and chronic constipation may also affect a child’s ability to control his or her bladder. Bedwetting may actually be a symptom of the illness, especially since children with urinary tract infections may experience difficulties in urination, both during day and night. Accidental incontinence may also be a result of the infection. For a child who suddenly experiences SNE, bedwetting may be a first indicator of diabetes.

For a minority of cases, anatomical defects can explain bedwetting. Abnormalities with the spinal cord, urethral valves, or the ureter of the child may be present. These cases may require more medical intervention.

Psychological stress and anxiety may trigger bouts of bedwetting. This is more common for secondary nocturnal enuresis. Bedwetting can be a sign of emotional problems that may be stirred up by stressful events. These may include problems in the home, abuse, loss, or difficulty adjusting to new situations.

Although some may say bedwetting is not a mental disorder or a behavioral problem, the American Psychiatric Association includes enuresis on its list of disorders diagnosed in infancy, childhood, or adolescence. The DSM-IV defines nocturnal enuresis, whether voluntary or involuntary, as repeated urination into clothes or bed, occuring with a frequency of twice a week for at least three months or causing distress or dysfunction, occuring at age five and above, and not caused by medication or a general medical condition. Involuntary enuresis, however, is more likely linked to behavioral problems.

The impact of bedwetting on a child and the family

Bedwetting can be an embarrassing and traumatic experience for a child, especially when this is coupled with anger or disappointment from parents and caregivers. Children with this problem have lower self-esteem and a less positive self-concept. They rate themselves more poorly when it comes to issues of competence as compared to those who do not have the problem. They also view themselves as less physically attractive and socially accepted.

These show how extensive the emotional toll bedwetting can have on a child as it has long-term effects on their self-esteem and how they view themselves. It can also fuel feelings of insecurity, as well as make them feel that there is something wrong with them.

Socially, a child with this problem may have difficulty engaging in activities like camping, slumber parties, and the like. In fact, a common social consequence of peers discovering a child’s bedwetting issues is bullying.

For the family, bedwetting can become a burden. Bedwetting can be physically exhausting as it would require more frequent changes of beddings. Furthermore, expenses for laundry and disposable diapers can compound the burden. Emotionally, having a child with this problem can be frustrating and exasperating, even if the parent does not mean to feel this way. This can also affect the way the family plans vacations, trips, and the like.

Physically, bedwetting may cause rashes or infections because of prolonged exposure to urine. It can also impact the quality of a child’s sleep, which can affect their body’s ability to stay healthy. Lack of sleep or consistent interrupted patterns of sleep can have a toll on one’s ability to concentrate in school (or tasks) as well as cause irritability, forgetfulness, and lack of focus.

What to do with a bedwetter

Most children can overcome bedwetting with no interventions while some may benefit from seeking treatment. Before anything else, identifying the root cause of the problem can go a long way in helping a child overcome the problem, especially if this goes beyond the ages of five to seven.

When it comes to treatment, there are two avenues parents can take: behavioral treatment or pharmacological intervention.

Behavioral modification techniques have been found to be quite effective in reducing and/or eliminating problems with nocturnal enuresis. These can include night-lifting, which is when a parent or caregiver wakes the child to go to the bathroom in the middle of the night, and retention control training or bladder training. The latter, however, should not be done without consulting a medical practitioner first. Other behavioral strategies that can be employed include:

lessening liquid intake at night
reminding the child to go to the bathroom right before sleeping
using a nocturnal enuresis alarm
giving the child rewards for keeping dry throughout the night

Medication can be resorted to if the child is above the age of seven and behavior therapy has not been effective. An example is the drug desmopressin acetate (DDAVP), which boosts the body’s natural anti-diuretic hormone vasopressin, thus reducing the body’s production of urine at night. Other drugs such as oxybutynin or hyoscyamine act on the bladder by reducing its contractions and increasing capacity. This is prescribed for children with small bladders.

It is important to note that, while medication can help address the problem, they should not be used without the proper diagnosis and workup of a licensed medical doctor. In the Philippines, there are a handful of pediatric urologists who are well-trained in treating enuresis.

More than just dealing with the problem of bedwetting, it is important for the family to care for the holistic well-being of the child struggling with the issue. Making him or her feel accepted and loved despite this problem can help build up confidence and self-esteem. Patience is an essential virtue in this battle with nocturnal enuresis. While frustrations may build up along the way, it is important to know that in time, with everyone pulling together, a good and dry night’s sleep is on the horizon.

Photo credits “Susannah sleeping” by Sally, c/o Flickr. Some Rights Reserved, “sad - triste” by Axel, c/o Flickr. Some Rights Reserved , “My little darlings.” by , c/o Flickr. Some Rights Reserved.

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Maria Andrea (Ria) S. Tirazona, M.S. (cand.), popularly known as Yapatoots in the online blogging and social networking community, is a preschool teacher at Playschool International and part-time lecturer at the Psychology Department of De La Salle University. She is also an Associate Psychologist at PsychConsult, Inc, where she specializes in Psychological Assessment. She holds a Bachelor's Degree in Family Life and Child Development from the University of the Philippines and is a thesis shy of completing her Master's Degree in Clinical Psychology at the De La Salle University. In her spare time she maintains several blogs, including www.theaccidentalteacher.com, www.fatgirlnomore.com and www.yapatoots.com.

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