U of M Section of 
Urology

Nocturnal Enuresis (Bedwetting)


Nocturnal enuresis (bedwetting) is so common in the first few years after toilet training that it is inaccurate to call it a disease and inappropriate to treat it medically in that age group. Most children outgrow bedwetting as this survey of 1,265 children in New Zealand shows:


Age (yrs)

2
3
4
5
6
7
8
Children with nocturnal enuresis (%)

92.5
43.2
20.2
15.7
13.1
10.3
7.4


Bedwetting in association with urinary infection, painful urination, stream abnormality, daytime incontinence, bowel problems or anatomic disorders may be a symptom of the underlying condition. Isolated bedwetting, however, is the condition that we tend to discuss here. We try to rule out other problems by history-taking, physical examination, and inspection of the urine. In some situations, an ultrasound or other imaging tests are performed.

Because most bedwetters become dry without treatment, patience and understanding are the best things to offer young children who wet the bed. After 6-7 years of age, however, the social cost of bedwetting begins to rise. An alarm system is a good place to start; some alarms are practical and inexpensive, others are neither.

Fluid restriction and waking the children at night may solve the problem in some instances. Behavioral modification and bladder training have little appropriate role.

Medications are used as a last resort. Imipramine (an anti-depressant known as Tofranil) helps in a little more than 50% of bedwetters, but it can cause mood changes and nightmares. Oxybutynin chloride (Ditropan, a bladder anti-spasmodic) is effective in occasional children. It may cause facial flushing, irritability, and even heat exhaustion - in summer months children need to be encouraged to drink plenty of water when they are active.

A new addition to drug therapy is DDAVP. This is a synthetic version of vasopressin, an important regulatory hormone that our bodies normally produce. The purpose of this hormone is to recycle water from the urine back into the bloodstream. At night, it is normal to have a higher level of this hormone, so that we normally don't make a lot of dilute urine during sleep. Many bedwetters (although not all of them) do not produce the normal high levels vasopressin at night and therefore make more urine than normal at night. In addition, they don't seem to get the message that the bladder is full and as a result have accidents when asleep.

For these children, DDAVP may help, but it is best used in cooperative patients. It is absorbed from the nasal mucosa and needs to be taken as a spray or inhaled. It is not cheap and must be kept in the refrigerator between applications. Before using DDAVP, we take a history, determine the degree of bedwetting (how many wet nights per week), and try to ascertain if the child has a fairly normal fluid intake. We want to know if there is a history of cystic fibrosis, seizures or headaches.

We recommend fluids be withheld after an hour before bedtime (usually 8 PM), and that the DDAVP is given at bedtime (9PM). No other fluids are to be consumed at night. DDAVP should not be used if the child has an unusually large fluid intake that day. To be certain that DDAVP doesn't alter the body chemistry we request that a morning set of electrolytes (a blood test) be performed around the third day of usage.

Children should be evaluated periodically when on DDAVP, and the medicine should be withheld if any questions arise. Doses should not be increased without discussion with a member of the pediatric urology service. Headaches, nosebleeds, nasal irritation, chills, dizziness, nausea, abdominal pain, or seizures are reasons to stop the medicine. The family should keep track of the number of accidents per week and, usually at 6 month intervals, they may try to withdraw the medicine to see if it is still necessary.

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