Bedwetting and Daytime Incontinence Program

Bedwetting (nocturnal enuresis) and daytime incontinence can be a source of frustration for parents and children. Children, especially as they get older, can feel embarrassed, anxious, ashamed and even angry about their day- and night-time wetting. Parents often feel confused, worried and sometimes even exasperated as they try to understand why the child cannot control his or her urination. At the CHOC Urology Center Bedwetting and Daytime Incontinence Program, we understand these frustrations, and work with children and their families to find solutions.

Day- and night-time wetting is typically kept a secret among families, leading many to believe that no one will understand what they are going through or that there is no actual medical treatment for the problem. Yet according to the American Academy of Pediatrics (AAP), nighttime bedwetting affects 5 million children older than age 6 in the U.S. Also, about 25% of school aged children have some form of voiding dysfunction.

How To Cope With Bedwetting

Bedwetting that continues beyond the age of 5 can impact a child’s self-esteem and create a sense of isolation, according to Christopher Link, post-doctoral fellow in CHOC Pediatric Psychology Department. Chris recently sat down with CHOC Radio host Bryan Mundia to talk about what parents can do to help their children cope with bedwetting.

CHOC Radio with Christopher Link

Frequently Asked Questions: Bedwetting (Nocturnal Enuresis)

Nocturnal enuresis is the medical term for bedwetting. Incontinence is urination that occurs at an unintended time. Nocturnal enuresis may be diagnosed in children who are developmentally over the age of 6 and are still wetting the bed at night. There are different types of bedwetting that may occur, including the following:

Primary nocturnal enuresis
A child that has never had a 6 month period of dryness at night.

Secondary nocturnal enuresis
A child who has been dry at night for over 6 months at some point in their life but who is having accidents at night again.
• Nocturnal enuresis occurs three times more frequently in boys than in girls.
• Primary enuresis is the most common form of urinary incontinence among children.
• It is estimated that nearly 25% of school-aged children have some form of incontinence.
• If a parent had nocturnal enuresis as a child, there is a higher chance that their children will as well.
• Nocturnal enuresis is very rarely an intentional act by a child. Normally the child is unable to control the urination at night and are unaware that they are urinating.
Nocturnal enuresis is diagnosed based on a complete medical history and physical examination of the child. In addition to talking with the child’s caregivers and the child, our pediatric urology specialists may perform the following to help rule out other causes for the wetting:

• Urine tests (to make sure there is not an underlying infection, or condition such as diabetes).
Voiding diaries to better understand the size of a patient’s bladder.
• Renal ultrasound to look for a physical anomaly in the urinary system.
• Uroflow and post void residual tests.
• KUB to look for constipation.
Specific treatment for enuresis will be determined by our pediatric urology specialists based on:

• The child’s age, overall health and medical history.
• Extent of the condition.
• The child’s tolerance for specific medications, procedures or therapies.
• Expectations for the course of the condition.
• The family’s opinion or preference.

Prior to starting treatment, it is important for caregivers to understand that it is not the child’s fault and that he or she should never be punished. Children cannot control their bed wetting. According to the American Association of Pediatrics (AAP), enuresis usually goes away on its own in about 15 percent of affected children each year. It is estimated that nearly 1 in 4 school-aged children have some degree of incontinence, and is very common.

Treatment may include:

• Positive reinforcement of the child (i.e., the use of sticker charts for dry nights).
• Use of night-time alarms to help tell the child wake up while they are urinating.
• Prescribed medications to help control the wetting for sleep-overs and vacations.
• Decreasing fluids and avoiding caffeine at night (if the child has properly hydrated during the day). Learn more about the amount of water children should consume each day.
• Medications may be recommended if the child’s bladder is found to be small for his or her age.
• Management of constipation or poor water intake.

In addition, counseling for the child and family may help to determine any stress the child may be under and can be beneficial.
There are many factors that may be involved, and many theories that are given for why children wet the bed at night. The following is a list of some possible reasons for the problem:
• Constipation.
• Maturity of a child’s bladder function.
• Small bladder capacity.
• Poor sleep habits or the presence of a sleep disorder.
• Medication that affects sleep.
Commonly the cause behind why a child is wetting at night is not determined. The communication between the bladder and the brain that works during the day to let a child know when they need to use the restroom is not functioning in the same manner at night. This is a process that improves as a child ages, but can take into teenage or adulthood to occur in some individuals.
It is important to remember that nocturnal enuresis is very rarely an intentional act by a child. Normally the child is unable to control the urination at night and is unaware that he or she is urinating.

Health Feature: Kids and Bedwetting

Bedwetting can frustrate parents and children who often feel embarrassed and anxious about this problem and suffer from low self-esteem. A child may need some motivation to work on staying dry at night. One option is to use an alarm with sensors that is placed on the child’s underwear and alerts the child when wetness is detected.

Young girl sleeping with her teddy bear

Frequently Asked Questions: Daytime Incontinence

Urinary incontinence (UI) is the loss of urine control, or the inability to hold your urine for a reasonable amount of time before reaching a restroom. UI can strike at any age and can be a temporary condition or long term. It can range from the discomfort of slight losses of urine to severe, frequent wetting.
Incontinence can be caused by a variety of concerns and will sometimes be the first or only symptom of a urinary tract infection. It may also be caused by bladder instability, small bladder capacities, poor water intake or other concerns. We carefully assess our patients to figure out the cause of each child’s incontinence.
The following are some types of urinary incontinence:

Urge incontinence
During strong sudden urges to urinate a person is unable to hold their urine long enough to reach a restroom.

Stress incontinence
People with this type of incontinence may leak urine during exercise, coughing, sneezing, laughing, lifting heavy objects or other body movements that put pressure on the bladder. This type of incontinence is more common in adults.

Functional incontinence
Leakage due to a difficulty reaching a restroom in time because of a physical condition.

Overflow incontinence
Leakage that occurs when the quantity of urine produced exceeds the bladder’s capacity to hold it.
Although each patient may experience symptoms differently, the following are the most common symptoms of urinary incontinence:

• Inability to urinate when feeling the urge to void.
• Pain related to filling the bladder and/or pain related to urination.
• Progressive weakness of the urinary stream with or without a feeling of incomplete bladder emptying.
• An increased frequency of urination.
• Needing to rush to the restroom and/or losing urine if you do not get to restroom in time.
• Problems starting or stopping the flow of urine.
• Urine leakage.
• Frequent bladder infections.

The symptoms of urinary incontinence may resemble other conditions or medical problems. Our specialists will work carefully to accurately diagnose a child’s incontinence.
Specific treatment for urinary incontinence will be determined by our urology specialists based on:

• The child’s age, overall health and medical history.
• Extent and type of the incontinence.
• The child’s tolerance for specific medications, procedures or therapies.
• Expectations for the course of the incontinence.
• The caregiver’s opinion or preference.

Because there are different types of incontinence, treatments vary and can include:

Behavioral therapies
Behavioral therapies help the child regain control of his or her bladder and including the following:

• Bladder training in which the child is taught to relax his or her bladder muscles while urinating.
• Toileting assistance in which we work with the child’s family to set routines or scheduled toileting, habit training schedules and prompted voiding to empty the bladder regularly to prevent leaking. A child should be urinating about once every two hours, or seven times per day.
• Increased water intake to ensure the child is hydrated. Clear urine is a sign of good hydration. Children should drink enough water so that their urine is clear every time he or she uses the restroom. Learn more about how much water children should drink.
• Relieving constipation, as constipation can complicate urinary symptoms greatly. Constipation can cause the bladder to have abnormal contractions and can also introduce bacteria into the urinary system. Learn more about constipation.

Pelvic muscle rehabilitation
The goal of pelvic muscle rehabilitation is to improve pelvic muscle tone and prevent urine leakage. Biofeedback is the most common form of pelvic muscle rehabilitation in which a specialized nurse teaches patients how to use their pelvic floor muscles correctly. A child will use their pelvic floor muscles to play computer games to help increase their control of these muscles. Biofeedback is non-invasive but does require the placement of stickers with sensors onto their skin around the pelvic area.

While evaluating a child’s incontinence, we look at the size of the child’s bladder. If the bladder is smaller than the average for the child’s age, the patient may be placed on medication to help the bladder relax and to grow.

Most causes of incontinence will not require surgery. If the incontinence is related to structural problems such as an abnormally positioned ureter or sized urethra, a surgery may be recommended.

Diet modifications
Some foods and liquids can be irritating to the bladder and cause concerns of incontinence, urgency, dysuria or frequency. Learn more about bladder irritants.

Children who will be seen in our office for incontinence, urgency of urination or frequency of urination should complete a voiding diary prior to their appointment. Please contact us with any questions.