Childhood bedwetting: How to help your child overcome it

Bedwetting can be a stressful condition for kids and their families. There is the inconvenience of changing bedding and clothing, the cost of products like waterproof pads, the worry about if this is normal, and the feelings of embarrassment. Because it can be an uncomfortable subject to talk about, it is often not spoken of in social circles; however, bedwetting is actually quite common, and is often considered part of normal childhood development.

What is bedwetting?

Bedwetting—which is medically referred to as nocturnal enuresis—is involuntary urination during sleep in children after the age that they can reasonably be expected to stay dry throughout the night.

There are two types of bedwetting: primary and secondary.

Primary nocturnal enuresis is when children have never had an extended period of time staying dry at night. Primary bedwetting is the most common type of bedwetting.

Secondary nocturnal enuresis is if a child has previously stayed consistently dry overnight for at least a six month stretch and then begins wetting the bed again, this is considered secondary bedwetting. This type is less common, accounting for approximately 25% of bedwetting.

How common is bedwetting?

“Bedwetting is extremely common,” says Baltimore pediatrician Ashanti Woods, MD. “It is considered a normal part of childhood development.” The number of children who experience regular bedwetting decreases with age. The approximate number of children who have nocturnal enuresis is as follows:

• 5- to 6-year olds: 15% to 20%
• 8- to 10-year olds: 6% to 10%
• 11- to 13-year olds: 4% to 5%
• 14- to 16-year olds: 2% to 3%
• 17- to 18-year olds: 1% to 2%

While daytime wetting is more common with girls, bedwetting is more common with boys. Boys make up approximately 75% of children who experience nocturnal enuresis. 

At what age is bedwetting considered a problem?

“Bedwetting is thought to be abnormal if it persists beyond 6 years of age,” says Dr. Woods, who also stresses that even after age six it is still quite common.

While bedwetting can be considered unproblematic until adolescence, it’s a good idea to consult your family physician  if your child is still frequently wetting the bed by age 7 or 8 in order to rule out possible medical conditions, or if the bedwetting is causing psychological problems (such as low self-esteem) for your child or your family.

There does not appear to be a specific age in which bedwetting becomes concerning—it varies from expert to expert, but most agree that barring another medical condition, whether or not to treat the bedwetting depends on how intrusive it is.

Bedwetting can also occur in adults. This is usually due to an underlying medical condition such as diabetes, problems with the ADH (antidiuretic) hormone, overactive bladder, blocked urethra, constipation, obstructive sleep apnea, pelvic organ prolapse, problems with the structure of the bladder or other urinary organs, enlarged prostate, urinary tract stones, or a urinary tract infection.  It can also be caused by certain medications such as sleeping pills or antipsychotics like clozapine or risperidone. 

Bedwetting in adults may be a symptom of more serious conditions like bladder cancer or prostate cancer, or diseases of the brain and spine like a seizure disorder, multiple sclerosis, or Parkinson’s disease.

Treatment options for bedwetting in adults depend on the reason for the bedwetting.

What causes bedwetting?

“Pediatricians still do not know an exact cause for bedwetting,” says Dr. Woods. “An observation that has been made is that bedwetting tends to run in families.” 

There is definitely a genetic component, according to Utah pediatrician Cindy Gellner, MD. “Scientists have even identified the genes for delayed nighttime bladder control,” Dr. Gellner said in an interview for University of Utah Health. “…they’re on chromosomes 8, 12, and 13. That’s why we see this run in families so much.”

Other factors can include:

• Children being deep sleepers, not waking up when the bladder is full 
• Inadequate production of the sleep hormone vasopressin, which signals the body to make less urine at night.
• An immature or small bladder

Occasionally, bedwetting can be caused by a bigger medical problem. “Some medical conditions that physicians consider when bedwetting is prolonged include constipation, urinary tract infections, diabetes, and stress,” says Dr. Woods. “In rare situations…due to anatomical reasons, surgery may be indicated [like a] blockage/narrowing that prevents a child from fully emptying his/her bladder.”

How can I stop bedwetting?

Bedwetting is usually outgrown, but there are several things that can help some kids.

1. Timed Voiding. Get children on a schedule of urinating every 2 to 3 hours during the day, whether or not they feel the urge. You can even get them a watch that vibrates at set times to remind them to go.
2. Double Voiding. There are different techniques; most commonly the child would urinate, relax on the toilet for 20-30 seconds, and then urinate again.
3. Monitor Liquids. Encourage more drinking during the day and less at the end of the day and evening (unless they are involved in sports and need additional hydration.) Avoid drinks with caffeine or bubbles, citrus juices, and sports drinks.
4. Motivational Therapy. Be patient and encouraging. All methods work better when the whole family is on board. Try a reward system, not just for having a dry night, but for sticking with a routine. Never shame, reprimand, or punish a child for bedwetting—they aren’t doing it intentionally.
5. Get Children Involved. Help them feel some control over the situation by coming up with a routine together. Let them help change bedding (but not as a punishment). 
6. Bedwetting Alarms. These come with a moisture sensor that clips to the child’s clothing or bedding. An alarm will sound as soon as the child begins to wet the bed. This method requires a commitment from both the child and the parent. At first, it’s likely only the parent will wake up with the alarm, and they will need to wake the child and take them to the bathroom. Over time, many children learn to wake with the alarm and eventually to wake with the sensation of a full bladder. Some improvement can happen within a few weeks, but the alarm usually needs to be used for three to four months to be most effective. This method doesn’t work for all kids, but when it does work it tends to have long-lasting success.
7. Medication. Medication is not a first resort, but can be helpful for some children. It is particularly helpful for special events such as a sleepover, traveling, or camp.

Are there medications that can help stop bedwetting?

While not the first line of treatment, there are some medications that can help.

Desmopressin

Desmopressin (DDAVP) is used to control the amount of urine made by the kidneys. It is taken orally, and the dosage depends on the patient and the condition. It is often a physician’s first choice of medication for bedwetting and it is effective in about 50% of patients.

While safe to take over long periods of time, it doesn’t usually help with reducing bedwetting in the long run. Bedwetting often returns once the medication is stopped.

Desmopressin can be very helpful when used for special events such as a sleepover, a long flight, camp, etc.

A partial list of potential side effects include headache, nausea, upset stomach, or flushing of the face. More serious side effects are rare but can occur. Seek medical help if there are signs of an allergic reaction.

This medicine may cause low levels of sodium in the blood. Carefully follow the doctor’s instructions about how much liquid to drink each day. This is especially important for children. Children can also be at risk for seizures due to water intoxication, making regulating fluid intake highly necessary.

Imipramine

Imipramine is an antidepressant that is sometimes used to control bedwetting. Ten to 50% of patients report full dryness, and others report some improvement. 

It isn’t well understood how this drug works, but it is thought to work in one of several ways:

• By changing the child’s sleep and waking pattern;
• By affecting the time a child can hold urine in the bladder; or
• By reducing the urine production.

Imipramine is more effective in older children, and not generally prescribed to children under age 6 to 7.

It is usually taken 1 to 2 hours before bedtime, and dosage depends on the age of the child.

Side effects are uncommon, but can include irritability, insomnia, drowsiness, reduced appetite, and rarely, unpleasant personality changes. These side effects can be reversed by reducing or stopping imipramine. 

Importantly, an overdose can cause death in children, and there have been reports of accidental overdoses. Imipramine must be kept out of reach of children and sealed in a childproof container or with a childproof cap.

As with desmopressin, bedwetting tends to reoccur once Imipramine is stopped.

Oxybutynin and Hyoscyamine

Oxybutynin and Hyoscyamine are anticholinergics used to treat urinary and bladder problems.

They are not generally helpful to kids who have nighttime wetting only when used on their own, but an anticholinergic can be used in combination with desmopressin to help some kids with bedwetting, particularly kids who have reduced function bladder capacity.

.Dosage for these medications varies based on age and weight. Common side effects include dry mouth and facial flushing. An overdose may result in blurring of vision and hallucinations. 

Tolterodine 

Tolterodine is another anticholinergic that has fewer reported side effects and is more specific for its action on the bladder. It is not approved for children under 12.

How to manage ongoing bedwetting

While you are waiting for treatment to work or for your child to outgrow bedwetting, there are some things you can do to make sleep time more manageable and enjoyable.

1. Absorbent or Waterproof Products. Reusable or disposable absorbent underwear can be useful for sleeping away from home. At home, disposable or reusable pads or mattress protectors help protect bedding.
2. Easy Nighttime Transitions. Lay out spare clothes for your child to change into if they wake up wet at night. Consider layering sheets with waterproof pads to make it easy for children to remove wet bedding during the night and in the morning.
3. Bathing. Make sure your child showers or bathes daily to remove the smell of urine.
4. Respect Privacy. If your child prefers to change on their own, allow them to. Don’t discuss their bedwetting around other people unless at a doctor’s visit.
5. Offer Encouragement. Talk to your child and let him know that bedwetting isn’t his fault and that you know he isn’t doing it on purpose. Tell him how common it is, and that it’s likely some of his friends wet the bed now or did at some point as well. Reassure him that he isn’t in trouble and that it will get better. If any adult family members in your family wet the bed as children, ask them to speak to your child about their experiences in a comforting manner. (Respect privacy and ask your child’s permission before doing so.)

Bedwetting is tough, but it’s important to remember that it’s common, often treatable, and usually outgrown. If other medical conditions and constipation have been ruled out, then it’s mostly a waiting game. Have patience, be kind, and you’ll all get through it.