Bedwetting

Dear Lisa,

I have a five year old boy. I started night training him when he was not quite four and I was five months pregnant with his little brother. The whole process went perfectly. I would get up two or three times a night and take him to the potty, gradually the number of times I had to get up reduced until about a month later when he began getting himself up to go potty without my assistance. I assumed that when his little brother was born he would regress somewhat. Just because of the emotional stress of having a new baby in the house. I was overjoyed when he didn't regress!!! He went seven whole months without one accident! Then we went to visit some family members out of town and he came down with the flu. He was seriously ill for the better part of a week. He started bedwetting. I thought it was just because he was so sick, and he would be back to getting himself up to go when he felt better.

That has been five months ago. I have tried everything I know to try. I am so frustrated. I have asked so many people and nobody can help me. I am very careful about being gentle and kind with him, I don't want to embarrass him or make him feel like he's done something wrong. But, if I don't get him up to go in the middle of the night, he WILL wet the bed, and sometimes he still wakes up with wet sheets. I asked him once why he started having accidents again and he said "Because I'm just too tired to get up." I'm trying really hard to do things right, but when I'm up changing sheets at two o'clock in the morning because my five year old didn't WANT to get up and go potty, it's almost more than I can take. I just don't understand what could have caused him to regress so completely. Please, please help me!!! This is putting a strain on the whole family.

Thank You,

“Tired and Frustrated”

Dear “Tired and Frustrated”,

It’s interesting how your son did not regress when your new baby was born, but started his bedwetting again after her was ill. Since your son had control of his urine for such a long time and the symptoms returned it would be important to figure out the cause of the return of his bedwetting.

Children with urinary incontinence only at night have Nocturnal Enuresis. Nocturnal Enuresis is a very common childhood condition that affects approximately 13% of all 6 year olds. (1) Children who never gain control of their urine at night have Primary Nocturnal Enuresis. This is the most common type of Nocturnal Enuresis. Children who gain control of their urine at night for at least 3 months and then resume bedwetting are considered to have Secondary Enuresis. (2) Your son’s symptoms fit into the category of Secondary Nocturnal Enuresis. This type of enuresis is usually not caused by a small bladder capacity or immature sleep arousal pattern. (2)

In order to treat your son’s wetting at night, it would be important to first find out the cause. It was very smart of you to ask him why he started wetting at night again. Whenever a child develops a change in behavior it is important to ask him directly about the problem. Since your son replied that he was too tired to get up , this is a good place to start.

It may be a good idea to investigate why your son feels that he is too tired. Has he been sluggish during the day? Is he more tired with exercise as compared to other children his age? Has he not been getting the appropriate amount of sleep? These are some questions that you need to ask yourself. Before we can assume his symptoms are behavioral, it would be a good idea to make sure the symptoms aren’t due to something out of his control.

Since the symptoms began after his prolonged illness, reasons for being tired after an illness should be investigated. Some childhood viruses or infections can cause a child to become temporarily Anemic. (3) A child can have Anemia without their parent knowing it because the signs are typically quite vague and non-specific. Signs of Anemia may include excessive sleepiness, irritability, disinterest in eating, pale skin color, pale mucus membranes, exercise intolerance, short attention span, poor school performance and difficulty eating in infancy. (2,4,5)

Two examples of such infections are the EBV virus and Mycoplasma. (5) Your doctor can evaluate your son for signs of Anemia, or other conditions such as Hypothyroidism that can cause a child to be fatigued. (2) Urinary screening may also be performed in order to look for signs of infection, the kidney’s ability to concentrate the urine, the presence of blood and sugar. (6)

Another very important question to ask is, does your son has any problems with urinary incontinence during the day? This is very important information to know, because children who experience Nocturnal Enuresis along with daytime incontinence may have an organic problem that needs to be ruled out. (2) A child who gains control of their urine during the day for a period of time and then develops incontinence has Secondary Enuresis.

Secondary Enuresis is a type a dysfunctional voiding that develops as a result of constipation or pelvic floor dysfunction. Secondary Enuresis may also occur following a urinary tract infection.(3) Some children who develop a urinary tract infection learn to suppress the need to urinate by controlling the pelvic floor muscles. When this occurs, the muscles of the bladder and the bowel become distended. The urine accumulates and pools in the distended bladder and as a result the child loses the sensation of needing to void. (3)

When this happens it takes months for the bladder to regain its tone. If your son is experiencing day time and night time incontinence, it would be important to bring him to the Doctor for an evaluation so that these factors can be ruled out. In some cases, the expertise of an Uurologist and diagnostic testing such as a bladder ultrasound may be needed.

Once you know that there is no organic cause for your son’s bedwetting, then you can work on the behavior. To start, there is no reason why you should get up in the middle of the night. All that is necessary is that you wake your son and bring him to the bathroom before you go to bed at night and bring him to the bathroom the first thing in the morning. The feeling of being wet and uncomfortable is necessary in order to provide an incentive for your son to change his behavior.

It would be a good idea to purchase a few washable waterproof pads and put one under his body, on top of the sheets before he goes to bed. When he wets himself this waterproof pad will absorb the moisture and prevent the sheets from getting soiled. This way the sheets will not need to be laundered everyday. It is much easier to wash a pad, then to change the whole bed.

Your son should be taught to remove the pad from his bed in the morning and put it in the wash. It is important that this is not viewed as a punishment, but a way of helping him become responsible for himself. It is a good idea to take a matter of fact approach, helping him realize that a mess needs to be cleaned. Understanding that an important step in overcoming bedwetting is having the child have an active role in dealing with their bedwetting should help you relinquish this responsibility. (2) Not only will this approach teach your son responsibility, it will keep you from being overburdened.


You can purchase one of these 34 inch by 26 inch washable pads at a baby supply store such as Babies R Us or Toys R Us. It is also a good idea to limit the amount of fluids that your son drinks in the evening by not letting him drink after 7:30 p.m. (6) Remind him gently before he goes to sleep that he has underwear on and that you expect him to stay dry.

The other thing to consider is a dietary change that may be causing your son’s bedwetting. Has there been a change in his diet since he was ill? Does he now drink soft drinks, caffeine or drinks with sugar-substitutes and he didn’t before? Recent literature has shown that food sensitivities can play a part in enuresis. (6) It has been reported that milk, milk products, caffeine, vitamin C, citrus juices, corn, heavily sugared foods and carbonated beverages may contribute to enuresis. (2,7)

If there has been a change in his diet since he was ill you may want to consider a food sensitivity as a possible cause of his bedwetting. You can eliminate the new products from his present diet for a period of two weeks in order to determine if they are causing a problem. Gradually add the products back, one at a time and take notice which nights your son wets his bed. (6) If the Nocturnal Enuresis consistently occurs when your child ingests a certain food then chances are that item can be contributing to the problem.

Since Constipation contributes to Nocturnal Enuresis it would be important to consider this as factor. It is common for school age children to have firm, infrequent stools. A full rectum can restrict the bladder’s expansion and cause a bladder contraction which leads to urinary incontinence. In addition, constant rubbing of the bladder by the full rectum decreases the sensitivity of the bladder and causes the brain to begin to ignore messages from the area. (3,6) If your son has hard, infrequent stools it would be important to bring this to your Doctor's attention so that this can be addressed before attempting to train your son to stay dry at night.

Bedwetting can be very frustrating, because it is a problem that usually takes some time to resolve. It puts a strain on the family emotionally and physically. It is a very messy problem and the effort that it takes to keep the child’s body and bed clean is not only time consuming, but exhausting. It is also very normal to become frustrated. Children frequently become very embarrassed by the situation and the emotional trauma can many times interfere with a child’s socialization. (8) You have done the correct thing by being gentle and kind with your son. Keeping a non-accusatory tone and having your son involved with his care will help everyone involved.

I wish you dry and restful nights in your near future.

References:
(1)Fergusson DM, Hons BA, Horwood LJ. Factors related to the age of attainment of nocturnal bladder control: an 8 year longitudinal study. Pediatrics. 1986;78:884-890.
(2)Schwartz M, Charney E, Curry T, Ludwig S. Pediatric Primary Care. A Problem Oriented Approach. 2nd Ed. Littleton, Mass:Year Book Medical Publishers, Inc. 1990:216-217, 440-441, 349,217.
(3)Listernick R. A Thirteen-Year-Old Girl with Anemia. Pediatric Annals. 2003.32(3);139-148.(4)Betz C, Hunsberger M, Wright S. Family-Centered Nursing Care of Children. 2nd ed. Philadelphia, PA:W.B.Saunders Company. 1994:1407.
(5)Behrman R, Kliegman R. Nelson Essentials of Pediatrics. Philadelphia ,PA: W.B.Saunders Company. 1990:495-501.
(6)Mercer R. Dry at Night. Advance for Nurse Practitioners. 2003. February:26-30.
(7)Maizels M, Rosenbaum D, Keating B. Getting to Dry: how to Help your child Overcome Bedwetting. Boston, Mass: The Harvard Common Press; 1999.
(8)Sacharyczuk C. Psychological implications of nocturnal enuresis demand treatment. Infectious Diseases in Children. 2006. April:72.


Lisa-ann Kelly R.N., P.N.P.,C.
Certified Pediatric Nurse Practitioner

Pediatric Advice For Parents