Summer is a time for youngsters to participate in a great Canadian tradition: summer camp.
At night, tired and in a deep sleep, a young boy enjoys a pleasant dream. He dreams about playing for his favourite baseball team. But then nature calls. He goes to the bathroom to empty his bladder, filled by the cool sweet lemonade he drank earlier that day. But as soon as he starts to urinate, the dream is over and he wakes up in a puddle of lukewarm urine. His sleeping bag gets cold from the fluid. It is 3 am. He wonders to himself when this problem of bedwetting will go away.
Bedwetting, although not in the league of terminal illnesses, causes many children a great amount of inconvenience and embarrassment. How common is it? Research published in Pediatrics a few years ago showed this: by age 3 almost 40% are wetting the bed; by age 7 the incidence declines to 10%; and by age 12 it is only 3%. Beyond the age of 15 it is less than 1%.
It’s no wonder then that most physicians tell patients and their parents “Your child will outgrow it.” In only 3% of cases will there be a more potentially serious reason for the child’s bedwetting, such as a bladder infection, diabetes or urinary flow problem, to name only a few. Bedwetting,
also referred to as enuresis, is mostly a physiological issue during a time when nature takes its time to develop normally.
It is quite unusual, when I take a history from my patient’s parents, that I do not identify the child as a very deep sleeper. Usually I’m told, “Doctor, a bomb can go off next to his bed and he will sleep right through it!” (I use the term “he”, because enuresis is much more common in boys than in girls.) In addition to being deep sleepers, there is a history of the child having a small bladder capacity. Normally a child’s bladder volume is equal to his age, plus two, in ounces. A 6-year-old will have a volume of 8 ounces (240 ml) and an 8-year-old approximately 10 ounces (300 ml). Lastly, our bodies produce a hormone, at night when we sleep, that enables us to enjoy a long sleep without having to empty our bladders every few hours. It is called antidiuretic hormone. In a bedwetter, his pituitary is still learning how to do this task and often these children lack the correct amount of this hormone. This allows for their little bladders to fill up with urine through the night. No wonder that this, combined with deep sleep, leads to our patient waking up at baseball camp at 3 am in a soaked sleeping bag.
In addition to the above, genetics also play a role. If one parent had this problem as a child, then the odds are close to 33% that his/her child will have enuresis. If both parents had enuresis, the percentage jumps up to 67%. We have to choose our spouses carefully indeed!
After completing a thorough history and physical exam, most physicians will find that an enuretic child fits into the 97 % category – that there is no underlying pathological problem. Some will ask for tests on the urine and basic blood testing for anemia, infections or diabetes. Very few will embark on more invasive radiological tests or scans of the bladder or kidney.
When to treat remains a matter of opinion. Clearly, not many doctors will treat a 3- or 4-year-old child. The older child becomes an easier candidate for treatment. Where the gray zone exists is the early school-aged child. My criteria are simply this: How does this condition affect the patient’s self-esteem? Although doctors may spend a long time explaining to the child why this problem occurs and that he will eventually outgrow it, subsequent research has shown that few are reassured. They want to be able to go camping, go to pajama parties and sleep overnight at a friend’s house without enduring the embarrassment of waking up in a puddle of urine almost every night.
Treatment options include the bedwetting alarm. It works on the basis of conditioning the patient’s sleep pattern. When urine flows, the alarm goes off and supposedly wakes up the child. Supposedly? I use this term because I’m often told “The alarm wakes up everybody in the house except the patient himself, who just snores away!” This may be true initially, but with perseverance things will improve. It usually takes months for the alarm to cure the patient. Once the patient improves, the relapse rate is low.
Another treatment option is a nasal spray called DDAVP, used before bedtime. It works by providing the hormone (antidiuretic hormone described above) to the patient via nasal absorption. It works much faster than the alarm but costs much more and the relapse rate is higher; as soon as the patient stops using it, the bedwetting returns. I find DDAVP spray to work well in the short term for the child who wants dry nights at a friend’s house or camp. It is not a cure, but it helps protect the patient’s self-esteem in a way that makes it hard to put a monetary amount on it.
Lastly, some clinicians suggest anti-depressants such as imipramine; acupuncture; homeopathy; the elimination of food colorants; limiting fluids at night; hypnosis and many other unproven therapies. The success rates with these treatments vary greatly. Some would say it is due to the placebo effect. I understand that evidence-based medicine should be the gold standard, but I am reticent to remove hope from the patient and deny the benefits of the placebo effect. I can’t recommend the unproven therapies when asked to do so, but in this day and age of alternative medicine, if some patients want to try something as simple as dietary changes, I would support them.
A child should never be punished or spanked for wetting the bed. They can’t help it because nature is still taking its time getting them out of the starting blocks. For further information, there are two web sites I strongly recommend: www.intellihealth.com and www.bedwetting.ferring.ca
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