Many people find bedwetting awkward and embarrassing. Parents are unable to talk about it and try to ignore it hoping it will sort itself out. However,  ignoring does not help as it leads to frustration for child and the family.

There are yet others who ‘educate’ the child and explain how they should control things with the mind. If the child does not improve, as is common, there is a lot of anxiety and disappointment. Sometimes this leads to the child being scolded and at times an absolute verbal lashing for wetting the underwear in the day. As some children pass urine very frequently, this drives parents up the wall as they cannot understand why or how can the child want to pass urine within a short time after having voided urine. This then gets attributed to the child’s behaviour being at fault and efforts are made to ‘teach’ the child how to behave properly.

Understanding the problem and addressing the issue

Is this all appropriate? The short answer is ‘No’. None of the above things work because the presumption is wrong. The child is not doing this deliberately or purposely. There are very easy ways to address this problem.

There are two main categories:

Nocturnal Enuresis 

The first category is ‘Nocturnal Enuresis’ meaning that the child wets himself/herself at night in bed. It can happen only once at night or several times a night. But there is no wetting at all in the daytime. This group tests the parents’ patience. Children wet consistently at night and this leads to a lot of heartburn. It can be of two main types. The commonest one is Primary Nocturnal Enuresis. This means that there is no underlying pathology causing it. When it occurs due to an underlying pathology, it forms the second group and we shall not talk about that because it needs special medical care.

Primary Nocturnal Enuresis

The commonest type is Primary Nocturnal Enuresis. The second category is where the child is having wetting during the daytime also. This may not be soaking wet underwear but sometimes only a few drops of urine in the underwear once or several times a day or week. The child may also display nocturnal enuresis (wetting at night in bed).

Diagnosis

The child needs to be seen by a medical professional. With a good history and examination, it is possible in most cases to ascertain that there is no underlying grave pathology causing this wetting. Sometimes, a urine test may also be requires to make sure that there is no urine infection or any underlying kidney problem. Once this has been done, what parents need to realise is that this occurs because the bladder is still ‘going to school’! Just like children go to school to become educated and mature adults, the bladder also needs to learn to ‘hold on’ to urine the entire night (a fairly long duration if you understand). Some bladders do it earlier while some take a little longer. In children where the bladder is taking long to learn, it manifests as wetting at night! It is very common. At about 5 years, 10-15 per cent children are wetting at night and by 10 years, about 3-5% children are wetting at night. So, if you do have a child who wets himself/herself, you are not alone. It is quite likely that someone in the family (mother, father, sibling, uncle etc) used to wet at night till a certain age. In most cases, one can usually find another person from the family that had a similar ‘problem’ that then resolved.

Helpful hints

Once the child is above 7-8 years and still wetting, you can facilitate the bladder learning by a few things. 

Do not stop fluids: While one can understand why this is done, remember that doesn’t help the bladder learn to hold more urine! So one would cut down excessive fluid intake but allow the child to have a normal fluid intake. Maybe the evening fluid intake can be kept minimal as required.

Make a star chart: The star charts have been shown to help a large number of children with nocturnal enuresis. If the child is motivated, it is the best treatment to get the child dry. Here is how it works. Help your child make a time-table for the week with days and dates written. For every night that the child remains dry, the child puts a star alongside the date in the time-table. The child and the parents have to decide goals for every week. Don’t aim for the moon! In the first 3-4 weeks, have a deal that if the child has one star per week, you will give a small gift at the end of the week. This deal has to be honoured by both sides. With positive re-enforcement, you are helping the bladder learn what needs to be done! If you do not give the gift at the end of the week, the whole point is lost! After 3-4 weeks, aim for 2 stars and then 3 and so on. Very soon, the child will be dry. If this does not work, (after a fair trial of 3-5 months), then there are other options like an alarm, medications etc. However, the point to note is that all children gain control of the bladder at some stage unless there is an underlying pathology. Virtually all children will be free of bed-wetting at some stage.

Medication: The second group of children who wet in the day time are the ones who will benefit from early medical attention. Again there are several pathological causes for such wetting in the daytime and each will need special medical attention. The commonest condition, however, is an excitable bladder. It is very common in the normal population. There is no underlying grave pathology. The bladder is very excitable and hence keeps sending repeated signals to the brain. This causes the child to go to void urine repeatedly even when there is not much urine in the bladder!

Treatment

A good history and examination is required to look for different causes of such wetting. Urine tests and an ultrasound scan of the bladder and kidneys may be required. Once this diagnosis is confirmed, certain simple measures reduce the excitability of the bladder. Foremost, one should ensure that constipation is treated and then prevented. Avoiding stimulant drinks like tea, coffee and certain juices goes a long way in reducing bladder excitability. If the child is going to school and this is happening in school (frequently passing urine and a few drops of urine in the underwear), simple medications can also help to relax the bladder and stop the excitability. The trick is in teaching the bladder and once the bladder has learnt ‘to relax’, usually the medications can be stopped.

What happens if this is not treated? As the child grows older, usually the excitability gets better and symptoms may improve. However, the major impact is on the child at school. No child likes the underwear to be wet and this leads to loss of self-esteem, irritability, poor performance and frustration at school. This is surely not what one wants to see when children should be enjoying school days to the maximum.

So it’s important to realise that it’s not a lack of effort from the child but elements beyond his/her control that cause wetting and address these elements appropriately. In general terms, one would suggest seeing the doctor if the child;

• Wetting at night persistently after 7-8 years of age
• Day-time wetting (even if it is only a few drops of urine wetting the underwear) once child is going to school
• Persistent day-time wetting with no dry intervals.
• Any associated problems with passing urine like inability to feel the urge to void, inability to void
• Any associated neurological problems (brain and spinal cord)
• Any associated kidney problems

Children don't wet the bed to irritate their parents. Because your child's bed-wetting is involuntary, it's illogical to punish wet nights or reward dry nights. Try to be patient and be sensitive to your child’s feelings as you and your child work through the problem together. With reassurance, support and understanding, your child can look forward to the dry nights ahead.  

Pic: Carla Peroni