Bedwetting

Bedwetting can be worrying and frustrating, but it's common for children to accidentally wet the bed during the night.

Introduction

Bedwetting can be worrying and frustrating, but it's common for children to accidentally wet the bed during the night. The problem usually resolves in time.

The medical name for bedwetting is nocturnal enuresis.

Bedwetting is common in young children but it gets less common as a child gets older.

It's estimated that about:

  • 1 in 12 children wet the bed regularly at four and a half years old (regularly is defined as at least twice a week)
  • 1 in 40 children wet the bed regularly at seven and a half years old
  • 1 in 65 children wet the bed regularly at nine and a half years old

About 1 in 100 people continue to wet the bed into adulthood.

Bedwetting is slightly more common in boys than girls.

When to see your doctor

Bedwetting is only really a problem if it begins to bother the children or parents. Only rarely will this be considered a problem in children under 5 years old. Many families first seek treatment when the bedwetting affects a child's social life (for example, preventing sleepovers).

Medical treatments aren't usually recommended for children under five (although exceptions can be made if a child finds bedwetting particularly upsetting).

If your child frequently wets the bed and finds it upsetting, speak to your doctor for advice.

Read more about the symptoms of bedwetting.

Why does my child wet the bed?

There's usually no obvious reason why children wet the bed and it's not your child's fault. In many cases, the problem runs in families.

Bedwetting could be due to your child:

  • producing more urine than their bladder can cope with
  • having an overactive bladder, meaning it can only hold a small amount of urine
  • being a very deep sleeper so they do not react to the signals telling their brain their bladder is full

Constipation is frequently associated with bedwetting, especially in children who do not wet every night. In these cases, bedwetting may occur during the night when the child has not passed any stool (faeces) during the day. Sometimes treating constipation is all that is required to treat bedwetting. Untreated constipation makes any treatment of bedwetting much harder.

Occasionally, bedwetting can be triggered by emotional distress, such as being bullied or moving to a new school.

In rare cases, bedwetting may be the symptom of an underlying health condition, such as type 1 diabetes.

Read more about the causes of bedwetting and diagnosing bedwetting.

Treating bedwetting

In most cases, the recommended plan is to first try a number of self-help techniques, such as limiting the amount of liquid your child drinks in the evening, making sure they go to the toilet before going to sleep.

Reassuring your child that everything is okay is also important, don't tell them off or punish them for wetting the bed as this will not help and could make the problem worse. It's important for them to know they're not alone and it will get better.

If self-help techniques alone don't help, a bedwetting alarm is often recommended. These are moisture-sensitive pads a child wears on their night clothes. An alarm sounds if the child begins to pee. Over time, the alarm should help train a child to wake once their bladder is full.

If an alarm doesn't work or is unsuitable, medication called desmopressin or oxybutinin can be used.

Most children respond well to treatment, although bedwetting can sometimes return temporarily.

Read more about treating bedwetting.

Symptoms

Bedwetting is usually only regarded as a medical issue when it occurs in children five years old or older who wet the bed at least twice a week.

Frequent bedwetting in children under the age of five isn't usually a cause for concern unless the child is upset by it.

Additional symptoms

In some cases, a child has additional symptoms related to their bedwetting, such as:

  • wetness during the daytime (urinary incontinence) - such as a sudden and urgent need to pee, which can result in your child wetting themselves if they can't reach a toilet in time
  • a frequent need to pee, or needing to pee infrequently (usually considered to be less than four times a day)
  • pain when urinating
  • having to strain to pass urine
  • constipation
  • soiling (accidental loss of bowel control)
  • feeling very thirsty all the time
  • high temperature (fever) of 38°C (100.4°F) or above
  • having blood in their urine

The medical name for this type of bedwetting is polysymptomatic enuresis. Bedwetting without additional symptoms is known as monosymptomatic enuresis.

When to seek medical advice

See your child's doctor if:

  • your child is five years old or older and regularly wets the bed, and it bothers you or your child
  • bedwetting episodes are particularly upsetting, even if your child is younger than five years old
  • your child has any additional symptoms (see above) along with bedwetting
  • your child has suddenly started wetting the bed after a long period of being dry at night

Aside from the physical effects, such as skin irritation, bedwetting can have a significant adverse impact on a child's self esteem and self confidence. You should seek medical help if you suspect this is the case.

If your child has additional symptoms or bedwetting that develops suddenly, they may have an underlying health problem, such as type 1 diabetes or a urinary tract infection (usually a bacterial infection of the urinary tract), which requires treatment.

Causes

Bedwetting is not your child's fault and there's often no obvious reason why it happens. In many cases, the problem runs in families.

Most experts believe there may be more than one underlying cause.

Bladder problems

The bladder is a hollow, balloon-like organ located in the pelvis that's used to store urine. Once the bladder is full, urine passes out of the body through a tube called the urethra, located in the centre of the penis in boys and just under the main opening of the vagina in girls.

Some children affected by bedwetting have what's known as overactive bladder syndrome. This is where the muscles that control the bladder go into spasm, leading to the involuntary passing of urine.

Excessive urine production

Urine is produced by the kidneys. The kidneys remove waste products from the blood. These are mixed with water to produce urine, which then flows into the bladder.

The more fluid your child drinks, the more urine their kidneys produce. Therefore, if your child drinks lots of fluids during the evening, it could result in them wetting the bed during the night, particularly if they have a small bladder capacity. Drinks that contain caffeine, such as cola, tea and coffee can also stimulate an increase in the production of urine.

In some cases of bedwetting, it may be that the child’s body doesn't produce enough of a hormone that regulates urine production, called vasopressin. This means their kidneys produce too much urine for their bladder to cope with.

Difficulties waking up during the night

Once the amount of urine in the bladder reaches a certain amount, the bladder should send signals to the brain.

The signals should convey the feeling of needing to go to the toilet, which would cause most people to wake up. However, some younger children are particularly deep sleepers, and their brain doesn't respond to the signals being sent from their bladder, so they don't wake up.

Alternatively, in some children the nerves attached to the bladder may not yet be fully developed, so they don't generate a strong enough signal to send to the brain.

Sometimes, a child may wake up during the night with a full bladder but not go to the toilet. This may be due to childhood fears, such as being scared of the dark.

Underlying health conditions

Bedwetting can also be caused by an underlying health condition, such as:

  • constipation – if a child’s bowels become blocked with hard stools (faeces), it can put pressure on the bladder and lead to bedwetting
  • type 1 diabetes – a lifelong condition that causes a person's blood sugar level to become too high and can result in the excessive production of urine
  • urinary tract infections (UTIs) – a UTI is an infection of the urinary tract which consists of the urethra, the bladder, the kidneys and the ureters (the tubes that connect the kidneys to the bladder)
  • abnormalities with the urinary tract – such as bladder stones
  • damage to the nerves that control the bladder – this could be due to an accident or a condition such as spina bifida

Emotional problems

In some cases, bedwetting can be a sign that your child is upset or worried. Starting a new school, being bullied or the arrival of a new baby in the family can all be very stressful for a young child.

If your child has started wetting the bed after previously being dry for a period of six months or more (known as secondary nocturnal enuresis), emotional problems such as stress and anxiety may be responsible.

Diagnosis

It's likely your doctor will ask you or your child about their bedwetting to check for any underlying cause and help determine the most effective treatment.

Examples of questions your doctor may ask include:

  • Has bedwetting started suddenly after a previous history of dryness, or has this been a persistent problem since early childhood?
  • If there has been no history of bedwetting, could there be any medical, physical or emotional triggers that might explain the symptoms?
  • How many nights a week does bedwetting happen?
  • How many times a night does bedwetting happen?
  • Is there a large amount of pee?
  • Does your child wake up after wetting the bed?
  • Is your child having any daytime symptoms, such as a frequent or urgent need to pee, loss of bladder control (urinary incontinence), or are they straining to pass urine?
  • Is your child having any additional symptoms that are unrelated to urination, such as constipation, feeling thirsty all the time or a high temperature (fever) of 38°C (100.4°F) or above?
  • How much fluid does your child drink during the day and have you ever tried restricting their fluid intake in the evenings?
  • How often does your child go to the toilet during the day?

As part of the assessment process, you may be asked to keep a ‘bedwetting diary’ to record things such as:

  • your child’s fluid intake
  • the number of times your child goes to the toilet during the day and how much urine they pass
  • how often they wet the bed (for example, how many days a week and how many times during the night)

Further investigation

Further tests are rarely needed, but they may be recommended if your doctor suspects that an underlying health condition or other problem is responsible for your child’s bedwetting (see causes of bedwetting for more information about these).

For example, if your doctor suspects your child may have a urinary tract infection (UTI) or type 1 diabetes, a urine test can be used to check for these conditions.

If your doctor thinks emotional problems might be responsible for your child’s bedwetting, they may recommend talking to your child's teacher or school nurse to see if there are any issues at school that could be causing your child concern.

Treatment

Although most children will stop wetting the bed as they get older, there are a number of treatments that can be tried.

These treatments probably don’t solve the problem, but they can help keep your child dry until they become dry naturally.

Your child's treatment plan

The treatment for your child will depend on a number of things, such as:

  • the frequency of bedwetting
  • the impact that wetting the bed is having, both on your child and on you, your partner and other members of your family
  • your child’s sleeping arrangements, such as whether they sleep alone or share a room with other children
  • whether there's a short-term need to control your child’s bedwetting – for example, if they're going away on a school trip
  • how your child feels about specific treatments

Depending on your child’s symptoms and how well they respond to treatment, the person in charge of their care will be their doctor or a paediatrician (doctor who specialises in treating children).

Alternatively, many clinical commissioning groups (CCGs) run bedwetting clinics, also known as enuresis clinics, which your doctor can refer you to.

There's no single approach to treating bedwetting that works for everybody, but in most cases the recommended plan is to first try a combination of self-help techniques.

If these don't work, a bedwetting alarm is often used. If the alarm is unsuccessful or unsuitable, medication may be recommended.

Self-help

A number of self-help techniques may prevent, or at least reduce, episodes of bedwetting. These are discussed below.

Controlling fluid intake

Drinking too much or too little can contribute to bedwetting. Ensuring your child gets the right amount of fluid each day is often recommended.

Although the amount of fluid your child needs can vary depending on things like how physically active they are and their diet, there are some general recommendations for daily fluid intake. These are:

  • boys and girls 4 to 8 years old - 1,000 to 1,400ml (1.7 to 2.4 pints)
  • girls 9 to 13 years old - 1,200 to 2,100ml (2.1 to 3.7 pints)
  • boys 9 to 13 years old - 1,400 to 2,300ml (2.4 to 4 pints)
  • girls 14 to 18 years old - 1,400 to 2,500ml (2.4 to 4.4 pints)
  • boys 14 to 18 years old - 2,100 to 3,200ml (3.7 to 5.6 pints)

However, it’s important to remember that these are just guidelines and many children do not drink this much.

As well as the quantity, timing is also important. Most of the recommended fluid intake should be consumed during the day, with only about a fifth during the evening.

Also encourage your child to avoid drinks that contain caffeine, such as cola, tea, coffee or hot chocolate because these increase the need to urinate during the night.

Toilet breaks

Encourage your child to go to the toilet regularly during the day. Most healthy children will urinate between four and seven times a day. You should also make sure that your child urinates before going to bed.

Reward schemes

Many parents find reward schemes helpful in managing bedwetting. This is because motivating your child can help bedwetting treatments be more effective.

However, it's important to emphasise that these are only effective when they promote positive behaviour rather than punishing negative behaviour.

Bedwetting is something your child cannot control, so rewards shouldn't be based on whether they wet the bed or not. Instead, you may want to give rewards for:

  • sticking to their recommended fluid intake
  • remembering to go to the toilet before going to bed

It's important not punish your child or withdraw previously agreed treats if they wet the bed. Punishing a child is often counterproductive as it places them under greater stress and anxiety, which could contribute to bedwetting.

If you have tried using a reward scheme to improve your child’s bedwetting and it has not been effective, there is little point continuing it as it is unlikely to be helpful.

Bedwetting alarms

If the self-help techniques don't help, a bedwetting alarm is usually the next step.

A bedwetting alarm consists of a small sensor and an alarm. The sensor is attached to your child’s underwear and the alarm is worn on the pyjamas. If the sensor starts to get wet, it sets off the alarm. Vibrating alarms are also available for children who are hearing impaired.

Bedwetting alarms are not prescribed on the NHS, but you may be able to borrow one from your local clinical commissioning group (CCG). Otherwise, they're available to buy commercially.

Over time, the alarm should help your child to recognise when they need to pee and wake up to go to the toilet.

Reward systems to promote good behaviour may help, such as getting up when the alarm sounds and remembering to reset the alarm. It also helps to make it as easy as possible for your child to go to the toilet during the night, such as using night lights.

The alarm will usually be used for at least four weeks. If there are signs of improvement by this point, the treatment will continue. If there's no sign of improvement, treatment is usually withdrawn as it's unlikely to work for your child.

The aim of the alarm is achieve at least two weeks of uninterrupted dry nights. If there's some improvement after three months, but no sign of this goal being achievable, alternative treatments are usually recommended (see below).

When bedwetting alarms are unsuitable

Bedwetting alarms require commitment from both children and parents. There may be some situations where they're not suitable. For example, if:

  • more immediate treatment is required, for example because you're finding it emotionally difficult to cope with your child’s bedwetting
  • there are practical considerations that make using an alarm problematic, such as if your child shares a room or the alarm disturbs sleep

Some children and their parents may also not like the idea of using an alarm to signify when the child has wet the bed.

Medication

If a bedwetting alarm doesn't help or isn't suitable, treatment with medication is usually recommended. The three main medicines used are described below.

Desmopressin

[Desmopressin] is a synthetic (man-made) version of the hormone that regulates the production of urine, called vasopressin. It helps to reduce the amount of urine produced by the kidneys.

Desmopressin can be used:

  • to provide short-term relief from bedwetting in certain situations – for example, if you're going on holiday or if your child is going on a trip with friends
  • as a long-term alternative treatment in situations where a bedwetting alarm is ineffective, unsuitable or unwanted

Desmopressin should be taken just before your child goes to bed.

The medication reduces the amount of urine that your child produces and makes it harder for their body to deal with excess fluid. Therefore, it's important that they don't drink from an hour before until eight hours after taking desmopressin. If your child drinks too much fluid during this time, it could cause a fluid overload leading to unpleasant symptoms, such as headache and sickness.

If your child isn't completely dry after one to two weeks of taking desmopressin, inform your doctor because the dosage may need to be increased.

Your child’s treatment should be reviewed after four weeks. If the bedwetting has improved, it's usually recommended that treatment continues for another three months, although your doctor may advise taking desmopressin earlier each night (1-2 hours before bedtime). If there is continuing improvement during this time, the course may continue.

If bedwetting stops while taking desmopressin, the medication is reduced gradually to see if your child can stay dry without taking it.

If desmopressin or a bedwetting alarm doesn't work, you will be referred to a specialist.

Anticholinergics

Another option is to use a combination of desmopressin and an additional medication known as an anticholinergic. An anticholinergic called [oxybutynin] can be used to treat bedwetting.

Oxybutynin works by relaxing the muscles of the bladder, which can help improve its capacity and reduce the urge to pass urine during the night.

Side effects of oxybutynin include feeling sick, dry mouth, headache, constipation or diarrhoea. Although these should improve after a few days once your child’s body gets used to the medication. If they persist or get worse, contact the doctor in charge of your child’s care for advice.

Imipramine

If the above treatments don't work, a prescribed medication called [imipramine] may be recommended.

Imipramine also relaxes the muscles of the bladder, increasing its capacity and reducing the urge to urinate.

Side effects of imipramine include dizziness, dry mouth, headache and increased appetite. Although these should improve once your child’s body gets used to the medication. It's important that your child doesn't suddenly stop taking imipramine because it can lead to withdrawal symptoms, such as feeling and being sick, anxiety and difficulties sleeping (insomnia).

Treatment should be reviewed after three months. Once it's felt that your child no longer needs to take imipramine, the dosage can be gradually reduced before the medication is stopped completely.

Treating an underlying condition

If an underlying health condition is the cause of your child's bedwetting, specific treatment will depend on the condition.

Advice for parents

It can be easy for experts to advise parents to remain calm and supportive if their child is bedwetting, but in reality it can be a difficult experience to live with.

While it's important never to blame or punish your child, it's also perfectly normal to feel frustrated.

You should tell your doctor if you feel that you need support, particularly if you're finding it difficult to cope.

You may also find it useful to talk to other parents who have been affected by bedwetting. Education and Resources for Improving Childhood Continence (ERIC) has a message board for parents.

The advice below may help you and your child cope better with bedwetting:

  • Make sure that your child has easy access to the toilet at night. For example, if they have a bunk bed they should sleep on the bottom. You could also leave a light on in the bathroom and put a child’s seat on the toilet.
  • Use waterproof covers on your child’s mattress and duvet. After a bedwetting, use cold water or mild bleach to rinse your child’s bedding and nightclothes before washing them as usual.
  • Avoid waking your child in the night or carrying them to the toilet, as these are unlikely to help them in the long-term.
  • Following a bedwetting, older children may want to change their bedding at night to minimise disruption and embarrassment, so having clean bedding and nightclothes available for them can help.
  • You can try taking off pull-ups at night, but this should be considered a trial rather than a treatment. If the child continues to wet, wearing pull-ups is often nicer for them and easier for the family to manage.
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