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Enuresis Content Supplied by NHS Choices
Introduction

Bedwetting (nocturnal enuresis) 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.

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

In the UK, 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 GP

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 GP 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 caused by 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 don't react to the signals telling their brain their bladder is full

Constipation is frequently associated with bedwetting, especially in children who don't wet themselves every night. In these cases, bedwetting may happen during the night when the child has not had a poo during the day. Sometimes, treating constipation is all that's needed 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

The recommended plan is usually to try a few measures yourself first, such as limiting the amount of liquid your child drinks in the evening, and 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 won't help and could make the problem worse. It's important for them to know they're not alone, and it will get better.

If these measures 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 sometimes returns temporarily.

Read more about treating bedwetting.

ERIC

Education and Resources for Improving Childhood Continence (ERIC) is a UK-based charity for people affected by bedwetting. The charity's website provides useful information and advice for both children and parents.

ERIC also has a telephone helpline - 0845 370 8008, open weekdays from 10am to 4pm.


Symptoms of bedwetting

Bedwetting is usually only regarded as a medical issue in children aged five 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.

Bedwetting is sometimes classified into two types depending on when the problem develops. These are:

  • primary nocturnal enuresis - where the child has wet the bed (or their nappy) regularly since birth
  • secondary nocturnal enuresis - where the child begins to wet the bed after a period of at least six months of persistent dryness

Additional symptoms

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

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 a GP if:

  • your child is five 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 
  • 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 of bedwetting

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 balloon-like organ in the pelvis that stores urine. When it's full, urine flows out of it through a tube called the urethra, found in the centre of the penis in boys and just above the main opening of the vagina in girls.

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

Producing lots of urine

Drinking lots of fluids during the evening could cause your child to wet the bed during the night, particularly if they have a small bladder capacity. Drinks containing caffeine, such as cola, tea, and coffee, can also stimulate an increase in the production of urine.

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

Not using the loo during the night

Once the amount of urine in the bladder reaches a certain point, most people wake up as they feel the need to go to the toilet. However, some younger children are particularly deep sleepers, and their brain doesn't respond to signals sent to the brain 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 because of childhood fears, such as being scared of the dark.

Underlying health condition

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

  • constipation - if a child's bowels become blocked with hard stools, 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 producing lots of urine
  • a urinary tract infection (UTI)
  • abnormalities with the urinary tract, such as bladder stones 
  • damage to the nerves that control the bladder - this could be caused by 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 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.


Diagnosing bedwetting

It's likely your GP 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 GP 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's 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 urine
  • 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 or loss of bladder control (urinary incontinence), or are they straining to pass urine
  • Is your child having any additional symptoms unrelated to urination, such as constipation, feeling thirsty all the time or a high temperature (fever) of 38C (100.4F) 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 may be recommended if your GP suspects 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 GP suspects your child may have a urinary tract infection or type 1 diabetes, a urine test can be used to check for these conditions.

If your GP 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 upsetting them.


Treating bedwetting

Most children stop wetting the bed as they get older, but in the meantime there are a number of treatments you can try.

These treatments may help keep your child dry until they grow out of the problem.

Your child's treatment plan

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

  • how often they're wetting the bed
  • the impact that bedwetting 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 GP 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 GP 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 measures yourself.

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

The various treatments for bedwetting are outlined below. You can also read a summary of the pros and cons of the treatments for bedwetting, allowing you to compare your treatment options.

Measures you can try yourself

The below measures may prevent, or at least reduce, episodes of bedwetting.

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 don't 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 urinate between four and seven times a day. You should also make sure your child urinates before going to bed and has easy access to a toilet.

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 can't 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 to 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 hasn't been effective, there's little point continuing it as it's unlikely to be helpful.

Bedwetting alarms

If the above measures 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 have impaired hearing.

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. For example, an organisation called Education and Resources for Improving Childhood Continence (ERIC) sells alarms for around 40 to 140, depending on the type of alarm.

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 your child produces and makes it harder for their body to deal with excess fluid. Therefore, it's important they don't drink from an hour before taking desmopressin, until eight hours after. 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 GP 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. 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. 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 your child no longer needs to take imipramine, the dosage can be gradually reduced before the medication is stopped completely.

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 condition 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 GP if you feel 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 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 bedwet, wearing pull-ups is often nicer for them and easier for the family to manage.

 
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