Solutions for Bedwetting

The Developmental Givens to Be Solved

Natural developmental control over elimination occurs in the sequence bowel-asleep, bowel-awake, bladder awake, and bladder asleep. Thus, bedwetting (enuresis) is the last eliminative function to be mastered. The child may be comforted to know that since it occurs in sleep when he or she has no conscious control or awareness that they can hardly be viewed as responsible for its occurrence. It is truly a “no fault” accident. Parents can likewise take solace that they are not responsible through neglect or emotional abuse for the bedwetting. However, there is a genetic contribution in that if one parent was a bedwetter their child or children have a 40 percent chance of becoming one and if both parents were bedwetters the likelihood of a child becoming enuretic approaches 80 percent! Altering genetic factors directly are beyond medical knowledge at this time, but we can affect their mechanisms of action.

First, No Harm

Most physicians resist intensive diagnostic procedures for enuresis because it is so common and regarded as a “functional” disorder in 95 percent or so of cases without a disease or abnormal physical basis. They will get a good history and perform simpler diagnostic “rule outs” to eliminate obvious medical causes. They will tend to avoid invasive and intensive diagnostic procedures and recommend fluid restrictions in the evening hours. Often behavioral or reinforcement charts will be employed for toileting compliance and dry nights. Some doctors may urge practicing to hold urine to strengthen the holding reflex with the idea of expanding the bladder and decreasing the tendency to void. These methods are not particularly successful.

Behavioral Problems and Solutions

There is evidence that children tend to restrict fluid intake and avoid urination during their school days which predisposes them to too much fluid loading in the late afternoon at home. This could be difficult to alter because of school policies, public lavatories, limited access to water and the children being away from parental control or reminders. Some parents have successfully used an alarm watch from the www.bedwettingstore.com to signal the child to excuse him/her self to toilet and drink some water. This can be done unobtrusively with a vibration alert option. School cooperation may be sought.

Another caution to check for is an overly full colon due to holding and resisting the toilet. Signs of this would be enormous toilet clogging stools or leakage into the underwear from oozing out due to built up pressure in the gastrointestinal (GI) tract which some parents may describe as “tire tracks”. Often parents will attribute this to inadequate wiping. Other signs are “prune drop” like pellets, hard ballish shaped stools, overly thick Kielbasa-like stools vs. hot dogs, and soupy stools which derives from leakage around a blockage higher up in the colon. If this is evident this must be dealt with first because of bowel pressure on the bladder. 

When the usual common approaches fail we have to look more closely at what is going on for insights on treatment. For example, we know that many bedwetters recognize their bladder urges during the day time and can void appropriately, but at night in the fog of sleep those bladder urges are more likely to go unrecognized by the brain and fail to initiate the holding reflex and arouse the child. Some children may be very naturally (genetically?) defensive of sleep and resist being awakened. This makes them more likely to have an accident. I suspect that most children naturally “learn” to become dry by becoming aware of or startled by their night time bedwetting episodes. They learn to arouse or clamp up in time to avoid a nighttime accident. This analysis accounts for the effectiveness of the bedwetting alarm which can be purchased through many medical supply houses, some pharmacies, or by going to the bedwetting store on the internet at www.bedwettingstore.com (the author has no commercial association with this company). This device conditions arousal by an immediate external sound warning, vibration, or voice-recording by a parent calling his name and urging him to “get up” at the very onset of wetting. Over nightly trials the child’s own natural internal alarm (filling bladder) begins to “beat” the external alarm through the well-known process of classical conditioning. That internal alarm becomes very well established and habitual. According to my own research this connection can be lost in old age. At that point the bedwetting alarm is ineffectual in remaking the necessary connection if there is substantial cognitive and neuronal loss. Children have a real advantage with rapid future brain development toward the beginning of life.

The high success rate and much lower relapse rate for the alarm approach is recognized widely in the research literature. However, its initial cost in the range of $60-$100 inhibits many parents. Also, the necessity to get up in the night to attend to the child is likely very disruptive and upsetting for all concerned. This may be especially true today because of working couples or working single parents. Some parents have expressed concern over traumatizing the child in sleep with sudden arousal and the occasional harsh demands to make the child, often against his will, to proceed to the bathroom and complete urination. The alarm treatment appears to be more widely accepted and offered in Europe than in the USA. Our American society prefers oral medication based solutions.

The Medical Side and Solutions

Another factor in explaining bedwetting is that some children do not have the natural biological rhythm developed sufficiently to concentrate their urine more over the course of sleep so as to reduce bladder volume and pressure. This natural development decreases the likelihood of accidents in the night and may have evolved to preserve sleep. The hormone involved is the naturally occurring anti-diuretic hormone (ADH). A synthetic form of ADH (Vasopressin or DDAVP) can be taken before bed, as a nasal mist or orally, and can activate and increase the kidney concentrating process to enable the child’s likelihood of getting through the night dry. This is the most popular physician prescription today to assist the child in getting through the night dry.  There is some indication that one of the mechanisms for the success of the bedwetting alarm is that it helps to establish natural ADH production in sleep. It may be that the alarm arousal and disturbance of sleep with a filling bladder may promote ADH production if it is not well-established in the night. When ADH alone is used and it is discontinued its relapse rate is very high, in the 80-90 percent range vs. 30-50 percent for the bedwetting alarm.  

Some children may have a spasmodic or an easily irritated bladder that is just hard to control. This is also referred to as an “uninhibited neurogenic bladder.” This condition is also frequently associated with poor daytime control. An anti-spasmodic medication such as Ditropan (Oxybutynin) may be prescribed for this condition.

When the above medications are not successful there is the old standby of a tri-cyclic antidepressant which has been much studied over the years in numerous studies for reducing the incidence of bedwetting. The most commonly prescribed and researched one was Tofranil (imapramine). It may be effective because it affects the architecture of sleep and relaxes the bladder and tightens the sphincter. Unfortunately, it can be cardiotoxic and cause death with an overdose. A very well organized household and parent could likely manage this well, but it has fallen into disfavor. One child reasoned that if one or two pills worked maybe the whole bottle would work better. He died.

Conclusions

While research studies show that the medicational approach can significantly reduce the number of wet nights per week compared to control groups, it often does not eliminate them altogether. Parents want to have a completely dry child. The bedwetting alarm properly applied until 14 consecutive dry nights are achieved over 1-4 months is a natural process which the child begins to take over and internalize. It is a case of skills over pills. There is no pill for German, French, or Calculus. Some things just have to be learned. The general consensus is that the bedwetting alarm is the treatment of choice and medications should only be used for temporary one night or very few nights’ usage. When the pill is metabolized out of the system, its effect is lost.