- Nocturnal enuresis or bedwetting is recurrent involuntary voiding during sleep that occurs twice a week after the age of 5.
- Primary enuresis is when a child has never had a dry period for more than 6 months or secondary enuresis is when the child had a dry period of greater than 6 months.
Brianna's Story
Brianna is 6 yo girl who has been wetting the bed every night. Her parents are concerned because she has not had more than a couple nights throughout her life in which she has been dry at night. She is not having any difficulty with toilet training during the day. She sleeps well at night and is not reported to snore.
Expert Insights
BEARS Screening
As part of the clinic’s routine protocols all patients are screened with a BEARS assessment tool. Open the categories below to review some of the history that was obtained from Brianna and her family.
Bedtime Problems
Brianna is reported to be a “heavy” sleeper - difficult to wake up during the middle of the night but does not have difficulty going to sleep.
Expert Insights
Bedtime problems are usually not a primary issue. However, in families in which bedwetting has become a “stress” involved with guilt, self esteem issues, or related to some trauma, it is important to screen for these issues.
Excessive Daytime Sleepiness
No reports of daytime sleepiness - see below.
Expert Insights
Excessive sleepiness usually is not a significant concern in primary enuresis. If there are other signs and symptoms suggestive of sleep apnea or nocturnal seizures with secondary nocgtural enuresis, then excessive sleepiness may be a concern. Overeall, a child with excessive sleepiness and bedwetting desereves further evaluation/consultation.
Awakenings
Brianna does not routinely awaken at night which tends to be the issue.
Expert Insights
Awakenings - is the parent / caregiver trying to awaken child to go to the bathroom during the night? Is child awakening during the night AFTER going to the restroom?
Awakenings are not typical of bedwetting. However, if they are occurring, this deserves further questioning
- What is waking them up?
- How often are they waking up?
- What happens when they wake up?
- Is it related to a secondary issue - seizures, diabetes mellitus, OSA, periodic limb movement, psychosocial stress?
Regularity & Duration
Brianna is reported to go to sleep easily. She needs to be awakened on school days but wakes on her own on weekends.
Expert Insights
Regularity / duration of sleep - it is important to get enough sleep based on recommended duration of sleep per age. If a child is overtired, it will be more difficult to awaken on own to go to the bathroom
Additionally, an irregular bedtime and wake up time can also contribute to bedwetting. This often contributes to daytime sleepiness.
Sleep-Disordered Breathing / Snoring
Reported to snore only with colds. Her parents don’t think she snores more than half the nights. No history of recurrent ear infections.
Expert Insights
Snoring - bedwetting can be related to Obstructive Sleep Apnea (OSA). It is very important to screen for OSA when evaluating for bedwetting. If snoring is occurring more than 50% of the nights, witnessed apneas, dry mouth, chronic nasal congestion, tonsillar hypertrophy, or other concerns for OSA, Brianna should be evaluated for OSA in the context of bedwetting.
Brianna's Evaluation & Diagnosis
What evaluation & diagnostic protocol should the medical provider use to diagnose Brianna’s nighttime behaviors?
Check all that apply:
The evaluation protocol strategies we recommend for Brianna’s case are:
- Determine child’s sleep history
- Perform Physical Exam
- Complete a Bedwetting Diary
As with any sleep related complaint, a thorough history is important. For Brianna, components of the history to concentrate on include how often this has been occurring, other events at night, as well as any other comorbid medical issues such as constipation or sickle cell anemia.
A sleep diary in this case is likely not valuable. However, a bedwetting diary may be beneficial especially for children in which bedwetting is improving or intermittent or the child lives at multiple homes.
Elements of Brianna's Sleep History
| Sleep History | Case Specific Questions | Brianna's Evaluation Results |
|---|---|---|
What the child does at night |
Has the child always wet the bed? If not, when did it stop and how long was he/she dry at night? Any history of constipation? |
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How many nights a week does the child wet the bed? Any history of urinary tract infections? Any history of bladder abnormalities? |
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Any history of wetting during the day? If so, how long as that been going on? |
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Children with primary enuresis usually do not have psychiatric concerns. However, children with secondary enuresis can have psychiatric concerns. Are there concerns of anxiety, depression, trauma in the context of bedwetting? |
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Any history of snoring?
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No reports of snoring or excessively restless sleep |
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Any concern for any of these other medical issues?
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Have any treatments been tried?
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Review timing of events at night |
How often does this happen at night? |
Parents are not sure when she wets the bed at night. They only know that the pull up is always wet in the morning. |
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How long as this been going on for? What was the age when this started? Are the events becoming more or less frequent? |
Brianna has not had a period of being dry during the night. |
Safety Concerns |
Are there any conerns for trauma, stress, or abuse? |
None. |
Family History |
Any family history of bedwetting or urologic issues in parents or siblings? |
Father with history of bedwetting into grade school - not sure what age he stopped but remembers it was past first grade. |
Physical Exam
| Case Evaluation Information |
|---|
A full physical exam is helpful particularly focusing on ENT evaluation if there is a concern of OSA, abdominal exam if concern of constipation, neurologic exam for any underlying neurological concerns. Additionally, you may consider a kidney ultrasound. |
Other
| Case Evaluation Information | |
|---|---|
Bedwetting Diary |
Parents kept track of Brianna’s bedwetting which occurs on a nightly basis. For patients in which bedwetting is intermittent, providing families with a month calendar or asking them to mark on a calendar which mornings the patient is dry or wet to determine the pattern of bedwetting. |
| Urinalysis | For Brianna, the urinalysis was normal. However, red flags on the urinalysis can include an inability to concentrate the urine, any signs of infection (ie, positive for leukocyte esterase or nitrites) or any glucosuria. A urinalysis is especially important in cases of secondary enuresis |
Options that are Not Recommended
Order Labs/Other Tests
Ordering labs or extra tests is not recommended in this case.
Order a Sleep Study
Consider sleep study if Brianna has secondary enuresis, especially if there is clinical history of snoring (concern for OSA) or restless sleep (concern for PLMD / limb movements). Additionally, consider a sleep deprived EEG if there is a concern of nocturnal seizures that could be contributing to nocturnal enuresis. Symptoms of this would be “stereotyped movements” at night, random awakenings, secondary enuresis, or daytime sleepiness
Refer to a Urologist
Often an initial evaluation, reassurance, and treatment can be done through a patient’s primary care physician. However, for cases in which bedwetting is persistent or there is a concern of a secondary urologic issue, referral to Urology can be beneficial. In some institutions, there may also be resources through psychology for specific behavioral interventions. Finally, if there are other comorbid issues such as constipation, a referral to Pediatric GI could be considered.
Red Flags
- Consider referral to psychiatry or therapist if there was onset of enuresis related to a significant stressor or trauma.
- Persistent enuresis in the context of symptoms of snoring would be a reason for a sleep study.
- Chronic constipation can contribute to nocturnal enuresis.
- Daytime incontinence could point to overactive bladder or other urologic abnormalities.
- If a patient is unable to concentrate urine, consider diabetes mellitus, diabetes insipidus or sickle cell disease.
- A patient with nocturnal enuresis, as well as a history of urinary tract infections, can also be at risk for an underlying urinary tract abnormality.
When evaluating a child for possible parasomnias,
consider how other health care providers may also need to be involved.
Evaluation & Diagnosis
What are potential contributing factors to Brianna’s bedwetting?
Check all that apply:
Brianna’s signs and symptoms are consistent with:
- Family History
- Age
Brianna is 6 years old. Maturational delay and the ability to awaken to a full bladder may be playing a role. Additionally, given that the father was having bedwetting past the age of 5, family history or a genetic component is likely a contributing factor. For some families, this can be reassuring in regards to overall time course.
Constipation and primary urlogic abnormality are not contributing factors to Brianna's bedwetting. Often at this age, if a child is potty trained, sometimes the family is unaware if regular stooling is occurring or not. One could consider an abdominal Xray to evaluate for stool burden. Secondary referral to urology or further testing may be indicated if bedwetting is not improving and especially if there is any daytime incontinence.
Brianna's Treatment & Referrals
Now it’s time to recommend treatment options for Brianna’s bedwetting.
Check all that apply:
The following treatment strategies are recommended for Brianna’s bedwetting:
- Restricting nighttime fluids
- Reassurance from family
For Brianna, who is 6 years of age and otherwise healthy, a period of restriction of nighttime fluids and reassurance is most appropriate. Additionally, familyi education about the importance of good bladder and bowel “health” and how that contributes to bedwetting should be given. This would include making sure that Brianna drinks enough fluids during the day and has ample opportunity to use the restroom during the day. Additionally, continuing to monitor for constipation with the recommendations for a soft, daily stool.
Treatment Strategies for bedwetting
- Evaluate for other contributing factors such as anatomic issues, infections, constipation, behavioral concerns, compounding sleep disorders such as obstructive sleep apnea.
- A period of clinical follow up at certain ages is very reasonable prior to enforcing a need for treatment.
- Very common so “normalizing” this at certain ages reassures family.
- 13% of 6 year olds with bedwetting
- 5% of 10 year olds
- Encourage good bladder health: going to the bathroom regularly during the day.
- Avoid caffeine
- Increased fluid intake
- Preventing constipation
- Behavioral treatments:
- Enuresis alarms - often this is best supported with a good behavioral plan in place as well as a developmentally appropriate age
- Awakening the child by caregivers during the night
- Usually within the first couple hours
- Sticker charts or rewards
- Minimizing fluids
- Avoiding Caffeine
- Bladder training which is adjunctive therapy to overall bladder health
- Medications
- Usually not used for children under the age of 7 years old
- Desmopressin (DDAVP)
- Imipramine
Reassurance and education
When to consult a sleep specialist or refer to another discipline:
- Signs of a urinary tract infection or having recurrent UTI’s
- Constipation
- Diabetes
- Snoring at night
- Signs of sleep apnea - witnessed apneas while breathing, chronic nasal congestion, mouth breathing
- If a child starts to have bedwetting after having been dry for more than 6 months
- Daytime wetting
- Frequent daytime urination
- History of urinary tract infections
- If the child is greater than 7 years old and still wetting the bed every night
Brianna's Results:
Good news!
Brianna’s parents followed up with their primary care physician at her 7 year old well child check. She has started to have less frequent bedwetting accidents. The family estimates that she is now dry about half of the nights. They have not allowed her to have fluids after supper.
Additionally, they noticed that she was having harder stools and only stooling about every 2-3 days. During the well child check, her primary care physician provided some further information on ways to address constipation. This included increasing fluids during the day, increasing fiber in her diet with increased fruits and vegetables, as well as considering a stool softener.
The family also felt like the use of a sticker chart may be beneficial for Brianna. However, because she is currently wet every night, it was discussed to initially see how treating her constipation may be beneficial. If this helps, then it was discussed that initially the goal on the sticker chart would be to start at an achievable goal of being dry more than 50% of the week and increasing the goal slowly from that baseline.
The family arranged for a follow up visit with the primary care physician in 3-6 months. At that visit, they discussed bringing in a bedwetting diary to better assess how frequently Brianna is awakening dry in the morning as well as also keeping track of her constipation issues. Finally, the parents expressed interest in further discussing a bedwetting alarm at that visit if there was not great improvement in the frequency of bedwetting at that time.