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Bedwetting

Introduction

Bedwetting can be a worrying and frustrating, but it's extremely common for children to accidentally wet the bed during the night. The condition will often resolve itself in time.

You may hear your doctor refer to bedwetting as nocturnal enuresis.

Medical treatments aren't usually recommended for children under the age of five as it's common to wet the bed at this age (though exceptions can be made if a child finds bedwetting particularly upsetting).

Bedwetting usually only becomes a concern in children who are five years of age or over and who are wetting the bed at least twice a week.

Although bedwetting doesn't pose a threat to a child’s physical health, it can have a considerable psychological impact on their self-esteem and confidence, particularly in older children.

So if your child is experiencing frequent bedwetting and is finding it upsetting, it's recommended that you contact your GP for advice.

Bedwetting can also be a frustrating and upsetting problem for parents, not only coping with its effects on the child, but having to deal with the practical and financial consequences, such as continually washing bedclothes.

Reassuring your child

Reassuring your child that everything is okay is very important if they regularly wet the bed. Your child should know that:

  • it's not their fault
  • they're not alone
  • it will get better

You should also never tell off or punish a child who wets the bed. Not only can this cause distress, it's also likely to make the problem worse.

Treatment

There's no single approach to treating bedwetting, but in most cases the recommended plan is to first try a combination of self-help techniques, such as restricting the amount of liquid your child drinks in the evening (avoid drinks with caffeine in them, such as cola, because caffeine encourages the production of urine).   

If this doesn't work, a bedwetting alarm is often recommended. They're moisture-sensitive pads that a child wears on their night clothes. An alarm sounds if the child begins to pass urine.

Over time, the alarm should help train a child to wake up once their bladder is full or helping them hold on to their urine during the night.

For children who don't respond to an alarm, or for those who are unwilling or unable to use one, a medication called desmopressin can also be used. 

Most children respond well to treatment, although the bedwetting sometimes returns temporarily.

Read more about treating bedwetting.

Why does my child wet the bed? 

In rare cases, bedwetting may be the symptom of an underlying health condition, such as type 1 diabetes (which can cause an excessive production of urine) or constipation (if the bowels aren't fully cleared it can place pressure on the bladder).

Secondary bedwetting, where bedwetting begins after a long period of dryness, can be triggered by some type of emotional distress, such as being bullied or moving to a new school.

However, in the majority of cases, there's no clear reason why a child wets their bed. It could be due to your child:

  • producing more urine than their bladder can cope with
  • the bladder is overactive or ‘irritable’ meaning that it can only hold a small amount of urine
  • their bladder is being very deep sleeper and not reacting to the signals telling their brain that their bladder is full

Bedwetting can also run in families. In about half of cases, one of the child’s parents (usually the father) had a history of bedwetting as a child.

Read more about the possible causes of bedwetting.

How common is bedwetting?

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

It's estimated that:

  • 1 in 6 five-year-olds regularly wets the bed (regularly is defined as at least twice a week)
  • 1 in 10 seven-year-olds regularly wets the bed
  • 1 in 14 10-year-olds regularly wets the bed
  • 1 in 100 18-year-olds regularly wets the bed

Bedwetting is slightly more common in boys than in girls.

Types of bedwetting

Bedwetting often falls into two distinct types. These are where the child:

  • has wet the bed (or their nappy) every night or almost every night since birth – this is known as primary nocturnal enuresis
  • begins to wet the bed after a period of at least six months of persistent dryness – this is known as secondary nocturnal enuresis

Bedwetting can also be classified as:

  • monosymptomatic – night time bedwetting is the only symptom
  • polysymptomatic – a child has other symptoms, such as a frequent need to pass urine during the day or a sudden and urgent need to urinate

Read more about the symptoms of bedwetting.

Bedwetting in adults

A small number of children (1 in a 100) will continue to wet the bed as they move into adulthood, or an adult may begin wetting the bed.

This usually requires referral to a specialist such as an incontinence adviser or an urologist (a specialist in treating conditions that affect the urinary system).

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Symptoms

Frequent bedwetting in younger children under the age of five isn't usually a cause for concern (unless the child is very upset by it). This is also the case for occasional episodes of bedwetting in older children.

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

Additional symptoms

In around 1 in 5 cases, a child has additional symptoms that are related to their bedwetting.

The medical name for this is polysymptomatic enuresis. These symptoms may include:

  • a sudden and urgent need to urinate, which can result in loss of bladder control (urinary incontinence) if your child can't reach a toilet in time
  • urinary incontinence that's unrelated to an urgent need to urinate
  • a frequent need to urinate or, alternatively, an infrequent urge to urinate, which in most cases would 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

When to seek medical advice

Most children will grow out of bedwetting so treatment is often not required. But if a child or the parents, or both, are finding episodes of bedwetting particularly upsetting or bothersome, then treatment should be sought.

Aside from the physical affects of bedwetting, such as skin irritation, the condition can have a significant adverse impact on some children’s self esteem and self confidence. In these cases, if bedwetting is left untreated, it may lead to psychological problems in later life.

It's therefore recommended that you arrange an appointment with your child’s GP. You should also visit your child’s GP if they have any of the additional symptoms listed above because they could be due to an underlying health condition, such as type 1 diabetes or a urinary tract infection (usually a bacterial infection of the urinary tract).

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Causes

There are some conditions that can cause a child to wet the bed. However, in most cases there's no obvious reason why some children wet the bed while others do not.

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

Bladder function

The bladder is a hollow, balloon-like organ located in the pelvis and is designed 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.

The size of the bladder is much smaller in younger children, which means that it can store less urine. Your child’s bladder won't reach full ‘adult size’ until they're 12 years old.

A five-year-old’s bladder can hold around 180ml (about a third of a pint) of urine. An adult bladder can hold 400-600ml (just over two thirds of a pint to just over one pint) of urine.

Due to the smaller size of their bladder, children are more likely to need to pass urine during the night; particularly if their urine production is higher than it should be.

Some children who are affected by bedwetting also 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.

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 is then transferred 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, can also stimulate an increase in the production of urine.

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

Nerve signals

Once the amount of urine in the bladder reaches a certain amount, the bladder should send nerve 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

A number of underlying health conditions can cause bedwetting and other symptoms. These are outlined below.

  • Type 1 diabetes – symptoms include producing an excessive amount of urine, feeling thirsty all the time and tiredness.
  • Constipation – if a child’s bowels become blocked with hard stools (faeces), it can put pressure on the bladder and lead to bedwetting.
  • 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 
  • Bedwetting can also be caused by damage to the nerves that control the bladder. This could be due to an accident or a condition such as spina bifida. This type of nerve damage is known as neurogenic bladder.

Emotional factors

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 (secondary nocturnal enuresis), emotional factors such as stress and anxiety may be responsible.

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Diagnosis

To assess the underlying cause of your child’s bedwetting (if there is one) and determine the most effective treatment for your child, it's likely that your GP will ask you a series of questions about their symptoms.

If your child is old enough, your GP may ask your child directly.

The questions that your GP asks will probably include those listed below.

  • 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 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 urinate, 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?
  • How often does your child go to the toilet during the course of a 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 amount of times your child goes to the toilet during the day
  • how often they wet the bed (i.e. how many days a week and how many times during the night)

Further testing

Further testing may be recommended if your GP suspects that an underlying health condition or other factor is responsible for your child’s bedwetting (see causes of bedwetting).

For example, if your child has additional symptoms that suggest they may have a urinary tract infection (UTI), such as a high temperature or pain when urinating, a urine test can be used to check for bacteria in their urine.

Alternatively, if your child has symptoms that could suggest type 1 diabetes, such as feeling thirsty and tired all the time, they will be referred for a series of blood and urine tests.

Constipation is often an underappreciated cause of bedwetting in children, so your GP may ask you about how often your child passes a stool.

Read more about the diagnosis of UTIstype 1 diabetes and constipation.

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

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Treatment

Your child’s treatment plan for bedwetting will depend on a number of factors, 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 GP or a paediatrician (doctor who specialises in treating children).

Alternatively, many health boards run bedwetting clinics, also known as enuresis clinics, which your GP can refer you to.

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

If these prove to be unsuccessful, a bedwetting alarm is often recommended. If the alarm proves unsuccessful or is unsuitable, medication may be recommended.

Self-help

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

Fluid intake

While drinking too much fluid can increase the risk of bedwetting, the same is true if your child doesn't drink enough fluids during the day.

There are several reasons for this. Firstly, not drinking enough fluid during the day can make children very thirsty in the evening, which results in them drinking lots of fluid before going to bed. Secondly, increasing the fluid intake levels to the recommended levels (see below) helps to ‘train’ the bladder to hold an increased amount of urine without triggering the urge to urinate.

The recommended fluid intakes can vary depending on the temperature, your child’s levels of physical activity and diet. However, the following intakes are generally recommended:

  • for boys and girls who are 4 to 8 years old, it's recommended that they drink between 1,000 to 1,400ml of fluid a day (1.7 to 2.4 pints)
  • for girls who are 9 to13 years old, it's recommended that they drink between 1,200 to 2,100ml of fluid a day (2.1 to 3.7 pints), and for boys of the same age between 1,400 to 2,300ml (2.4 to four pints) of fluids a day
  • for girls who are 14 to 18 years old, it's recommended that they drink between 1,400 to 2,500ml (2.4 to 4.4 pints) of fluids a day, and for boys of the same age between 2,100 to 3,200ml (3.7 to 5.6 pints) of fluids a day

As well as the quantity, the timing of fluid intake is also important. Your child should consume most of their fluid intake during the day and only about a fifth of their recommended intake during the evening.

Also encourage your child to avoid drinks that contain caffeine during the evening, such as cola, tea, coffee or hot chocolate because this will 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 it useful to use reward schemes to help manage bedwetting. However, it's important to emphasise that these types of schemes are only effective when they're designed to promote positive behaviour rather than to punish negative behaviour.

Remember, bedwetting is a symptom over which your child has no control, so it would be inappropriate to give rewards if your child is dry.

For example, you may want to give your child a treat if they:

  • stick to their recommended fluid intake over the course of a week
  • remember to go to the toilet before going to bed
  • taking their medication as required

However, don't 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 their symptoms.

Bedwetting alarms

If the self-help techniques described above don't help, the next recommended step is to try a bedwetting alarm.

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.

Over time, the alarm should help your child to:

  • recognise the need to pass urine
  • wake up to go to the toilet
  • learn to wake up spontaneously, go to the toilet and stop wetting the bed

You can use a similar reward system as discussed above to promote good behaviour, such as getting up when the alarm sounds and remembering to reset the alarm. To assist your child, you should make it as easy as possible for them to go to the toilet during the night, such as using night lights.

It may take several weeks for you to notice any improvements in your child’s symptoms. If there's no sign of improvement after four weeks, treatment is usually withdrawn as it's unlikely to work for your child.

However, in the long-term, treatment is usually successful, and the majority of children achieve persistent dryness. Treatment with the alarm will usually continue until your child has had at least two weeks of uninterrupted dry nights. If there's no sign of this goal being achievable after three months, treatment is usually withdrawn and replaced by an alternative.

When bedwetting alarms are unsuitable

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

  • the bedwetting isn't frequent enough (less than once or twice a week) to warrant treatment
  • you're finding it emotionally difficult to cope with your child’s bedwetting and a more immediate treatment is required
  • there are practical considerations that make using an alarm problematic, such as if your child shares a room with other members of your family or the alarm is causing sleep disturbances

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

Desmopressin 

Desmopressin is a synthetic (man-made) version of the vasopressin hormone. It has a similar effect in that it reduces the amount of urine produced by the kidneys. Desmopressin can be used in two ways to treat bedwetting. It can be used:

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

Desmopressin should be taken at bedtime. The medication will lead to a build-up of fluid inside your child’s body so it's very important that they don't drink any additional fluid from an hour before until eight hours after taking desmopressin.

If your child drinks too much fluid during this time period, it could lead to a fluid overload in their body. This could cause a number of 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 or the doctor in charge of your child’s care because their dosage may need to be increased.

Your child’s treatment will then be reviewed after four weeks. If the bedwetting has stopped, or at least their symptoms have improved, it's usually recommended that treatment continues for another three months. If, after this time, there is continuing improvement, the course may continue.

If bedwetting stops while taking desmopressin, withdrawing the medication at regular intervals (one week for every three months) will usually be recommended to check whether they can maintain dryness without taking desmopressin.

If your child fails to respond to either desmopressin or a bedwetting alarm, it's likely that you will be referred to a specialist. A possible option may be to use a combination of a bedwetting alarm and desmopressin.

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 should improve its capacity and reduce the urge to pass urine during the night.

Side effects of oxybutynin include:

These side effects should improve after a few days once your child’s body gets used to the medication. If they persist or get worse, you should contact the doctor in charge of your child’s care for advice.

Imipramine

If your child fails to respond to any of the treatments discussed above, a prescribed medication called imipramine may be recommended.

Imipramine works in a similar way to oxybutynin in that it relaxes the muscles of the bladder, increasing its capacity and reducing the urge to urinate.

Side effects of imipramine include:

  • dizziness
  • drowsiness
  • dry mouth
  • headache
  • increased appetite
  • feeling sick

The side effects of imipramine 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
  • headache
  • difficulties sleeping (insomnia)

Your child’s treatment will 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 withdrawn 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 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 GP 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.

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Recommendations

The recommendations listed below may help you and your child to 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 and absorbent, quilted sheets. After a bedwetting, use cold water or mild bleach to rinse your child’s bedding and nightclothes; then wash them as usual.
  • Following a bedwetting, older children may want to change their bedding at night to minimise disruption and embarrassment. If so, have clean bedding and nightclothes available for them.
  • After your child has wet the bed, wash them thoroughly (including their hair) before re-dressing them. Use a simple emollient (moisturiser) on your child’s skin to help prevent chapping (red and irritated skin). If necessary, spray the room with a deodoriser after a bedwetting.
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