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Bedwetting (also called nocturnal enuresis or sleep wetting) is very common in the first few years after toilet training. It is so common that it is inaccurate to call it a disease. Most children eventually outgrow their bedwetting as the following table shows:

Age (yr)	Percentage of Children with Bedwetting
2	92.5 %
3	43.2 %
4	20.2 %
5	15.7 %
6	13.1 %
7	10.3 %
8	7.4 %

Bedwetting is usually an isolated problem and that is the condition we will primarily be discussing here. Bedwetting can be associated with urinary tract infections, daytime wetting, and other anatomic and physiological disorders. These problems must be ruled out by taking a proper history, physical examination, inspection of the urine, and, in some cases, using ultrasound or x-ray tests.

In general, bedwetting children have wet their beds all of their lives. Parents tend to find that the children are very sound sleepers and that it is difficult to awaken them at night. The children often do not remember that they are awakened. Sixty percent of the children will have brothers and sisters or fathers and mothers, grandparents or close aunts and uncles who also wet the bed. The common problem that seems to be present in all of the children is that they do not wake to the signal from their full bladder.

As can be seen from above, bed wetters can often become dry without treatment. Approximately, 15 % of bed wetters per year will spontaneously stop wetting the bed. Therefore, patience and understanding are the best thing to offer young children. By the age of 7 or 8 the children's world begins to expand. They would like to have friends overnight at their house or to stay overnight at their friend's house. That is when the social cost of bedwetting begins to rise.

Most of the children have had fluid restriction and have been awakened at night before we see them. This may work for some children, but it certainly does not work for all.

One treatment is to use no treatment as many of the children will outgrow the problem on their own. We have to weigh the pros and cons of active treatment to decide if it is worthwhile to treat the children. I often find that it is not particularly useful to treat children less than 7 years of age because the child is too young to actually collaborate with a treatment program.

Psychological Counseling is another form of treatment. Its primary role is probably to help the parents and child understand the condition. It may not directly influence the course of the bedwetting problem.

Medications: We use several medications to treat bedwetting

• Imipramine (known as Tofranil) has been used for many years to help bed wetters. Approximately, 60 % of the children will respond and become completely or mostly dry at night. The medication may have to be taken for months or years, as it does not directly correct the cause of the bedwetting problem. Periodically, the child should stop the Imipramine to determine if he/she continues to need the medication. Imipramine can be associated with mood changes and nightmares. It is an antidepressant in adults. It must be kept in a childproof bottle.


• Oxybutynin chloride (Ditropan) stops the bladder from having spasms and has a positive effect in approximately one half of the children. Like Imipramine, it may need to be taken for months or years. In the summer months, some of the children may exhibit symptoms of heat exhaustion and there may be facial flushing and irritability, blurred vision, and constipation.


• DDAVP is a relatively new drug therapy. This is a synthetic version of vasopressin, which is an important regulatory hormone that our bodies produce naturally. The hormone is used to reduce the volume of urine at nighttime. One theory is that the sleep wetting children do not have a high enough level of this hormone and therefore produce too much urine while they are sleeping. Thus, DDAVP is administered as a nasal spray and must be used on a nightly basis. One, two, three, or four sprays of DDAVP are used each night. The medication is quite expensive and must be kept in a refrigerator between applications. We need to know if there is a history of cystic fibrosis, seizures or headaches. Often a blood test will be performed after the DDAVP usage has started to determine the status of the blood electrolytes (sodium and potassium). Periodically the DDAVP should be stopped to evaluate whether the child needs to continue the DDAVP. The child may potentially need the medication for weeks or months or years. Headaches, nosebleeds, nasal irritation, chills, dizziness, nausea, abdominal pain, or seizures are reasons to stop the medication and report to us. The use of this medication is relatively new for bedwetting. The long-term side effects are not known.


• Bedwetting buzzer alarm systems are very popular and probably have the highest cure rate in motivated families. Up to 90% of the children can have positive results from the use of these devices. They are not particularly effective below the age of 7. I usually advise that the child have a glass of water or perhaps Coke at bedtime to encourage them to wet. This in turn makes the alarm system work. When the alarm goes off, the child must be awakened and then must remake his bed. This is not punishment. It is a way to be certain that the child is awake. He might walk to the bathroom by sleepwalking and that is not effective. A calendar is kept. When the child has been dry for 30 nights in a row, the system may be discontinued. Many of the children can be dry within 3 months. We encourage a positive reward system with this treatment.

Patience and understanding are always necessary. These children do not intentionally wet the bed. They would not sleep wet if they could possibly help it. The wetting occurs when they are very sound asleep. Thus no amount of shame, punishment or reward will correct the problem. They may already feel bad about themselves and thus need your support. Simple steps such as plastic covers for the mattress or "pull-ups" can be of help. This problem has plagued children since Adam and Eve and will certainly continue well into the next century. It appears to be a genetic (inherited) problem.