How to deal with bed-wetting

 

My six year old son is fighting going to summer camp. He really wants to, but he is fearful that he will wet the bed. He tends to have one or two accidents per week and summer camp is for two weeks. What can I do to help my son stay dry throughout the night?

My family has a huge secret. My son is sixteen years old and still wets the bed. We went to the doctor when he was eight or nine, but received little help. We have tried everything! When my son is upset he says that he sees himself as a freak and that he hates himself. My husband and I used to tell ourselves that he would grow out of it, but it hasn’t happened yet.

Let’s start our discussion by dispelling some myths. The following statements are parental myths that I have heard over the years. None, I repeat none, are based in medical or psychological fact:

 

“Children who wet the bed are less intelligent.” Not true.

“Children who wet the bed are lazy.” Not true.

“Children who start to wet the bed after having nighttime bladder control have been sexually molested.” Not true (but extreme emotional stress can lead to problems of bed wetting).

 

There are four major reasons for bed-wetting, each will be discussed individually:

 

  1. Medical conditions that influence bed-wetting.
  2. Emotional conditions that influence bed-wetting.
  3. Developmental conditions that influence bed-wetting.
  4. Behavioral conditions that influence bed-wetting.

What is bed-wetting?

Enuresis is the medical term for voiding into the clothing or bed not due to a general medical condition. Most children begin to stay dry throughout the night between the ages of 24 and 36 months. A large portion of children are unable to stay dry throughout the night until age five. It is not unusual for nighttime “accidents” to occur until age twelve. In most cases this should not worry parents. If an accident happens, parents should encourage their child to take age appropriate responsibility for their hygiene and their bed. It is best to be supportive but non-concerned. Most children are very uncomfortable if they have an accident. Many children are worried about their parents’ reaction, while others are very hard on themselves for many internal reasons. A few children are very frightened that they are physically ill, reverting back to infancy, or “broken” in some way. Warm assurance is by far the best way for their parents to help them.

Bed-wetting is a common childhood problem. It is imperative that parents do not ridicule their children about bed-wetting. Over the years I have counseled numerous adults that relate their present (low) level of self esteem directly to being ridiculed for bed wetting. On the opposite side of the coin, parents should not alienate the bed-wetting child. Treating your child with disgust or anger can harm his emotional stability.

It is common in our society for us to blame the child for bed-wetting. This is unfortunate and narrow minded. Research shows us that only 75 percent of four-year-olds and 85 percent of five-year-olds stay dry at night more nights than not. It is common for adolescents and even adults to wet the bed occasionally. Researchers have reported that 4 percent of adolescents and 1 percent of adults wet the bed. Over the course of childhood, 1 out of every 4 children between the ages of four and sixteen have a problem with bed-wetting. It is more common for boys to have bed-wetting problems than girls. When we look at the population of children who wet the bed after the age of four we find two groups, continuous and discontinuous bed-wetters. Continuous bed-wetters continue to wet the bed from infancy. Discontinuous bed-wetters re-initiate bed-wetting following at least three months of dry beds. Eighty percent of bed-wetters are continuous.

Medical conditions that influence bed-wetting

Research shows us that 1-2 percent of bed-wetting is caused by a medical condition. Some medications as well as physical ailments can influence the urinary nerves and/or bladder capacity of your child. The most common medical cause of discontinuous bed-wetting is a urinary tract infection. A urinary tract infection can be easily diagnosed by your child’s medical doctor. Even though medical conditions are rare, it is a good practice to start with a general physical by your child’s medical doctor. In rare instances your child’s doctor may refer you to a pediatric urologist.

Emotional conditions that influence bed-wetting

Research shows us that approximately 20 percent of discontinuous bed-wetting is do to an emotional problem. Most of the time, the emotional trauma to the child is readily noticeable. Changes in the family such as a new baby, moving, or starting school are common causative agents. It is common for this type of emotional baggage to elicit nightmares and anxiety at bedtime. Often the child will be “extra” clingy during the day. Many children will outwardly verbalize their concerns, “You don’t love me now that that baby showed up.” Or, “It’s scary to sleep in this new house!”

Parental assurances go a long way to solving this transitory problem.

Developmental conditions that influence bed-wetting

Developmental conditions are the most common cause of bed-wetting. In this situation we are specifically talking about your child’s physical bladder development. Although your child may have no medical condition that causes bladder control problems, the bladder, like all parts of the body, grows and develops at its own pace. Many children, simply put, just do not have the storage capacity to hold what their kidneys can make throughout the night.

Think of the bladder as a water balloon. The balloon expands as more liquid is placed into it. To keep the water in the balloon you have to hold the opening very tightly. The same is true with the urinary bladder. It expands as the kidneys send it more urine to store. There are a ring of muscles at the bottom of the bladder that keeps a tight squeeze on the urethra, the tubing the urine travels through to exit the body. See Figure 1, top. Rather than injuring the urinary bladder, the body voids itself.

The bladder is made up of elasticized tissue. Because of this the capacity can be stretched over time to allow for greater storage capacity. The urinary sphincter is mostly muscle tissue. As with all muscles of the body, the urinary sphincter can be strengthened over time. See Figure 1.

 

 

Most children have a urinary bladder capacity of about 12 ounces. With a capacity of 12 ounces a child tends to have little trouble storing urine throughout the night. Many children with a urine capacity of 4-10 ounces will have difficulty storing urine throughout a normal night’s sleep.

I will discuss a bladder training method later in this section.

Behavioral conditions that influence bed-wetting

We have spent a lot of time discussing the individuality of your children. When children are awake they “show” us their personality and temperament. Children also sleep like individuals. Some children are light sleepers, others can sleep through a train wreck. This individuality is known as your sleep pattern. If your child’s sleep pattern is such that he sleeps deeply, he may not notice the internal mechanism that tells him to wake up and go empty his bladder. The problem is often confounded when a deep sleeper is equipped with a small urine storage tank and/or a weak sphincter.

There are two major behavioral conditions that influence bed-wetting. Children who do not notice the internal signal to wake-up to use the toilet are the first kind. The second are children who manipulate the family with their bed-wetting. It is rare, but secondary gain can be a powerful reinforcer if the child is controlling the family situation with her bed-wetting.

The good news is that there is help for children and adults with enuresis.

Solving the problem of bed-wetting

There needs to be a two prong approach to solving the problem of bed-wetting. The first prong is the possibility of a medical solution. The second is a behavioral approach to solving the problem.

Medical intervention

I have read research studies that have found that 1-10 percent of bed-wetting is due to a medical condition. In my experience the 1 percent finding seems more likely. But, we need to rule out a medical cause first for the simple reason that, if it is a medical condition, our behavioral intervention cannot work. It is important to note that bed-wetting often continues after the medical condition is effectively treated.

If your child has a urinary tract infection your child’s medical doctor will most likely prescribe an antibiotic or antiviral and some cranberry juice. Make sure you follow the prescription. It is important that the medication is taken for the prescribed period of time, even if your child is feeling better before you are out of the medication.

If your child is the anxious type, many medical doctors will prescribe tricyclic antidepressants with Imipramine. Research shows us that tricyclic antidepressants work well for 1 in 3 children. Unfortunately, when the antidepressant is discontinued, the bed-wetting tends to return quickly.

Behavioral interventions

Parents have had great success in stopping bed-wetting by using behavioral interventions. There are four parts to this process. Your child may need all four or just one or two.

 

  1. Your child needs to feel safe within the family.
  2. We need to enlarge your child’s urine storage capacity.
  3. We need to strengthen your child’s urinary bladder sphincter.
  4. We need to teach your child to notice the “wake-up and go to the bathroom signal” even in a deep sleep.

Your child needs to feel safe within the family.

I cannot over emphasize the fact that your child needs to share his problems with others within the family. I advocate that your child hear that “we” have a bed-wetting problem. Parents need to advocate for their children. I am sure he feels deep shame due to the bed-wetting. This shame tends to be exhibited as an “I don’t care attitude” for older children and adolescents.

I advocate that parents focus on how their child is dealing with the problem versus the problem itself. Depending on the emotional maturity of the child, dealing with the wet sheets and remaking the bed should be a Minor Rule. If your child is not ready for the Minor Rule, the process of taking care of himself should be a Must Rule. One family found the following Must Rule very helpful:

 

Must Rule: If a bed is wet, the sheets and PJ’s must be taken out to the garage before breakfast.

Consequence: If the sheets are not in the garage before breakfast, 1/2 hour chore of folding laundry to help mom with her work.

 

Must Rule: If you wet the bed, you must shower, using soap, and wash your hair before breakfast.

Consequence: 1 hour of room restrictions for not caring about yourself.

 

After three years of morning fighting and family anger the above family implemented these Must Rules. After three weeks their teen son asked for the Must Rules to be made into Minor Rules. The parents agreed to try this. After two months of bladder training, described below, this teen went on his first sleep over. This family moved from blaming to advocating for their son’s problem. They made sure that he knew that he had a problem but that his parents loved him and supported him.

Bladder size is a family heritage. Most children find it very helpful when their father or uncle tells them that they used to wet the bed. When the child learns that it is not the worst thing in the world and there are ways to solve the problem, their future looks a lot sunnier and a lot less lonely.

Many families try to restrict liquids for some time before bed. This has limited help due to the fact that the human body is mostly water. There is plenty of liquid for your child to urinate with later. I do get concerned when children are limited liquids at dinner. Your child needs plenty of clean water for healthy growth.

We need to enlarge your child’s urine storage capacity.

Your child needs to have a urine bladder storage capacity of at least 12 ounces to be able to sleep dry throughout the night. Buy a 16 ounce measuring cup. Make sure you get one with 1 ounce lines clearly marked.

The first thing to do is to teach your child about how his body works. You explain that he has two kidneys and that his kidneys filter waste from his blood. The kidneys mix the waste with water and float the waste in the water to the storage tank called the urinary bladder. Use graphics such as Figure 1. Kids find it fascinating to learn about their guts. Explain that the bladder is like a balloon that gets bigger as more urine gets stored inside. Teach your child that the bladder can grow if it is slowly stretched. And, once it is stretched, it will stay big.

Explain that if his bladder was bigger, he would be able to store all the urine his kidneys could make while he slept. Once that happens, he will not have to let the urine out at night before he wakes up.

Explain that he can make his bladder bigger by slowly stretching it a little bit every day. Most kids find that it is pretty easy and in about a month their bladder is much bigger.

The way to stretch his bladder is to make it hold more urine for a little bit. This is pretty simple. Tell your child that when he feels the need to urinate he should go into the bathroom and get ready. Just as he gets ready to urinate he should stop and hold as long as he can. At first he may only be able to hold for 5 to 10 seconds. However, after a few days he will notice that he can hold it longer and longer, maybe even a minute or two.

Then, when he does urinate, he should do so into the measuring cup. This is so we can keep track of how much urine he can hold. Give your child the responsibility of pouring the urine into the toilet and rinsing out the measuring cup so it is ready for the next time. When he is away from home (i.e., school, friend’s house, etc.) he should just practice the holding part and not worry about the measuring.

A chart is kept in the bathroom to keep track of the process. For older kids we tend to keep a calendar and simply log the amount. For younger kids we draw up a chart in the shape of a measuring cup.

Make this a team effort. Make it fun. As your child learns about his internal signal, he can hold his urine without being right at the toilet. At first it is best to practice holding right in the bathroom. Daytime accidents are embarrassing and defeat the goal of this activity.

I generally recommend against attaching an external reward to this activity. Your child is getting a lot of reward by conquering a real life problem. I have seen lots of bribery techniques help kids wet the bed for years. (See: Bribery Does Not Work)

We need to strengthen your child’s urinary bladder sphincter

At the bottom of the urinary bladder there is a tube that takes the urine out of the body. This tube is kept closed by a ring of muscles called a sphincter. Often this muscle needs to be strengthened.

There are two relatively easy ways to strengthen this sphincter. Many moms may recall this exercise from their own pregnancy preparation.

The first exercise is to start and stop urine flow while voiding. Teach your child to urinate a little then stop the flow and count to 10. Then repeat the process until empty. In only a few weeks the sphincter tends to show great improvement. This can be done in association with the measuring cup as described in number 2.

The second exercise is the Kegel exercise developed by Dr. A. M. Kegel in the 1950s. This exercise can be done anywhere for a total of 20 minutes. The muscles that control the bladder are the pubococcygeal muscles. The exercise consists of tightening the anal sphincter. Simulate preventing a bowel movement. Then relax. Tighten the anal muscle, then relax, and breathe deeply. Repeat 20 -30 times in an exercise set. Do this exercise set 3 or 4 times every day.

By improving the quantity of urine your child can store and the muscle tone of the bladder, your child will find dry nights in his future. Be patient, it takes most children 2-3 months to stretch and tone completely.

We need to teach your child to notice the “wake-up and go to the bathroom signal” even in a deep sleep.

When your child is able to store 12 ounces of liquid at a time but he is still having wet nights, I recommend you continue the techniques above and add a fourth method — a bell and pad conditioning device.

Some children sleep so soundly that they do not notice the internal signal telling them to go to the bathroom. A relatively inexpensive device can be purchased from most pharmacies that will help your child learn to notice his internal signal.

The battery powered device is very safe and comes in two forms. One is a special moisture sensitive pad that is placed under your child. The second is a small moisture sensor that is attached to your child’s underwear. When the moisture sensor detects liquid an alarm is set off. (Some even turn on a light.) The alarm disturbs your child’s sleep enough for him to notice the internal signal ... “Get up and take me to the bathroom!”

Research shows us that in a few months about 70 percent of children benefit from this apparatus. Of this 70 percent group, some 30 percent relapse and need to use the apparatus again.

It has been my experience that parents try the “bell and pad” method too early, looking for a quick fix for their child’s bed-wetting. I have found that the “bell and pad” are useful for only a few. Children who enlarge their bladder and strengthen their muscle tone tend not to need it.

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