Bedwetting is involuntary urination while asleep after the age at which bladder control would normally be anticipated. The medical term for this condition is " nocturnal enuresis ." Primary nocturnal enuresis (PNE) is when a child has not yet stayed dry on a regular basis. Secondary nocturnal enuresis (SNE) is when a child or adult begins wetting again after having stayed dry.
Bedwetting is the most common pediatric-health issue. Studies show that parents become worried too quickly because they expect children to stay dry too early. Most girls can stay dry by age six and most boys stay dry by age seven. By ten years old, 95% of children are dry at night. Studies place adult bedwetting rates at between 0.5% to 2.3%.
Most bedwetting is a developmental delay, not an emotional problem or physical illness. Only a small percentage (5% to 10%) of bedwetting cases are caused by specific medical situations. Bedwetting is frequently associated with a family history of the condition.
Treatment ranges from behavioral-based options such as bedwetting alarms, to medication such as hormone replacement, and even surgery such as urethral enlargement. Since most bedwetting is simply a developmental delay, most treatment plans aim to protect or improve self-esteem. Bedwetting children and adults can suffer emotional stress or psychological injury if they feel shamed by the condition. Treatment guidelines recommend that the physician counsel the parents, warning about psychological damage caused by pressure, shaming, or punishment for a condition children cannot control.
Normal processes of staying dry
Two physical functions prevent bedwetting. The first is a hormone that reduces urine production at night. The second is the ability to wake up when the bladder is full. Children usually achieve nighttime dryness by developing one or both of these abilities. There appear to be some hereditary factors in how and when these develop.
The first ability is a hormone cycle that reduces the body's urine production. At about sunset each day, the body releases a minute burst of antidiuretic hormone (also known as arginine vasopressin or AVP). This hormone burst reduces the kidney's urine output well into the night so that the bladder does not get full until morning. This hormone cycle is not present at birth. Many children develop it between the ages of two and six years old, others between six and the end of puberty, and some not at all.
The second ability that helps people stay dry is waking when the bladder is full. This ability develops in the same age range as the vasopressin hormone, but is separate from that hormone cycle.
Most children develop the ability to stay dry as they grow older. The typical development process begins with one- and two-year-old children developing larger bladders and beginning to sense bladder fullness. Two- and three-year-old children begin to stay dry during the day. Four- and five-year-olds develop an adult pattern of urinary control and begin to stay dry at night.
Frequency of bedwetting (epidemiology)
Most girls can stay dry at night by age six and most boys stay dry by age seven. Males of all ages are more likely to wet the bed than females. Males make up 60% of bedwetters overall and make up more than 90% of those who wet nightly.
Doctors frequently consider bedwetting as a self-limiting problem, since most children will outgrow it. Children 5 to 9 years old have a spontaneous cure rate of 14% per year. Adolescents 10 to 18 years old have a spontaneous cure rate of 16% per year.
Approximate bedwetting rates are:
- Age 5: 20%
- Age 6: 10 to 15%
- Age 7: 7%
- Age 10: 5%
- Age 15: 1-2%
- Age 18-64: 0.5%-1%
As can be seen from the numbers above, a portion of bedwetting children will not outgrow the problem. Adult rates of bedwetting show little change due to spontaneous cure. Persons who are still enuretic at age 18 are likely to deal with bedwetting throughout their lives.
Studies of bedwetting in adults have found varying rates. The most quoted study in this area was done in the Netherlands. It found a 0.5% rate for 18- to 64-year-olds. A Hong Kong study, however, found a much higher rate. The Hong Kong researchers found a bedwetting rate of 2.3% in 16- to 40-year-olds.
Medical definitions: primary vs. secondary enuresis
The medical name for bedwetting is nocturnal enuresis . The condition is divided into two types: primary nocturnal enuresis (PNE) and secondary nocturnal enuresis.
Primary nocturnal enuresis (PNE)
Primary nocturnal enuresis (PNE) is the most common form of bedwetting. Bedwetting counts as a disorder once a child is old enough to stay dry, but continues either to average at least two wet nights a week with no long periods of dryness or to not sleep dry without being taken to the toilet by another person.
Medical guidelines vary on when a child is old enough to stay dry. Common medical definitions allow doctors to diagnose PNE beginning at between 4 to 5 years old. This type of classification is frequently used by insurance companies. It defines PNE as, "persistent bedwetting in the absence of any urologic, medical or neurological anomaly in a child beyond the age when over 75% of children are normally dry."
Some researchers, however, recommend a different starting age range. This guidance says that bedwetting can be considered a clinical problem if the child regularly wets the bed after turning seven years old. D'Alessandro refines this to bedwetting more than twice a month after six years old for girls and seven years old for boys.
Secondary nocturnal enuresis
Secondary enuresis occurs after a patient goes through an extended period of dryness at night (roughly 6 months or more) and then reverts to nighttime wetting. Secondary enuresis can be caused by emotional stress or a medical condition, such as a bladder infection.
U.S. psychological definition
Psychologists may use a definition from the American Psychiatric Association's DSM-IV, defining nocturnal enuresis as repeated urination into bed or clothes, occurring twice per week for at least 3 consecutive months in a child of at least 5 years of age and not due to either a drug side effect or a medical condition. Even if the case does not meet these criteria, the DSM-IV definition allows psychologists to diagnose nocturnal enuresis if the wetting causes the patient clinically significant distress.
Causes of and increased risks for bedwetting
The following list summarizes bedwetting's known causes and risk factors. Enuretic patients frequently have more than one cause or risk factor from the items listed below.
Most common causes
Most cases of bedwetting are PNE-type, which has two related most common causes:
- Neurological-developmental delay
This is the most common cause of bedwetting. Most bedwetting children are simply delayed in developing the ability to stay dry and have no other developmental issues.- Genetics
Bedwetting has a strong genetic component. Children whose parents were not enuretic have only a 15% incidence of bedwetting. When one or both parents were bedwetters, the rates jump to 44% and 77% respectively. Genetic research shows that bedwetting is associated with the genes on chromosomes 13q and 12q (possibly 5 and 22 also).Developmental delay and genetics are the most common factors, but doctors cannot directly identify them as the cause of a child's bedwetting. There is no test to prove that bedwetting is only a developmental delay, and genetic testing offers little or no benefit.
Instead, doctors try to rule out other causes. The following causes are less common, but are easier to prove and more clearly treated:
- Infection/disease
Infections and disease are more strongly connected with secondary nocturnal enuresis and with daytime wetting. Less than 5% of all bedwetting cases are caused by infection or disease, the most common of which is a urinary tract infection.- Physical abnormalities
Less than 10% of enuretics have urinary tract abnormalities, such as a smaller than normal bladder. Current data does support increased bladder tone in some enuretics, which functionally would decrease bladder capacity.- Insufficient anti-diuretic hormone (ADH) production
A portion of bedwetting children do not produce enough of the anti-diuretic hormone. As explained above, the body normally increases ADH hormone levels at night, signalling the kidneys to produce less urine. The diurnal change may not be seen until about age 10.- Psychological
Psychological issues (e.g., death in the family, sexual abuse, extreme bullying) are established as a cause of secondary nocturnal enuresis (a return to bedwetting), but are very rarely a cause of PNE-type bedwetting.
When Enuresis is caused by a psychological disorder, the bedwetting is considered a symptom of the disorder. Enuresis does have a psychological diagnosis code (see previous section), but it is not considered a psychological condition itself. (See section on psychological/social impact, below)- Constipation
Chronic constipation can cause bedwetting. When the bowels ar
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