![]() Fluid limitation after dinner may decrease the volume of incontinence but is unlikely to stop it. ![]() One option for sleepovers is placing pullups and plastic bags in the child’s sleeping bag so that the other children do not know about the incontinence. Children may come up with ways to live with the incontinence and still participate in normal childhood activities. 13 Parents must understand that, unlike daytime behaviour, nighttime incontinence is not within the child’s control. The most critical aspect of treatment is reassurance for the child, who may experience low self-esteem. Treatment options for bedwetting include lifestyle modification, medications and alternative therapies. Some argue that even urinalysis may be unnecessary. 12 Performing more than a urinalysis and culture for children with nocturnal enuresis would not be cost effective nor helpful to the child. Cayan and colleagues reported that the findings of ultrasonography and uroflowmetry were no different in children with nocturnal enuresis than in children without the condition. This approach is supported by the literature. If the sole symptom is urinary incontinence at night, urinalysis and urine culture may be the only investigations that are necessary. Investigations may include bladder pressure monitoring for those with daytime symptoms and magnetic resonance imaging of the spine to exclude spinal malformations. A history of recurrent urinary tract infections or daytime symptoms such as urinary frequency, incontinence or constipation suggests that further investigation is required. Physical examination should include an abdominal examination to palpate for stool and a back examination to look for signs of congenital spinal malformations such as dimples or hairy patches. More importantly, physicians should ask about the impact of bedwetting on the child’s quality of life. It is reasonable to ask about any stressors (e.g., new baby in the home, recent move, loss of a loved one), particularly in children with secondary enuresis (i.e., who were previously continent at night). Life stressors have, in some studies, been linked to bedwetting however, for most children with bedwetting, there have not been any major life events. The history should focus on the presence of daytime symptoms, which may suggest bladder dysfunction. 11Ī thorough history and focused physical examination are important for all children who present with incontinence. 10 This may also be the mechanism behind nocturnal enuresis in children with obstructive sleep apnea. ![]() 9 Sleep disruption may result in a loss of the physiologic inhibitory signals to the bladder seen in animal studies. In one recent study of children with bedwetting, sleep was significantly more fragmented and there was excessive daytime sleepiness. Parents of children who wet the bed often claim that they are “deep sleepers.” Children with nocturnal enuresis may, however, have sleep disruption. Newer theories point to the role of the central nervous system in bedwetting. Yeung performed ambulatory cystometries and found that bladder overactivity is an important cause of therapy-resistant nocturnal enuresis. 6, 7 Other children may have an “overactive bladder ” however, these children typically have daytime symptoms including urgency, frequency and incontinence. Excessive nocturnal urine production in some children is based on abnormal nocturnal plasma vasopressin release. Each mechanism can be supported by various studies, and no one theory is likely to explain bedwetting in all children. These include excessive nocturnal urine production, bladder overactivity and a failure to awaken in response to bladder sensations. There are three commonly proposed mechanisms to bedwetting. Here we discuss the proposed pathophysiology behind bedwetting, investigations and evidence for current treatments. 5Īlthough very little progress has been made recently in the treatment of bedwetting, there is a greater understanding of the pathophysiology of this condition, in particular, the role of the central nervous system. 4 Boys have also been found to have more severe bedwetting than girls. In a large American study of children between 8 and 11 years of age, the prevalence of bedwetting was 6.21% among boys and 2.51% among girls. 3 Gender also plays a role in bedwetting. 2 There is a strong genetic component to bedwetting in one large study, the odds of a child being a “severe” bedwetter were 3.6 times higher when there was maternal nocturnal enuresis. 1 The prevalence of bedwetting (≥2 nights per week) in one large British study was 8% at 9.5 years. Nocturnal enuresis is defined as nighttime bedwetting in children five years of age or older. Nighttime incontinence, otherwise known as nocturnal enuresis, is a common condition that can cause substantial psychological distress in children with the condition.
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