"Enuresis" is the term for the involuntary passage of urine during sleep. It is a very common problem affecting 40% of 3-year-olds, 10% of 6-year-olds, and 3% of 12-year-olds. We consider it normal until at least 6 years of age.

Most of these children have inherited small bladders, which cannot hold all the urine produced in a night. In addition, they don't awaken to the signal of a full bladder. The kidneys are normal. Physical causes are very rare, and your physician can easily detect them. Emotional problems do not cause enuresis, but they can occur if it is mishandled.

Most children who wet the bed overcome the problem between 6 and 10 years of age. Even without treatment, all children eventually  get over it. Therefore, treatments that might have harmful complications should not be used. On the other hand, treatments without side effects can be started as soon as your child has achieved complete daytime bladder control for 6 to 12 months.

What you can do:

• Encourage your child to get up to urinate during the night. This advice is more important than any other. Tell your child at bedtime, "Try to get up when you have to pee." Leaving a light on in the bathroom may help. Some preschoolers prefer to use a potty chair left next to the bed.
• Encourage postponing urination. Encourage your child to urinate infrequently during the daytime. If your child urinates often, sometimes encourage him to wait, but don't make an issue of it. Don't remind him to use the bathroom except at bedtime.
• Encourage daytime fluids. Encourage fluid during the morning and early afternoon. The more fluids your child drinks, the more urine your child will produce, and more urine leads to larger bladders.
• Discourage evening fluids. Discourage your child from drinking more than 2 ounces during the 2 hours before bedtime. Give gentle reminders about this, but don't worry about a few extra swallows of water.
• Protect the bed from urine. Your child should wear extra thick underwear in addition to his pajamas. This keeps much of the urine from getting through to the sheets. Diapers or plastic pants should no longer be used by 4 years of age. Odor becomes a problem if urine soaks into the mattress or blankets. Protect the mattress with a plastic mattress cover.
• Establish a morning routine for wet pajamas and wet bedding. On wet mornings your child can rinse his pajamas and underwear in the sink until the odor is gone. If your child smells of urine, he will need to take a quick rinse in the shower so he won't be teased at school. You can cut down on the laundry by placing a dry towel under your child's bottom each night. This can be rinsed each morning and saved until you do your wash. If a wet bed is left open to the air, the wet sheets will usually be dry by noon. Because of odor, the sheets may need to be washed  a few extra times each week.
• Respond positively to dry nights. Praise your child on mornings when he wakes up dry. A calendar with gold stars or "happy faces" for dry nights may also help.
• Respond gently to wet nights. Your child does not like being wet. Most bed-wetters feel quite guilty and embarrassed about this problem. They need sympathy, not blame or punishment. Siblings should not be allowed to tease bed-wetters. Punishment or pressure will delay a cure and cause secondary emotional problems.

What you can do when your child reaches 6 years of age:

Follow the previous recommendations in addition to the guidelines given below:

• Self-awakening program for children with small bladders. Children with small bladders cannot stay dry unless they get up to urinate one or more times every night. Make sure your child understands this. His goal should be getting up, not holding his urine until morning. Getting up can keep a person dry regardless of how small the bladder is or how much fluid he drinks. To help your child learn to awaken himself at night, encourage him to practice the following pep talk at bedtime.
  • Lie on your bed with your eyes closed
  • Pretend it's the middle of the night
  • Pretend your bladder is full
  • Pretend it's starting to hurt
  • Pretend it's trying to wake you up
  • Pretend it's saying: "Get up before it's too late."
  • Then run to the bathroom and empty your bladder
  • Remind yourself to get up like this during the night
• Encourage changing wet clothes during the night. If your child wets at night, he should try to get up and change himself. First, if your child feels any urine leaking out, he should try to stop the flow of urine. Second, he should hurry to the toilet to see if he has any urine left in his bladder. Third, he should change himself and put a dry towel over the wet part of the bed. This step can be made easier if dry pajamas and towels are always kept on a chair near the bed. The child who shows the motivation to carry out these steps is close to being able to awaken from the sensation of a full bladder.
• Determine the capacity (size) of your child's bladder. Do this by having your child hold his urine as long as possible on at least three occasions. Each time have your child urinate into a container. Measure the amount of urine in ounces. The largest of the three measurements can be considered your child's bladder capacity. The normal capacity is 1 or more ounces per year of age. In a 6-year-old, a capacity of 5 ounces or less is small; a capacity of 6 to 8 ounces is normal and means that the bladder can hold a night's urine production until morning. Normal adult bladder size is 14 to 16 ounces.
• Encourage bladder-stretching exercises. These can gradually enlarge the size of the bladder so that it can hold more urine at night. Just as importantly, waiting 10 to 15 minutes during the day can help the bladder wait at night until your child can get out of deep sleep and wake up. To stretch the bladder, encourage your child to hold his urine as long as possible during the daytime. Whenever your child feels the urge to go, he can try to distract himself for the 10 seconds or so it takes for the bladder spasms to stop. Learning to resist the first urge to urinate is especially important. At least once each day, have your child urinate into a measuring cup to see if he has maintained or even beaten his previous record (in ounces). Mark the highest volume achieved with a piece of masking tape on the cup. These exercises should be introduced only if your child wants to try them; for some children this won't occur before 8 years of age.
• Help your child assume responsibility. Your child should feel responsible for solving this problem. The bladder exercises, self-awakening program, control of fluid intake, and record keeping need your child's involvement and commitment. By all means, don't try to awaken your child at night. As long as you are doing it, your child is less likely to do it himself. Your child should look  on his parents and physician as people who can provide suggestions and support but who do not take responsibility for the bed-wetting.

What you can do when your child reaches 8 years of age:

Follow the previous recommendations. Talk with us about possibly using alarms or drugs as well, as described below:

• Bed-wetting alarms. Alarms are used to teach a child to awaken when he needs to urinate during the night. They have the highest cure rate (about 70%) of any available approach. They are the treatment of choice for any bed-wetter with a small bladder who can't otherwise train himself to awaken at night. The new transistorized alarms are small, lightweight, sensitive to a few drops of urine, not too expensive (about $50), and easy for a child to set up by himself. Children using alarms still need to work on the self-awakening progam. Request the special instruction sheet on bed-wetting alarms.
• Alarm clocks. If your child is unable to awaken himself at night and you can't afford a bed-wetting alarm, teach him to us an alarm clock or clock radio. Set if for 3 or 4 hours after your child goes to bed. Put it beyond arm's reach. Encourage your chld to practice responding to the alarm during the day while lying on the bed with eyes closed. Have your child set the alarm each night. Praise your child for getting up at night, even if he isn't dry in the morning.
• Drugs. Most bed-wetters need extra help with staying dry during slumber parties, camping trips, vacations, or other overnight stays. Some take an alarm clock with them and stay dry by awakening once at night. Some are helped by temporarily taking a drug at bedtime. One drug (given by nasal spray) decreases urine production at night and is quite safe. Another older drug (taken as a pill) temporarily increases bladder capacity. It is safe at the correct dosage but dangerous if too much is taken or younger siblings get into it. If you do use a drug, be careful about the amount you used and where you store the drug, and be sure to keep the safety cap on the bottle. The drawback of these medicines is that when they are stopped, the bed-wetting usually returns. They do not cure bed-wetting. Therefore children on drugs for enuresis should also be using an alarm and learning to get up at night.

Contact your doctor if urination causes pain or burning, the urine stream is weak or dribbly, your child also has daytime wetting, your child also drinks excessive fluids, bed-wetting is a new problem (your child used to be dry), your child is over 12 years old, or if your child is over 6 years of age and is not better after 3 months using these treatment programs.

Contact Lake Area Pediatrics at
(936) 582-5620

Barton D. Schmitt, MD