Bedwetting (बिस्तर गीला करना), also called Nocturnal enuresis, is involuntary urination while asleep after the age at which bladder control usually begins. Bedwetting in children and adults can result in emotional stress. Complications can include urinary tract infections. Most bedwetting is a developmental delay—not an emotional problem or physical illness. Only a small percentage (5 to 10%) of bedwetting cases have a specific medical cause. Bedwetting is commonly associated with a family history of the condition. Nocturnal enuresis is considered primary when a child has not yet had a prolonged period of being dry. Secondary nocturnal enuresis is when a child or adult begins wetting again after having stayed dry. Bedwetting is the most common childhood complaint.
What is Bedwetting?
Types of Bedwetting
Considering different cases and facts, there are two types of bedwetting: Primary bedwetting and Secondary bedwetting. In Primary bedwetting, the children have been wetting their beds since early childhood and have never been dry at night for a long period. However, when the child begins to wet the bed after a long consecutive gap, such as six months or more, the situation is called Secondary bedwetting. In this type, the children have been dry for a long time, and due to specific reasons, the situation arises again.
Risk factors for Bedwetting
Gender and genetics are among the main risk factors for developing bedwetting in childhood. Both boys and girls may experience episodes of nocturnal enuresis during early childhood, usually between ages 3 and 5. But boys are more likely to continue to wet the bed as they get older. Family history plays a role, too. A child is more likely to wet the bed if a parent, sibling, or other family member has had the same issue.
Impact of Bedwetting
A review of the medical literature shows doctors consistently stressing that a bedwetting child is not at fault for the situation. Many medical studies state that the psychological impacts of bedwetting are more important than physical considerations. “It is often the child’s and family members’ reaction to bedwetting that determines whether it is a problem or not.”
Whether bedwetting causes low self-esteem remains a subject of debate, but several studies have found that self-esteem improved with the management of the condition. Bedwetters face problems ranging from being teased by siblings, being punished by parents, the embarrassment of still having to wear diapers, and being afraid that friends will find out.
Psychologists report that the amount of psychological harm depends on whether the bedwetting harms self-esteem or the development of social skills. Key factors are:
- How much bedwetting limits social activities like sleepovers and campouts?
- The degree of social ostracism by peers.
- (Perceived) Anger, punishment, refusal, and rejection by caregivers along with subsequent guilt.
- The number of failed treatment attempts.
- How long the child has been wetting.
Studies indicate that children with behavioral problems are more likely to wet their beds. For children who have developmental problems, behavioral problems, and bedwetting are frequently part of/caused by the developmental issues. For bedwetting children without other developmental issues, these behavioral issues can result from self-esteem issues and stress caused by the wetting.
As mentioned below, current studies show that it is very rare for a child to intentionally wet the bed as a method of acting out:
Punishment for bedwetting
Medical literature states and studies show, that punishing or shaming a child for bedwetting will frequently make the situation worse. It is best described as a downward cycle, where a child punished for bedwetting feels shame and a loss of self-confidence. This can cause increased bedwetting incidents, leading to more punishment and shaming.
In the United States, about 25% of enuretic children are punished for wetting the bed. In Hong Kong, 57% of enuretic children are punished for wetting. Parents with only a grade-school level education punish bedwetting children at twice the rate of high-school- and college-educated parents.
Parents and family members are frequently stressed by a child’s bedwetting. Soiled linens and clothing cause additional laundry. Wetting episodes can cause loss of sleep if the child wakes and/or cries, waking the parents. A European study estimated that a family with a child who wets nightly will pay about $1,000 a year for additional laundry, extra sheets, diapers, and mattress replacement.
Despite these stressful effects, doctors emphasize that parents should react patiently and supportively.
Bedwetting does not indicate a greater possibility of being a sociopath, as long as caregivers do not cause trauma by shaming or punishing a bedwetting child. Bedwetting was part of the Macdonald triad, a set of three behavioral characteristics described by John Macdonald in 1963. The other two characteristics were fire-starting and animal abuse. Macdonald suggested that there was an association between a person displaying all three characteristics, then later displaying sociopathic criminal behavior.
Up to 60% of multiple-murderers, according to some estimates, wet their beds post-adolescence. Enuresis is an “unconscious, involuntary [..] act”. Bedwetting can be connected to past emotions and identity. Children under substantial stress, particularly in their home environment, frequently engage in bedwetting, to alleviate the stress produced by their surroundings. Trauma can also trigger a return to bedwetting (secondary enuresis) in both children and adults.
It is not bedwetting that increases the chance of criminal behavior, but the associated trauma. For example, parental cruelty can result in “homicidal proneness”.
The etiology of NE is not fully understood, although there are three common causes:
- Excessive urine volume,
- Poor sleep arousal, and
- Bladder contractions.
Differentiation of cause is mainly based on patient history and fluid charts completed by the parent or carer to inform management options.
Strong genetic component
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.
These first two factors (etiology and genetic component) are the most common in bedwetting, but current medical technology offers no easy testing for either cause. There is no test to prove that bedwetting is only a developmental delay, and genetic testing offers little or no benefit. As a result, other conditions should be ruled out. The following causes are less common, but are easier to prove and more clearly treated:
No increase in ADH
In some bed-wetting children, there is no increase in ADH (antidiuretic hormone) production, while other children may produce an increased amount of ADH but their response is insufficient.
- Individuals with reported bedwetting issues are 2.7 times more likely to be diagnosed with Attention deficit hyperactivity disorder.
- Caffeine increases urine production.
- Chronic constipation can cause bed wetting. When the bowels are full, it can put pressure on the bladder. Often such children defecate normally, yet they retain a significant mass of material in the bowel which causes bedwetting.
Infections and certain diseases
- 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.
- Patients with more severe neurological-developmental issues have a higher rate of bedwetting problems. One study of seven-year-olds showed that “handicapped and intellectually disabled children” had a bedwetting rate almost three times higher than “non-handicapped children” (26.6% vs. 9.5%, respectively).
- 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. Bedwetting can also be a symptom of a pediatric neuropsychological disorder.
- Sleep apnea stemming from an upper airway obstruction has been associated with bedwetting. Snoring and enlarged tonsils or adenoids are a sign of potential sleep apnea problems.
- Sleepwalking can lead to bedwetting. During sleepwalking, the sleepwalker may think they are in another room. When the sleepwalker urinates during a sleepwalking episode, they usually think they are in the bathroom, and therefore urinate where they think the toilet should be. Cases of this have included opening a closet and urinating in it; urinating on the sofa, and simply urinating in the middle of the room.
- Stress is a cause of people who return to wetting the bed. Researchers find that moving to a new town, parent conflict or divorce, arrival of a new baby, or loss of a loved one or pet can cause insecurity, contributing to returning bedwetting.
Diabetes and Alcohol
- Type 1 diabetes mellitus can first present as nocturnal enuresis. It is classically associated with polyuria, polydipsia, and polyphagia; weight loss, lethargy, and diaper candidiasis may also be present in those with new-onset disease.
- Alcohol intoxication is a leading cause of nocturnal enuresis among adults. Alcohol suppresses the production of anti-diuretic hormones and irritates the detrusor muscle in the bladder, these factors paired with a large amount of fluid ingested, particularly during binge drinking sessions or when paired with caffeinated drinks, can lead to episodes of nocturnal enuresis.
Thorough history regarding the frequency of bedwetting, any period of dryness in between, associated daytime symptoms, constipation, and encopresis should be sought.
People are asked to observe, record and measure when and how much their child voids and drinks, as well as associated symptoms. A voiding diary in the form of a frequency volume chart records voided volume along with the time of each micturition for at least 24 hours.
The frequency volume chart is enough for patients with complaints of nocturia and frequency only. If other symptoms are also present then a detailed bladder diary must be maintained. In a bladder diary, times of micturition and voided volume, incontinence episodes, pad usage, and other information such as fluid intake, the degree of urgency, and the degree of incontinence are recorded.
Each child should be examined physically at least once at the beginning of treatment. A full pediatric and neurological exam is recommended. Measurement of blood pressure is essential to rule out any renal pathology. External genitalia and lumbosacral spine should be examined thoroughly.
A spinal defect, such as a dimple, hair tuft, or skin discoloration, might be visible in approximately 50% of patients with an intraspinal lesion. A thorough neurologic examination of the lower extremities, including gait, muscle power, tone, sensation, reflexes, and plantar responses should be done during the first visit.
Nocturnal urinary continence is dependent on three factors:
1) Nocturnal urine production,
2) Nocturnal bladder function, and
3) Sleep and arousal mechanisms.
Any child will experience nocturnal enuresis if more urine is produced than can be contained in the bladder or if the detrusor is hyperactive, provided that he or she is not awakened by the imminent bladder contraction.
Primary nocturnal enuresis
Primary nocturnal enuresis is the most common form of bedwetting. Bedwetting becomes a disorder when it persists after the age at which bladder control usually occurs (4–7 years), and it either results in an average of at least two wet nights a week with no long periods of dryness or not able to sleep dry without being taken to the toilet by another person.
New studies show that anti-psychotic drugs can have a side effect of causing enuresis. It has been shown that diet impacts enuresis in children. Constipation from a poor diet can result in impacted stool in the colon putting undue pressure on the bladder and creating loss of bladder control (overflow incontinence).
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 7 years old.
Secondary nocturnal enuresis
Secondary enuresis occurs after a patient goes through an extended period of dryness at night (six months or more) and then reverts to night-time wetting.
Psychologists are usually allowed to diagnose and write a prescription for diapers if nocturnal enuresis causes the patient significant distress. Psychiatrists may instead use a definition from the DSM-IV, defining nocturnal enuresis as repeated urination into bed or clothes, occurring twice per week or more for at least three 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.
There are several management options for bedwetting. The following options apply when the bedwetting is not caused by a specifically identifiable medical condition such as a bladder abnormality or diabetes. Treatment is recommended when there is a specific medical condition such as bladder abnormalities, infection, or diabetes. It is also considered when bedwetting may harm the child’s self-esteem or relationships with family/friends. Only a small percentage of bedwetting is caused by a specific medical condition, so most treatment is prompted by concern for the child’s emotional welfare. Behavioral treatment of bedwetting overall tends to show increased self-esteem for children.
Punishment is not effective and can interfere with treatment.
Bedwetting Treatment approaches
Simple behavioral methods are recommended as initial treatment. Other treatment methods include the following:
Motivational therapy in nocturnal enuresis mainly involves parent and child education. The child should participate in morning cleanup as a natural, nonpunitive consequence of wetting. This method is particularly helpful in younger children (<8 years) and will achieve dryness in 15-20% of the patients.
Almost all children will outgrow bedwetting. For this reason, urologists and pediatricians frequently recommend delaying treatment until the child is at least six or seven years old. Physicians may begin treatment earlier if they perceive the condition is damaging the child’s self-esteem and relationships with family/friends.
Physicians also frequently suggest bedwetting alarms that sound in a loud tone when they sense moisture. This can help condition the child to wake at the sensation of a full bladder.
DDAVP (desmopressin) tablets are a synthetic replacement for antidiuretic hormone, the hormone that reduces urine production during sleep. Patients taking DDAVP are 4.5 times more likely to stay dry than those taking a placebo. The drug replaces the hormone for that night with no cumulative effect.
US drug regulators have banned using desmopressin nasal sprays for treating bedwetting since the oral form is considered safer.
Desmopressin is most efficient in children with nocturnal polyuria (nocturnal urine production greater than 130% of expected bladder capacity for age) and normal bladder reservoir function (maximum voided volume greater than 70% of expected bladder capacity for age). Other children who are likely candidates for desmopressin treatment are those in whom alarm therapy has failed or those considered unlikely to comply with alarm therapy. It can be very useful for summer camp and sleepovers to prevent enuresis.
Tricyclic antidepressant prescription drugs with anti-muscarinic properties have been proven successful in treating bedwetting, but also have an increased risk of side effects, including death from overdose. These drugs include amitriptyline, imipramine, and nortriptyline. Studies find that patients using these drugs are 4.2 times as likely to stay dry as those taking a placebo. The relapse rates after stopping the medicines are close to 50%.
What is Alarm therapy for Bedwetting?
Wearing a diaper can reduce embarrassment for bedwetters and make cleanup easier for caregivers.
A major benefit is the reduced stress on both the bedwetter and caregivers. Wearing diapers can be especially beneficial for bedwetting children wishing to attend sleepovers or campouts, reducing emotional problems caused by social isolation and/or embarrassment in front of peers. According to a study of one adult with severe disabilities, extended diaper usage may interfere with learning to stay dry.
Home remedies for Bedwetting
Now, as you have noticed that your child is a bed wetter, you tried to stop this habit in every possible way, but you end up in frustration you feel insecure to stay outside at night. But there is nothing to be worried about how to stop someone from bedwetting. Be with us to know what is a good home remedy for bedwetting:
Reduce Fluid Intake in the Evening
To prevent your child’s bedwetting habit, it’s a natural way to make the bladder free of pressure during the night. But it is necessary to increase your child’s fluid intake during the first half of the day to keep the water balance.
It’s the necessary step you can take at the primary stage to prevent your child from bedwetting. Ask your child to go to the toilet after a certain time break and check whether they are following the schedule or not. Usually, kids only rush to the toilet when they cannot hold the urine anymore, which is harmful to their health.
Use of Honey
It’s a surprise that besides being helpful in beauty treatment, honey is also beneficial for our health and can cure bedwetting issues. You can make a drink with one teaspoonful of honey and a glass of warm milk for your child. It works magically to reduce bedwetting if taken before going to bed at night.
Use of Jaggery and Sesame Seed
One of the best home remedies for bedwetting. Mix one teaspoon of black sesame seed powder, a half teaspoon of celery seed powder, and one teaspoon of jaggery in hot milk. Stir well to make a drink. Give it to your child in the early morning. It helps to warm the body.
As a rich source of edible oil, the mustard seed has wide use in the kitchen as a spice; it is also a well-known home remedy for treating bedwetting in children and adults. Mustard seed powder is helpful to reduce any infection in the urinary tract. Mix one teaspoonful of mustard seed powder with milk and give your kid to drink one hour before bedtime.
Apple Cider Vinegar
Apple cider vinegar can treat the issue of bedwetting very effectively at home. It reduces the acid levels and balances the ph level. Thus it reduces the urge to urinate frequently at night. Add one teaspoonful of apple cider vinegar into one glass of drinking water and give your kid to drink after the meal. It will also solve if your kid has constipation.
Olive oil Massage
If your child is a chronic bed wetter, massaging the lower abdomen with warm olive oil is an excellent option to reduce bedwetting. Just take two teaspoonfuls of olive oil in a bowl, heat it, and massage with your palm on the abdomen surface of your child for a few minutes. Do it regularly to get positive results.
Use of Raisins and walnuts
Raisins and walnuts are full of nutrients that can meet the deficit of protein and minerals and thus beneficial for the bladder health of the child. Therefore, give your child a handful of raisins and walnut in the morning and before they go to bed at night.
If you are tired of trying every solution, cinnamon powder is the best home remedy for treating bedwetting problems. As we all know, cinnamon is obtained from the bark of the cinnamon tree, and it has hundreds of benefits for our health. Being used in the kitchen for its unique smell, it is helpful to cure specific health issues like bedwetting. Add cinnamon powder and sugar on butter toast and serve them as a breakfast or make them chew cinnamon sticks.
Amla or gooseberry has lots of health benefits, and it is enriched with vitamin C. Gooseberry juice is an effective home remedy to cure bedwetting. Take a few ripe gooseberries and smash them in the grinder to make the pulp with water. You can add one teaspoon of honey and black pepper powder to the concoction. Give this to your child every day before bedtime and in the morning to get relief from the chronic disorder.
How to Prevent Bedwetting in Toddlers
The best way to prevent bedwetting in toddlers will vary depending on their situation and needs. However, some tips that may help include:
Making sure that the toddler is sleeping in a comfortable and dry bed
A lot of bedwetting happens during sleep, so making sure that the toddler is sleeping in a relaxed and dry bed can help reduce the likelihood of wetting during the night.
Teaching children about bladder control
It is essential to teach children about bladder control from an early age to know how to manage their bodies and stay hydrated. This will help them build a healthy sense of self-confidence, which is key to preventing toddler bedwetting.
One of the most important things you can do to help prevent bedwetting in toddlers is to encourage frequency. This means making sure that the toddler takes a break every few hours to drink a glass of water or juice. This will help them stay hydrated and stop wetting their beds.
If your toddler cannot keep themselves dry, set limits on how often they are allowed to wet the bed. This way, you can ensure that they are staying safe and healthy while maintaining their independence.
Keeping a close eye on your toddler
It’s important to keep a close eye on your toddler at all times, so you can notice any changes in their bladder habits. If you notice that your toddler is beginning to wet the bed more often, talk to them about it and see if they can identify why this is happening.
Trying a bedwetting prevention product
Besides trying these home remedies, you should consult the medical advisor if your child has other health problems like urinary tract infection, small bladder, etc.
Given the above, I am confident that you have learned the basics of what is bedwetting, meaning, types, impact, causes, diagnosis, management, home remedies, prevention, etc. Now is the right time to use acquired knowledge for solving related problems.
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