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{{short description|Involuntary urination while asleep}}{{cs1 config|name-list-style=vanc|display-authors=6}}{{For|the Chris Brown song|Wet the Bed}}

factoids

Nocturnal enuresis (NE), also informally called bedwetting, 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.WEB, Definition & Facts for Bladder Control Problems & Bedwetting in Children,www.niddk.nih.gov/health-information/urologic-diseases/bladder-control-problems-bedwetting-children/definition-facts, National Institute of Diabetes and Digestive and Kidney Diseases, 25 October 2017, September 2017, live,web.archive.org/web/20171025073642/https://www.niddk.nih.gov/health-information/urologic-diseases/bladder-control-problems-bedwetting-children/definition-facts, 25 October 2017, BOOK, Lallemand, François, A Practical Treatise on the Causes, Symptoms, and Treatment of Spermatorrhoea, McDougall, Henry J, Blanchard and Lea, 1853, McDougall, Henry J., Harvard University, 231, BOOK, Cooper, Samuel, The first lines of the practice of surgery, Richard Phillips, 1807, the University of California, 456, 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.WEB,www.duj.com/Johnson.html, Nocturnal Enuresis, www.duj.com, 2008-02-02, Johnson, Mary,www.duj.com/Johnson.html," title="web.archive.org/web/20080122063339www.duj.com/Johnson.html,">web.archive.org/web/20080122063339www.duj.com/Johnson.html, 2008-01-22, Bedwetting is commonly associated with a family history of the condition.WEB, Bedwetting, The Royal Children’s Hospital Melbourne,www.rch.org.au/kidsinfo/fact_sheets/Bedwetting/, 2009-10-20, live,www.rch.org.au/kidsinfo/factsheets.cfm?doc_id=3716," title="web.archive.org/web/20081226144048www.rch.org.au/kidsinfo/factsheets.cfm?doc_id=3716,">web.archive.org/web/20081226144048www.rch.org.au/kidsinfo/factsheets.cfm?doc_id=3716, 2008-12-26, 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.Treatments range from behavioral therapy, such as bedwetting alarms, to medication,JOURNAL, Trousseau, Armand, 1882, Clinical Medicine, Clinical Medicine Lectures Delivered at the Hôtel-Dieu, Paris, P. Blakiston, Son, 2, 304, JOURNAL, Adee, D., 1843, The Retrospect of Practical Medicine and Surgery, Being a Half-yearly Journal Containing a Retrospective View of Every Discovery and Practical Improvement in the Medical Sciences, 1-4, 73, such as hormone replacement, and even surgery such as urethral dilatation. Since most bedwetting is simply a developmental delay, most treatment plans aim to protect or improve self-esteem. Treatment guidelines recommend that the physician counsel the parents,JOURNAL, Cook DE, Monro IS, West DH, 1945, Standard Catalog for Public Libraries: 1941-1945 supplement to the 1940 edition, Standard Catalog for Public Libraries: Supplement... 1941-, H.W. Wilson Company, H. W. Wilson Company, 1945, 1, 18, warning about psychological consequences caused by pressure, shaming, or punishment for a condition children cannot control.Bedwetting is the most common childhood complaint.WEB,www.hawaii.edu/medicine/pediatrics/pedtext/s13c09.html, Case Based Pediatrics For Medical Students and Residents, 2010-05-28, Paredes, Potenciano Reynoso, Department of Pediatrics, University of Hawaii John A. Burns School of Medicine, live,www.hawaii.edu/medicine/pediatrics/pedtext/s13c09.html," title="web.archive.org/web/20100530071129www.hawaii.edu/medicine/pediatrics/pedtext/s13c09.html,">web.archive.org/web/20100530071129www.hawaii.edu/medicine/pediatrics/pedtext/s13c09.html, 2010-05-30, WEB,urology.ucla.edu/body.cfm?id=146, Nocturnal Enuresis, 2010-05-28, UCLA Urology, live,urology.ucla.edu/body.cfm?id=146," title="web.archive.org/web/20100707101513urology.ucla.edu/body.cfm?id=146,">web.archive.org/web/20100707101513urology.ucla.edu/body.cfm?id=146, 2010-07-07, JOURNAL, Butler RJ, Holland P, 35856153, The three systems: a conceptual way of understanding nocturnal enuresis, Scandinavian Journal of Urology and Nephrology, 34, 4, 270–7, August 2000, 11095087, 10.1080/003655900750042022,

Impact

A review of 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 the physical considerations. “It is often the child’s and family members’ reaction to bedwetting that determines whether it is a problem or not.”

Self-esteem

Whether bedwetting causes low self-esteem remains a subject of debate, but several studies have found that self-esteem improved with management of the condition.WEB,www.nursingcenter.com/prodev/ce_article.asp?tid=659967, Helping Children with Nocturnal Enuresis, www.nursingcenter.com, 2008-02-03, Berry, Amanda, live,www.nursingcenter.com/prodev/ce_article.asp?tid=659967," title="web.archive.org/web/20080121094022www.nursingcenter.com/prodev/ce_article.asp?tid=659967,">web.archive.org/web/20080121094022www.nursingcenter.com/prodev/ce_article.asp?tid=659967, 2008-01-21, Children questioned in one study ranked bedwetting as the third most stressful life event, after “parental war of words”, divorce and parental fighting. Adolescents in the same study ranked bedwetting as tied for second with parental fighting.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 development of social skills. Key factors are:WEB,psychologytoday.com/conditions/enuresis.html, Psychology Today’s Diagnosis Dictionary: Enuresis, Psychology Today, 2008-02-02, {{Dead link|date=March 2024 |bot=InternetArchiveBot |fix-attempted=yes }}{{ums|date=January 2018}}

• How much the bedwetting limits social activities like sleep-overs and campouts
• The degree of the 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

Behavioral impact

Studies indicate that children with behavioral problems are more likely to wet their beds. For children who have developmental problems, the behavioral problems and the 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.{{ums|date=January 2018}}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.{{citation needed|date=April 2021}}

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.WEB,edis.ifas.ufl.edu/HE794, Bedwetting, 2009-09-12, live,edis.ifas.ufl.edu/HE794," title="web.archive.org/web/20090922115037edis.ifas.ufl.edu/HE794,">web.archive.org/web/20090922115037edis.ifas.ufl.edu/HE794, 2009-09-22, In the United States, about 25% of enuretic children are punished for wetting the bed.JOURNAL, Haque M, Ellerstein NS, Gundy JH, Shelov SP, Weiss JC, McIntire MS, Olness KN, Jones DJ, Heagarty MC, Starfield BH, Parental perceptions of enuresis. A collaborative study, American Journal of Diseases of Children, 135, 9, 809–11, September 1981, 7282655, 10.1001/archpedi.1981.02130330021007, In Hong Kong, 57% of enuretic children are punished for wetting.JOURNAL,www.hkjpaed.org/details.asp?id=85&show=1234, Primary Nocturnal Enuresis: Patient Attitudes and Parental Perceptions, Hong Kong Journal of Paediatrics, New Series, 2004, 9, 54–58, 2008-02-03, live,www.hkjpaed.org/details.asp?id=85&show=1234," title="web.archive.org/web/20080121230523www.hkjpaed.org/details.asp?id=85&show=1234,">web.archive.org/web/20080121230523www.hkjpaed.org/details.asp?id=85&show=1234, 2008-01-21, Parents with only a grade-school level education punish bedwetting children at twice the rate of high-school- and college-educated parents.In Korea and in small parts of Japan, there is a folk tradition whereby bedwetters are made to wear a winnowing basket on their head and sent to ask their neighbors for salt. This is motivated in part by a desire to publicly embarrass the child into compliance, as neighbors would recognize why the child was knocking on their door.JOURNAL, Noh, Seonghwan, April 2021, 한국 오줌싸개 치유에 대한 비교민속학적 고찰, Korean Bedwetter and East Asian Folklore,www.dbpia.co.kr/Journal/articleDetail?nodeId=NODE10568118, 비교민속학, Comparative Folklore, ko, 73, 45–88, 1598-1010, 10.38078/ACF.2021.4.73.45, 238041634,

Families

Parents and family members are frequently stressed by a child’s bedwetting. Soiled linens and clothing cause additional laundry. Wetting episodes can cause lost 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.WEB,www.kidshealth.org/parent/general/sleep/enuresis.html, Bedwetting, www.kidshealth.org, 2008-02-03, live,www.kidshealth.org/parent/general/sleep/enuresis.html," title="web.archive.org/web/20080202125727www.kidshealth.org/parent/general/sleep/enuresis.html,">web.archive.org/web/20080202125727www.kidshealth.org/parent/general/sleep/enuresis.html, 2008-02-02,

Sociopathy

{{Update|inaccurate=yes|date=December 2021}}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.JOURNAL, Macdonald JM, 1963, The threat to kill, Am J Psychiatry, 120, 2, 125–130, 10.1176/ajp.120.2.125, The other two characteristics were firestarting and animal abuse. Macdonald suggested that there was an association between a person displaying all three characteristics, then later displaying sociopathic criminal behavior.JOURNAL, Parfitt, Charlotte Hannah, Alleyne, Emma, April 2020, Not the Sum of Its Parts: A Critical Review of the MacDonald Triad, Trauma, Violence & Abuse, 21, 2, 300–310, 10.1177/1524838018764164, 1552-8324, 29631500, 206738131,kar.kent.ac.uk/66782/1/Parfitt%20%26%20Alleyne%20%28in%20press%29.pdf, Up to 60% of multiple murderers, according to some estimates, wet their beds post-adolescence.BOOK, Helen, Gavin, Criminological and Forensic Psychology, 120, 2013, Enuresis is an “unconscious, involuntary [...] act”.BOOK, Hickey, Eric, Serial Murderers and their Victims, 2010, Wadsworth, Cengage Learning, Belmont, CA, 978-4-9560081-4-3, 101, Bedwetting can be connected to past emotions and identity. Children under substantial stress, particularly in their home environment, frequently engage in bedwetting, in order to alleviate the stress produced by their surroundings.{{citation needed|date=April 2021}} 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.JOURNAL, 1919, The Journal of Delinquency, Volumes 4-5, The Journal of Delinquency, California Bureau of Juvenile Research, Whittier State School, Department of Research, 4-5, 41–55, Parental cruelty can result in “homicidal proneness”.BOOK, Encyclopedia of Violence, Dicanio, Margaret, iUniverse, 2004, 0-595-31652-2,

Causes

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.JOURNAL, Magura, Ratidzai, Nocturnal enuresis in children, The Pharmaceutical Journal, 2015-01-05, 294, 7843/4, 10.1211/pj.2015.20067378,digital.library.wisc.edu/1793/40627, JOURNAL, Hallgren, Bertil, 1956, Enuresis, Acta Psychiatrica Scandinavica, 31, 4, 405–436, 10.1111/j.1600-0447.1956.tb09699.x, 221430598, 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.JOURNAL, Fritz G, Rockney R, Bernet W, Arnold V, Beitchman J, Benson RS, Bukstein O, Kinlan J, McClellan J, Rue D, Shaw JA, Stock S, Kroeger Ptakowski K, Practice parameter for the assessment and treatment of children and adolescents with enuresis, Journal of the American Academy of Child and Adolescent Psychiatry, 43, 12, 1540–50, December 2004, 15564822, 10.1097/01.chi.0000142196.41215.cc, free, These first two factors (aetiology 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:{{citation needed|date=April 2021}}In some bedwetting 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.JOURNAL, Eggert P, Kühn B, Antidiuretic hormone regulation in patients with primary nocturnal enuresis, Archives of Disease in Childhood, 73, 6, 508–11, December 1995, 8546506, 1511443, 10.1136/adc.73.6.508,

• People with reported bedwetting issues are 2.7 times more likely to be diagnosed with attention deficit hyperactivity disorder.
• Caffeine increases urine production.WEB,www.nlm.nih.gov/medlineplus/ency/article/003144.htm, MedlinePlus Medical Encyclopedia: Urination – bed wetting, www.nlm.nih.gov, 2008-02-02, live, 2007-06-09,www.nlm.nih.gov/medlineplus/ency/article/003144.htm," title="web.archive.org/web/20070609144009www.nlm.nih.gov/medlineplus/ency/article/003144.htm,">web.archive.org/web/20070609144009www.nlm.nih.gov/medlineplus/ency/article/003144.htm,
• Chronic constipation can cause bed wetting.JOURNAL, Medical Association, Texas, 1910, Texas State Journal of Medicine, Volume 5, Issue 12, Texas State Journal of Medicine, Texas Medical Association., 1910, 5, 12, 433, When the bowels are full, it can put pressure on the bladder.WEB,www.hawaii.edu/medicine/pediatrics/pedtext/s13c09.html, Case Based Pediatrics For Medical Students and Residents, Department of Pediatrics, University of Hawaii John A. Burns School of Medicine, 2008-02-02, Reynoso Paredes, Potenciano, live,www.hawaii.edu/medicine/pediatrics/pedtext/s13c09.html," title="web.archive.org/web/20080120165022www.hawaii.edu/medicine/pediatrics/pedtext/s13c09.html,">web.archive.org/web/20080120165022www.hawaii.edu/medicine/pediatrics/pedtext/s13c09.html, 2008-01-20, Often such children defecate normally, yet they retain a significant mass of material in the bowel which causes bedwetting.WEB,www.wakehealth.edu/Urology/Pediatric/Bedwetting-Can-be-Due-to-Hidden-Constipation-Research-Shows.htm, Bedwetting and Constipation, www.wakehealth.edu, 22 February 2018, live,www.wakehealth.edu/Urology/Pediatric/Bedwetting-Can-be-Due-to-Hidden-Constipation-Research-Shows.htm," title="web.archive.org/web/20180222104900www.wakehealth.edu/Urology/Pediatric/Bedwetting-Can-be-Due-to-Hidden-Constipation-Research-Shows.htm,">web.archive.org/web/20180222104900www.wakehealth.edu/Urology/Pediatric/Bedwetting-Can-be-Due-to-Hidden-Constipation-Research-Shows.htm, 22 February 2018,
• 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.WEB,cks.library.nhs.uk/enuresis_nocturnal/in_depth/background_information, CKS: Enuresis — nocturnal – In depth – Background information, National Library for Health, National Health Service, 2008-02-02,cks.library.nhs.uk/enuresis_nocturnal/in_depth/background_information," title="web.archive.org/web/20071010011938cks.library.nhs.uk/enuresis_nocturnal/in_depth/background_information,">web.archive.org/web/20071010011938cks.library.nhs.uk/enuresis_nocturnal/in_depth/background_information, 2007-10-10,
• 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).JOURNAL, Järvelin MR, Vikeväinen-Tervonen L, Moilanen I, Huttunen NP, Enuresis in seven-year-old children, Acta Paediatrica Scandinavica, 77, 1, 148–53, January 1988, 3369293, 10.1111/j.1651-2227.1988.tb10614.x, 34177052,
• 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.JOURNAL, Butler RJ, Childhood nocturnal enuresis: developing a conceptual framework, Clinical Psychology Review, 24, 8, 909–31, December 2004, 15533278, 10.1016/j.cpr.2004.07.001, Bedwetting can also be a symptom of a pediatric neuropsychological disorder called PANDAS.WEB,www.nimh.nih.gov/health/publications/pandas/pandas-frequently-asked-questions-about-pediatric-autoimmune-neuropsychiatric-disorders-associated-with-streptococcal-infections.shtml, PANDAS: Frequently Asked Questions about Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections, 2010-06-01, NIMH, live,www.nimh.nih.gov/health/publications/pandas/pandas-frequently-asked-questions-about-pediatric-autoimmune-neuropsychiatric-disorders-associated-with-streptococcal-infections.shtml," title="web.archive.org/web/20100527174457www.nimh.nih.gov/health/publications/pandas/pandas-frequently-asked-questions-about-pediatric-autoimmune-neuropsychiatric-disorders-associated-with-streptococcal-infections.shtml,">web.archive.org/web/20100527174457www.nimh.nih.gov/health/publications/pandas/pandas-frequently-asked-questions-about-pediatric-autoimmune-neuropsychiatric-disorders-associated-with-streptococcal-infections.shtml, 2010-05-27,
• Sleep apnea stemming from an upper airway obstructionJOURNAL, Lewis, Daniel, 1909, Medical Review of Reviews Volume 15, Medical Review of Reviews, Austin Flint Association, Incorporated, 15, 748, 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.{{Citation needed|reason=Is this phenomenon mentioned anywhere?|date=November 2022}}
• 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.
• 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 for nocturnal enuresis among adults. Alcohol suppresses the production of anti diuretic hormones and irritates the detrusor muscle in the bladder. These factors, paired with the large amount of fluid ingested, particularly during binge drinking sessions or when paired with caffeinated drinks, can lead to episodes of nocturnal enuresis.WEB,health.clevelandclinic.org/adults-booze-bedwetting-heres-happens/, Adults + Booze = Bedwetting? Here’s Why It Happens to You, 27 July 2020,

Unconfirmed

• Food allergies may be part of the cause for some patients. This link is not well established, requiring further research.JOURNAL, Mungan NA, Seckiner I, Yesilli C, Akduman B, Tekin IO, 33708606, Nocturnal enuresis and allergy, Scandinavian Journal of Urology and Nephrology, 39, 3, 237–41, 2005, 16118098, 10.1080/00365590510007739, WEB,healthinfo.cedars-sinai.edu/library/healthguide/en-us/Cam/topic.asp?hwid=hn-1006005, Allergies and Sensitivities, Cedars-Sinai Health System, 2008-02-02,healthinfo.cedars-sinai.edu/library/healthguide/en-us/Cam/topic.asp?hwid=hn-1006005," title="web.archive.org/web/20080515203038healthinfo.cedars-sinai.edu/library/healthguide/en-us/Cam/topic.asp?hwid=hn-1006005,">web.archive.org/web/20080515203038healthinfo.cedars-sinai.edu/library/healthguide/en-us/Cam/topic.asp?hwid=hn-1006005, 2008-05-15,
• Improper toilet training is another disputed cause of bedwetting. This theory was more widely supported in the last century and is still cited by some authors today. Some say bedwetting can be caused by improper toilet training,JOURNAL, Mowrer OH, Mowrer WM, Enuresis—a method for its study and treatment., American Journal of Orthopsychiatry, July 1938, 8, 3, 436–459, 10.1111/j.1939-0025.1938.tb06395.x, either by starting the training when the child is too young or by being too forceful. Recent research has shown more mixed results and a connection to toilet training has not been proven or disproven.WEB,uimc.discoveryhospital.com/main.php?id=2863, Enuresis, University of Illinois Medical Center:Health Library, 2008-02-02,uimc.discoveryhospital.com/main.php?id=2863," title="web.archive.org/web/20080126052155uimc.discoveryhospital.com/main.php?id=2863,">web.archive.org/web/20080126052155uimc.discoveryhospital.com/main.php?id=2863, 2008-01-26, According to the American Academy of Pediatrics, more child abuse occurs during potty training than in any other developmental stage.{{citation needed|date=March 2022}}
• Dandelions are reputed to be a potent diuretic, and anecdotal reports and folk wisdom say children who handle them can end up wetting the bed.NEWS,www.cbc.ca/news/background/living-green/dandelions.html, Dandelions:time to throw in the trowel, 2007-07-10, CBC News, 2007-06-13, live,www.cbc.ca/news/background/living-green/dandelions.html," title="web.archive.org/web/20070717153346www.cbc.ca/news/background/living-green/dandelions.html,">web.archive.org/web/20070717153346www.cbc.ca/news/background/living-green/dandelions.html, 2007-07-17, English folk names for the plant are “peebeds” and “pissabeds”.WEB,www.answers.com/topic/dandelions-1, English folklore, Answers.com, live,www.answers.com/topic/dandelions-1," title="web.archive.org/web/20090615022413www.answers.com/topic/dandelions-1,">web.archive.org/web/20090615022413www.answers.com/topic/dandelions-1, 2009-06-15, In French the dandelion is called pissenlit, which means “piss in bed”; likewise “piscialletto”, an Italian folkname, and “meacamas” in Spanish.WEB, Benefits of herbal tea,www.herbalteatips.com/Benefits.php," title="web.archive.org/web/20080106134125www.herbalteatips.com/Benefits.php,">web.archive.org/web/20080106134125www.herbalteatips.com/Benefits.php, 2008-01-06,www.herbalteatips.com/Benefits.php,

Mechanism

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.JOURNAL, von Gontard, A., Schaumburg, H., Hollmann, E., Eiberg, H., Rittig, S., December 2001, The genetics of enuresis: a review, The Journal of Urology, 166, 6, 2438–2443, 10.1097/00005392-200112000-00117, 0022-5347, 11696807, 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.JOURNAL, 2005–2012, Management of primary nocturnal enuresis, Paediatrics & Child Health, 10, 10, 611–614, 10.1093/pch/10.10.611, 1205-7088, 2722619, 19668675, Feldman, M., 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.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.

Diagnosis

Thorough history regarding frequency of bedwetting, any period of dryness in between, associated daytime symptoms, constipation, and encopresis should be sought.

Voiding diary

• 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.JOURNAL, Wang CC, Chen JJ, Peng CH, Huang CH, Wang CL, 2008, Use of a voiding diary in the evaluation of overactive bladder and nocturia,www.tcs.org.tw/issue/Folder/2_2Suppl/05-V2suppl%201-PP%209-11.pdf, Incontinence & Pelvic Floor Dysfunction, 2, 9–11,

Physical examination

• Each child should be examined physically at least once at the beginning of treatment. A full pediatric and neurological exam is recommended.BOOK, Von Gontard A, Enuresis, Rey JM, IACAPAP e-Textbook of Child and Adolescent Mental Health., Geneva, International Association for Child and Adolescent Psychiatry and Allied Professions, 2012, Measurement of blood pressure is important 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. Thorough neurologic examination of the lower extremities, including gait, muscle power, tone, sensation, reflexes, and plantar responses should be done during first visit.

Classification

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.JOURNAL, Nevéus T, Nocturnal enuresis-theoretic background and practical guidelines, Pediatric Nephrology, 26, 8, 1207–14, August 2011, 21267599, 3119803, 10.1007/s00467-011-1762-8,

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 is either resulting 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.JOURNAL, Barnes TR, Drake MJ, Paton C, Nocturnal enuresis with antipsychotic medication, The British Journal of Psychiatry, 200, 1, 7–9, January 2012, 22215862, 10.1192/bjp.bp.111.095737, free, 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 creating loss of bladder control (overflow incontinence).WEB,urology.ucsf.edu/patient-care/children/urinary-incontinence/nocturnal-enuresis, Nocturnal Enuresis, ucsf.edu, live,urology.ucsf.edu/patient-care/children/urinary-incontinence/nocturnal-enuresis," title="web.archive.org/web/20140517132629urology.ucsf.edu/patient-care/children/urinary-incontinence/nocturnal-enuresis,">web.archive.org/web/20140517132629urology.ucsf.edu/patient-care/children/urinary-incontinence/nocturnal-enuresis, 2014-05-17, 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.WEB, Heidi Liss, Radunovich, Garret D., Evans,edis.ifas.ufl.edu/HE794, Bedwetting, University of Florida IFAS Extension, 2008-02-02, live,edis.ifas.ufl.edu/HE794," title="web.archive.org/web/20080119185645edis.ifas.ufl.edu/HE794,">web.archive.org/web/20080119185645edis.ifas.ufl.edu/HE794, 2008-01-19,

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. Secondary enuresis can be caused by emotional stress or a medical condition, such as a bladder infection.WEB,pedclerk.bsd.uchicago.edu/enuresis.html, Enuresis, University of Chicago Pritzker School of Medicine, 2008-02-02,pedclerk.bsd.uchicago.edu/enuresis.html," title="web.archive.org/web/20080206103432pedclerk.bsd.uchicago.edu/enuresis.html,">web.archive.org/web/20080206103432pedclerk.bsd.uchicago.edu/enuresis.html, 2008-02-06,

Psychological definition

Psychologists are usually allowed to diagnose and write a prescription for diapers if nocturnal enuresis causes the patient significant distress.JOURNAL, Mellon MW, McGrath ML, Empirically supported treatments in pediatric psychology: nocturnal enuresis, Journal of Pediatric Psychology, 25, 4, 193–214; discussion 215–8, 219–24, June 2000, 10814687, 10.1093/jpepsy/25.4.193, free, Psychiatists 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.

Management

There are a number of 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.JOURNAL, 10.1037/h0100319, Behavioral treatment for nocturnal enuresis, Journal of Early and Intensive Behavior Intervention, 2, 4, 259–267, 2005, Friman, Patrick C., Jones, Kevin M., Parents become concerned much earlier than doctors. A study in 1980 asked parents and physicians the age that children should stay dry at night. The average parent response was 2.75 years old, while the average physician response was 5.13 years old.JOURNAL, Shelov SP, Gundy J, Weiss JC, McIntire MS, Olness K, Staub HP, Jones DJ, Haque M, Ellerstein NS, Heagarty MC, Starfield B, Enuresis: a contrast of attitudes of parents and physicians, Pediatrics, 67, 5, 707–10, May 1981, 10.1542/peds.67.5.707, 7255000, 12300964, Punishment is not effective and can interfere with treatment.

Treatment approaches

Simple behavioral methods are recommended as initial treatment.JOURNAL, Caldwell PH, Nankivell G, Sureshkumar P, Simple behavioural interventions for nocturnal enuresis in children, The Cochrane Database of Systematic Reviews, 7, 7, CD003637, July 2013, 23881652, 10.1002/14651858.cd003637.pub3, free, Other treatment methods include the following:

• Motivational therapy in nocturnal enuresis mainly involves parent and child education. Guilt should be allayed by providing facts. Fluids should be restricted 2 hours prior to bed. The child should be encouraged to empty the bladder completely prior to going to bed. Positive reinforcement can be initiated by setting up a diary or chart to monitor progress and establishing a system to reward the child for each night that they are dry.JOURNAL, K., Popler, 1976, Token reinforcement in the treatment of nocturnal enuresis: A case study and six month follow-up.,doi.org/10.1016/0005-7916(76)90051-3, Journal of Behavior Therapy and Experimental Psychiatry, 7, 1, 83–84, 10.1016/0005-7916(76)90051-3, The child should participate in morning cleanup as a natural, nonpunitive consequence of wetting. This method is particularly helpful in younger children (