Everything You Need to Know About Paediatric Enuresis

Paediatric enuresis, also known as bedwetting, is a common condition that affects many children and adolescents. It is defined as involuntary urination during sleep in children who are at least five years old. It can cause embarrassment, shame, and low self-esteem for the child, as well as frustration and stress for the parents.

There are different types of paediatric enuresis, depending on the presence or absence of other symptoms and the history of bladder control. The most common type is monosymptomatic enuresis, which means that the child only wets the bed at night and has no other problems with urination during the day. This type of enuresis is usually due to a combination of factors, such as:

- Nocturnal polyuria: This means that the child produces more urine at night than their bladder can hold. This can be influenced by fluid intake, hormone levels, kidney function, and sleep patterns.

- Detrusor overactivity: This means that the bladder muscle contracts too often or too strongly, causing a sudden urge to urinate or leakage. This can be caused by infection, inflammation, nerve damage, or psychological stress.

- Increased arousal threshold: This means that the child does not wake up easily when their bladder is full or when they start to wet the bed. This can be affected by genetics, sleep quality, medication, or medical conditions.

Another type of paediatric enuresis is nonmonosymptomatic enuresis, which means that the child also has other symptoms of lower urinary tract dysfunction, such as daytime incontinence, urgency, frequency, pain, or recurrent infections. This type of enuresis may indicate an underlying problem with the bladder, urethra, or nervous system.

Paediatric enuresis can also be classified as primary or secondary. Primary enuresis means that the child has never been dry at night for a long period of time. Secondary enuresis means that the child has started to wet the bed again after being dry for at least six months. Secondary enuresis may be triggered by medical, emotional, or physical factors.

How to Diagnose Paediatric Enuresis

The diagnosis of paediatric enuresis is based on the child's age, frequency of bedwetting episodes, presence of other symptoms, and medical history. The doctor may ask questions about:

- The onset and duration of bedwetting

- The number of wet nights per week or month

- The amount and timing of urine loss

- The fluid intake and output of the child

- The bowel habits and constipation status of the child

- The sleeping arrangements and routine of the child

- The family history of bedwetting or urinary problems

- The emotional and social impact of bedwetting on the child and family

- The previous treatments tried and their outcomes

The doctor may also perform a physical examination to check for any signs of infection, inflammation, injury, or abnormality in the genital or urinary tract. The doctor may also request some tests to rule out any underlying medical conditions that could cause or worsen bedwetting, such as:

- Urinalysis: This is a test that checks for blood, sugar, protein, bacteria, or other substances in the urine that could indicate an infection, diabetes, kidney disease, or other problems.

- Urine culture: This is a test that grows bacteria from the urine sample to identify the type and sensitivity of the infection.

- Blood tests: These are tests that measure the levels of glucose, electrolytes, creatinine, and other substances in the blood that could reflect kidney function, hormone levels, or metabolic disorders.

- Ultrasound: This is a test that uses sound waves to create images of the kidneys, bladder, and urethra to look for any abnormalities in their size, shape, or structure.

- Uroflowmetry: This is a test that measures the speed and volume of urine flow during urination to assess for any obstruction or weakness in the urinary stream.

- Postvoid residual: This is a test that measures the amount of urine left in the bladder after urination to check for any incomplete emptying or retention.

- Urodynamics: These are tests that measure the pressure and activity of the bladder and urethra during filling and emptying to evaluate for any dysfunction or overactivity.

How to Treat Paediatric Enuresis

The treatment of paediatric enuresis depends on the type, severity, and cause of bedwetting. The main goals are to reduce the frequency and impact of wetting episodes and to improve the quality of life of the child and family. The treatment options include:

- Behavioural therapy: This involves changing some habits and routines

that may affect bedwetting, such as:

- Limiting fluid intake in the evening and avoiding caffeine or carbonated drinks

- Encouraging regular daytime voiding and bowel movements

- Using a reward system or positive reinforcement for dry nights or efforts

- Avoiding punishment, blame, or shame for wet nights

- Providing a supportive and comfortable environment for the child

- Using a waterproof mattress cover, absorbent underwear, or bed pads to protect the bedding and clothing

- Waking the child up at night to urinate or using a night-light or toilet nearby

- Alarm therapy: This involves using a device that senses wetness and triggers an alarm sound, vibration, or light to wake up the child and prompt them to go to the toilet. This helps the child to associate a full bladder with the need to urinate and to develop a better bladder control and arousal response. The alarm therapy is usually done for several weeks or months until the child achieves a consistent dryness. The alarm therapy is considered the most effective treatment for monosymptomatic enuresis, but it requires motivation and cooperation from both the child and the parents.

- Medication: This involves using drugs that can reduce the amount of urine produced at night, increase the capacity of the bladder, or relax the bladder muscle. The medication is usually prescribed as a short-term or intermittent option for children who do not respond to or cannot tolerate behavioural or alarm therapy, or who need a temporary relief for special occasions. The medication is not a cure for bedwetting and may have some side effects or interactions. The most common drugs used for paediatric enuresis are:

- Desmopressin: This is a synthetic hormone that mimics the action of antidiuretic hormone (ADH), which regulates the water balance in the body. Desmopressin reduces the amount of urine produced by the kidneys at night, thus decreasing the risk of wetting. Desmopressin is taken as a tablet, nasal spray, or melt before bedtime. The dose may vary depending on the child's weight, age, and response. The side effects may include headache, nausea, abdominal pain, or hyponatremia (low sodium level in the blood). Desmopressin should not be used in children with kidney disease, heart failure, dehydration, or fluid restriction.

- Anticholinergics: These are drugs that block the action of acetylcholine, a neurotransmitter that stimulates the contraction of the bladder muscle. Anticholinergics increase the capacity and compliance of the bladder, thus reducing the frequency and urgency of urination. Anticholinergics are usually combined with desmopressin for children who have nonmonosymptomatic enuresis or detrusor overactivity. Anticholinergics are taken as a tablet or liquid once or twice a day. The dose may vary depending on the type of drug, such as oxybutynin, tolterodine, or solifenacin. The side effects may include dry mouth, constipation, blurred vision, drowsiness, or confusion. Anticholinergics should not be used in children with glaucoma, urinary retention, or bowel obstruction.

How to Prevent Paediatric Enuresis

Paediatric enuresis is not always preventable, as it may be influenced by genetic, developmental, or physiological factors that are beyond the control of the child or parents. However, some measures that may help to reduce the risk or severity of bedwetting include:

- Encouraging healthy drinking habits during the day and limiting fluids in the evening

- Avoiding caffeine or carbonated drinks that may irritate the bladder or increase urine production

- Promoting regular daytime voiding and bowel movements to prevent constipation or infection

- Practicing good hygiene and avoiding irritants that may cause inflammation or infection in the genital or urinary tract

- Providing a supportive and comfortable environment for the child and avoiding stress or anxiety that may affect sleep quality or bladder function

- Seeking medical advice if there are any signs of underlying medical conditions that could cause or worsen bedwetting

Recommendations for Parents

Paediatric enuresis can be a challenging condition for both the child and parents, but it is important to remember that it is not the fault of anyone and that it can be treated successfully with patience and persistence. Some recommendations for parents who have a child with bedwetting are:

- Do not blame, punish, or shame your child for wetting the bed, as this may make them feel worse and affect their self-esteem and confidence

- Do not compare your child with other children who are dry at night, as this may make them feel inadequate or different

- Do praise your child for their efforts and achievements in staying dry at night, such as using an alarm device, taking medication, or following behavioural therapy