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AN AGE-LONG PROBLEM: BEDWETTING


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Bedwetting is the loss of bladder control, which often occurs during sleep at night. The medical term for bedwetting is nocturnal (night-time) enuresis. Bedwetting is often normal in children below the age of seven because it is usually considered as part of a child's development as some children below that age are yet to learn nighttime bladder control.

Studies that have looked at bedwetting have shown that it is a common disorder affecting 20% of 5-year-olds, 10% of 10-year-olds, and 3% of 15 year- olds. [1] About 2 - 3% percent of male and female adults over 18 years of age experience enuresis, which can be attributed to a variety of causes and may require treatment. [2]


Types of Enuresis

Traditionally, enuresis has been classified into two – Primary and Secondary Enuresis. Children who have never had a consistent six-month period of being dry, are said to have primary enuresis while children who have had a six-month period of being dry, then suddenly begin to bed wet again are said to have secondary enuresis.

Furthermore, enuresis can also be classified based on presence or absence of additional symptoms: [1] Monosymptomatic Nocturnal Enuresis (MNE): refers to bedwetting that occurs in children who have no other bladder problems and who do not wet themselves during the day. Non-Monosymptomatic Nocturnal Enuresis (NMNE): refers to children who wet the bed at night and have additional daytime symptoms.


Causes of Enuresis in Children

Nocturnal enuresis can be caused by :

psychosocial factors,

genetic factors, and

certain disorders.

Although not common, research has shown that psychosocial factors have a role to play in enuresis. Children from disorganized homes are more likely to have nocturnal enuresis than children from stable homes. In addition, secondary enuresis occurs more commonly in children who have gone through one form of stress/abuse or the other, such as the stress of divorce, the stress of being neglected, physical abuse, sexual or emotional abuse. It is also associated with children who have developed emotional and behavioral conditions such as anxiety and sleep disorders; children who are deep sleepers also tend to wet the bed.

Enuresis also tends to run in families; there is a 15% incidence of enuresis in children from families without the problem compared to 44% and 77% of children when one or both parents, respectively, were themselves enuretic. [3]

Medically, children with urinary tract infections, chronic constipation, small bladder, and children who produce too much urine are likely to bed wet. Furthermore, it can also be a side effect or consequence of some types of medications that cause changes in behavioral patterns.


Causes of Enuresis in Adults

The causes of enuresis in adults are numerous, they include but are not limited to genetics, hormonal imbalances, overactive bladder muscles, small bladder, medications, substance abuse, stress and urinary tract infections.

  1. Genetics: It has been discovered that children with both parents who bed-wet have a 77% chance of coming down with enuresis, while children with a parent who had enuresis as a child, have a 40% chance of also having the condition. [2]

  2. Hormonal imbalances: The body produces a hormone known as an antidiuretic hormone. This hormone decreases the production of urine and should be secreted in high quantities at night. However, if the hormone is not produced in enough quantity or if produced but is not responded to by the kidney, it could lead to a very high amount of urine produced. This in turn could cause an adult to wet the bed.

  3. Overactive bladder muscles: The muscles of the bladder, known as the detrusor muscles, if overactive can lead to enuresis. This has been found as the cause of about 70-80% of enuretic adults.

  4. A small bladder: Here, the physical bladder is not small but the functional capacity of the bladder can be decreased.

  5. Medications: Bedwetting can also be a side effect of certain medications like hypnotic and psychiatric medications.


Effects of Enuresis

Enuresis has a myriad of effects on an individual, ranging from social to psychological.

Social Effects of Enuresis

Children with enuresis could feel inhibited to participate in simple activities such as school camps, family holidays, and sleepovers due to the fear of being teased and bullied if discovered. Additionally, this social exclusion can have an impact on behavior and growth.

Enuresis can also affect the choice of job and performance at work. Enuretic adolescents are also less likely to go to a university compared to adults who do not wet their beds. Financially, enuresis takes a toll on finances as money is spent on bedcovers, bed sheets, and in some cases, diapers. It also takes a toll on the family of the patients as the embarrassment goes round.


Psychological Effects Of Enuresis

Enuresis in children can lead to behavioral problems due to guilt and embarrassment; it can also cause anxiety and withdrawal to self. It could also have an effect ect on the self-esteem of children; B Hägglöf et al [4] discovered that children who do not wet the bed had significantly higher self-esteem compared to children who wet the bed. Enuresis in adolescents and adults can lead to depression, low self-esteem, and in some cases sexual dysfunction.


Solutions to the Age-long problem

For children, the following can be done:

  1. Reduce food and drinks before the child goes to sleep

  2. Encourage children to use the toilet before they sleep

  3. Do not punish the child for accidents as this can increase stress and feelings of shame.

  4. Keep track of dry nights to motivate children by rewarding them.

  5. Waking children in the middle of the night intermittently to use the toilet

  6. Use plastic sheets/covers to protect the mattress

  7. Set bedwetting alarms

  8. Consult the doctor.

In adults, there are three major solutions

1. Lifestyle modification

  1. Monitor fluid intake

  2. Wake yourself up at night

  3. Make regular urinating a lifestyle

  4. Cut down on bladder irritants like caffeine

2. Medication

Four primary types of medications are prescribed to treat adult bed-wetting, depending on the cause:

  1. Antibiotics to treat urinary tract infections

  2. Anticholinergic drugs can calm irritated or overactive bladder muscles

  3. Desmopressin acetate to boost levels of ADH so your kidneys will stop producing as much urine at night

  4. Alpha-reductase inhibitors, such as finasteride (Proscar), shrink an enlarged prostate [5]

3. Surgery

Surgery could be done on nerves to increase signaling when the bladder is full or on overactive bladder muscles to lower their impact.

In conclusion, while enuresis has been an age-long problem, a good outcome is possible with early detection, early intervention and less stigmatization.


References

1. Impact of Bed Wetting | myVMC [Internet]. myVMC. 2018 [cited 5 September 2020]. Available from: https://www.myvmc.com/lifestyles/impact-of-bed-wetting/#:~:text=A%20Hong%20Kong%20study%20looking,didn't%20wet%20the%20bed.

2. Bedwetting causes and treatments for adults, children and teens - URINARY INCONTINENCE EDUCATION | BLADDER HEALTH | NATIONAL ASSOCIATION FOR CONTINENCE [Internet]. URINARY INCONTINENCE EDUCATION | BLADDER HEALTH | NATIONAL ASSOCIATION FOR CONTINENCE. 2018 [cited 5 September 2020]. Available from: https://www.nafc.org/bedwetting

3. Bed Wetting/Enuresis | Child & Family Psychological Services [Internet]. Child & Family Psychological Services. 2020 [cited 5 September 2020]. Available from: https://www.cfpsych.org/condition/bed-wetting-enuresis/#:~:text=Psychological%20factors%20are%20clearly%20contributory,in%20response%20to%20the%20stress.

4. B H, O A, E B, L M, M W. Self-esteem before and after treatment in children with nocturnal enuresis and urinary incontinence [Internet]. PubMed. 1997 [cited 5 September 2020]. Available from: https://pubmed.ncbi.nlm.nih.gov/9165615/

5. Adult Bed Wetting (Nocturnal Enuresis): Treatment and Causes [Internet]. Healthline. 2020 [cited 5 September 2020]. Available from: https://www.healthline.com/health/adult-bed-wetting#treatment

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