Nocturnal Enuresis in Children

oPatientPlus articles are written by UK doctors and are based on research evidence, UK and European Guidelines. They are designed for health professionals to use, so you may find the language more technical than the condition leaflets.

Nocturnal enuresis (bedwetting): involuntary wetting during sleep without any inherent suggestion of frequency of bedwetting or pathophysiology.

Children with nocturnal enuresis may have excessive nocturnal urine production, poor sleep arousal and/or reduced bladder capacity. Children with nocturnal enuresis may also have daytime urinary urgency, frequency or incontinence of urine.[1] 

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  • Primary nocturnal enuresis. This is the recurrent involuntary passage of urine during sleep by a child aged 5 years or older, who has never achieved consistent nighttime dryness. This may further be subdivided into children who have enuresis only at night and those who also have daytime symptoms (urgency, frequency, or daytime wetting).
  • Secondary nocturnal enuresis. This is is the involuntary passage of urine during sleep by a child who has previously been dry for at least six months.

Primary enuresis most often represents developmental delay which resolves in time. In secondary enuresis the patient regresses after a period of continence, which requires the exclusion of underlying pathology - eg, a urinary infection.

Three aetiological factors are commonly involved: a disorder of sleep arousal, a low nocturnal bladder capacity and nocturnal polyuria. Constipation may be an additional aggravating condition.[3]

  • At age 4½, 30% of children still wet the bed, 21% infrequently (less than two times per week) and 8% of these more frequently.[4][5]
  • 2.6% of children aged 7½ years wet their bed on two or more nights a week.[6] 
  • Children with more frequent wet nights are more likely to have a persistent problem and benefit from early identification and investigation.
  • The prevalence of nocturnal enuresis is 0.5-2% for adults.[6] 

Risk factors

There are a number of factors that predispose to persistent nocturnal enuresis.

  • There is a genetic predisposition. One study found that patients with a family history of primary nocturnal enuresis had a higher incidence of small bladder capacity or outflow obstruction than controls.[7]
  • 23% of nocturnal enuresis is associated with encopresis and daytime incontinence.[8]
  • Enuresis is to be expected as a manifestation of developmental delay, in those with global developmental delay, with or without an associated syndrome such as Down's syndrome. Even without gross developmental delay, there is more likely to be persistent bedwetting in children with delayed developmental milestones, premature delivery or behavioural disorders such as hyperactivity or inattention deficits.[9]
  • There may be neurological problems such as spina bifida or cerebral palsy. Those with physical problems are more likely to have daytime enuresis or trouble with encopresis. Physical problems are a rare cause of nocturnal enuresis per se.
  • Nocturnal enuresis can be associated with daytime urinary incontinence, bowel problems, developmental or psychological problems, and sleep disordered breathing.[6] 
  • Drinks containing methylxanthines (eg, caffeine and theophylline found in 'high-energy' drinks) can aggravate the situation by their diuretic action. These include tea, coffee, cola and chocolate.
  • Stresses in the child's life, such as an admission to hospital with separation from the mother, or bullying, are more likely to cause secondary enuresis. The older the child, the more likely it is that psychological problems are the result of enuresis and not the cause.

To decide on appropriate investigations and treatment it is important to identify:[2]

  • Whether there are any daytime symptoms (abnormal frequency of urination (either too frequent (more than seven times/day) or infrequent (less than four times/day)), urgency, daytime wetting, difficulty (straining) with poor stream, or pain on urination. Whether symptoms occur only in some situations - eg, avoidance of toilets at school.
  • Whether the child has previously been dry at night without assistance for six months (ie this is secondary enuresis). If so, ask about any medical, physical or environmental, social or emotional causes or triggers for the change (eg, bereavement, bullying, parental separation, etc).[5]

Also ask:

  • How many times a night and how many nights a week?
  • Do there seem to be large quantities of urine in the bed?
  • Is there any pattern - what time does bedwetting occur?
  • Does the child wake after wetting the bed?
  • What is the daytime pattern of toilet use?
  • Is there also constipation or soiling?

Consider whether the child has:

  • Developmental, attention or learning difficulties.
  • Behavioural or emotional problems.
  • Family problems or a vulnerable child/young person/family.
  • Been subjected to maltreatment (especially if bedwetting is reported as deliberate or the child is being punished for bedwetting).
  • Undiagnosed diabetes mellitus.

A diary of fluid intake, symptoms, bedwetting and toileting patterns may help clarify the history in some cases.

  • Passing large volume in the first few hours is typical of bedwetting only.
  • Variable volumes, more than once a night or every night - possible overactive bladder, or other physical disease.

Urinalysis is not recommended unless bedwetting is of recent origin, there are daytime symptoms, or symptoms are suggestive of possible infection or diabetes mellitus.[5]

Investigate (and treat) daytime symptoms before addressing enuresis - eg, symptoms suggestive of diabetes, urinary tract infections (UTIs) or constipation.

Simple behavioural therapies[6] 

  • More children become dry when rewarded, when lifted during the night or both.
  • Potentially ineffective and even harmful strategies, such as fluid restriction, retention control training (encouraging the child not to void for as long as possible to expand bladder capacity), should be avoided.
  • Rewarding agreed behaviour (eg, drinking adequately, voiding before sleep, and engaging in management) may be more effective than rewarding dry nights, which are out of the child's conscious control.
  • Although simple behavioural therapies are better than no active treatment, they are inferior to confirmed effective treatments.

Children without daytime symptoms

If the child is aged under 5, reassure parents that this usually resolves over time without treatment. Some things may help:

  • Ensure adequate but not excessive fluid intake during the day (1000-1400 ml per day in a child aged 5), healthy diet and avoid caffeine-based drinks before bed.
  • Encourage the child to empty their bladder before bed, and ensure there is access to the toilet at night. A potty by the bed may help.
  • If the child has been dry during the day for >6 months, a trial without nappies can be tried (waterproofing of the mattress will be required). Trial needs to be for at least two nights, longer if a reduction of wetness is achieved and the circumstances allow it.
  • If the child wakes at night, encourage them to use the toilet before returning to sleep. Planned waking at regular times may have practical short-term success, but there is no evidence it promotes long-term dryness.[2]
  • If there are some dry nights, a positive reward system may be tried (reward for drinking the right quantities during the day, toilet before bed, helping change sheets, but don't take rewards away for wet nights).[2]

Older children without severe daytime symptoms

  • Again, ensure adequate but not excessive fluid intake during the day.
  • Elicit the child's view on the problem and whether they feel it needs treatment.
  • Advise regular use of the toilet during the day and before bed.
  • If the child wakes at night, encourage them to use the toilet before returning to sleep. Planned waking at regular times may have practical short-term success (and can be used by young people who have not responded to other treatment), but there is no evidence it promotes long-term dryness once discontinued.[2]

Referral criteria[6] 

Indications for a child to be further assessed or referred include:

  • Children with nocturnal enuresis if they have severe daytime symptoms.
  • History of recurrent UTIs.
  • Abnormal renal ultrasound results (not indicated as an investigation for isolated nocturnal enuresis).
  • Known or suspected physical or neurological problems.
  • Comorbid conditions (eg, faecal incontinence, diabetes, and attention, learning, behavioural, or emotional problems), or family problems.
  • Those who have not responded to treatment in primary care after six months.

Alarm training

Alarm training is a first-line treatment for nocturnal enuresis and is the most effective long-term strategy.[6]

One study comparing alarm training with desmopressin (see below) found that there was no difference between desmopressin and enuresis alarm during treatment for achieving dryness, but the chance of relapse after treatment stopped was higher following desmopressin.[10] 

Adding alarm training to pharmacotherapy is also an effective second-line strategy for children with pharmacotherapy-resistant nocturnal enuresis.[11] 

  • Alarms can be bought from ERIC (Education and Resources for Improving Childhood Continence).[12] They may be available for loan through a local enuresis advisor or clinic.
  • Assess response after four weeks; stop only if there are no early signs of response (significant improvement).
  • Continue until a minimum of 14 dry nights have been achieved. Assess and consider alternative treatment after three months unless still improving.
  • NB: an alarm may help some children with daytime symptoms or secondary enuresis.

Desmopressin

Desmopressin should be offered first-line to children aged over 7 where rapid control is needed or an alarm is inappropriate. Otherwise it should be used second-line after an alarm has been tried.[5] It may be used in children aged 5-7 if treatment is required under the same circumstances.

  • If used following a trial with the alarm, desmopressin may be used initially with the alarm, unless the alarm is no longer acceptable.[5]
  • Desmopressin should be given orally or sublingually for the treatment of children with nocturnal enuresis. Always check with the British National Formulary (BNF).[13] 
  • Assess success after four weeks and continue for three months if there is some response.
  • Desmopressin can be given 1-2 hours before bedtime in resistant cases (same rules about fluid restriction).
  • If desmopressin is being used long-term, withdraw for one week every three months to see if dryness has been achieved.

Other medications[6] 

Imipramine

  • Imipramine and other tricyclic antidepressants can be effective, with a reduction in the frequency of bedwetting, but the effect compared with placebo is not sustained after stopping.
  • Imipramine is approved for use in treating nocturnal enuresis in children aged 6 years and above. Because of the potential side-effects (eg, cardiac arrhythmias, hypotension, hepatotoxicity, central nervous system depression, interaction with other drugs, and the danger of intoxication by accidental overdose.
  • Tricyclics are therefore reserved for treating resistant cases only.

Anticholinergic drugs - eg, oxybutinin
Although anticholinergic monotherapy is ineffective, it can improve treatment response when combined with other established treatments, including imipramine, desmopressin, or enuresis
alarms, especially in the treatment of resistant cases.

Complementary and alternative therapies[6] 

  • Complementary and alternative therapies can be used but their effectiveness is limited by low-quality studies.
  • One systematic review found that acupuncture seems to be as effective as desmopressin and more effective than no treatment.
  • One small randomised controlled trial found that hypnotherapy appeared to be as effective as imipramine with a lower relapse rate after cessation of treatment.
  • Bedwetting can be very distressing, especially for older children and it may lead to social isolation, bullying and low self-esteem. Whilst an expectant approach is appropriate for younger children, older children need a more active approach.
  • If enuresis persists into adult life, there may be severe psychosocial problems affecting self-esteem, careers, social life and personal relationships. It is unpleasant to sleep with a bedwetter.
  • Parents have extra work and cost of extra laundry along with the additional stress of caring for a child with enuresis. Up to 30% of parents become intolerant of the enuresis and consequently also of their child.

The majority of patients who do not have a serious neurological defect or severe learning difficulties can expect to achieve nocturnal continence sooner or later. Primary enuresis without daytime symptoms resolves in approximately 15% of children each year.[2] Even after dry nights have been reliably achieved, the occasional 'accident' is still to be expected and is no cause for concern unless there is apparent regression. Those with a family history of late nocturnal continence, those with behavioural disorders and those with developmental delay will take longer. Boys tend to take longer than girls but all cases are highly variable.

In 1% of patients enuresis will persist into adulthood.[2] One study found that children with the most severe form of bedwetting are likely to persist with the problem.[4] A typical scenario is after a night of heavy consumption of beer. The alcohol causes deep sleep and the volume puts the bladder under great stress.

Further reading & references

  1. Deshpande AV, Caldwell PH; Medical management of nocturnal enuresis. Paediatr Drugs. 2012 Apr 1;14(2):71-7. doi: 10.2165/11594870-000000000-00000.
  2. Bedwetting (enuresis); NICE CKS, January 2010
  3. Robson WL; Current management of nocturnal enuresis. Curr Opin Urol. 2008 Jul;18(4):425-30.
  4. Butler RJ, Heron J; The prevalence of infrequent bedwetting and nocturnal enuresis in childhood. A large British cohort. Scand J Urol Nephrol. 2008;42(3):257-64.
  5. Nocturnal enuresis - the management of bedwetting in children and young people; NICE Clinical Guideline (October 2010)
  6. Caldwell PH, Deshpande AV, Von Gontard A; Management of nocturnal enuresis. BMJ. 2013 Oct 29;347:f6259. doi: 10.1136/bmj.f6259.
  7. Wang QW, Wen JG, Zhu QH, et al; The effect of familial aggregation on the children with primary nocturnal enuresis. Neurourol Urodyn. 2008 Nov 14.
  8. Sureshkumar P, Jones M, Caldwell PH, et al; Risk Factors for Nocturnal Enuresis in School-Age Children. J Urol. 2009 Oct 19.
  9. Elia J, Takeda T, Deberardinis R, et al; Nocturnal enuresis: a suggestive endophenotype marker for a subgroup of J Pediatr. 2009 Aug;155(2):239-44.e5. Epub 2009 May 15.
  10. Kwak KW, Lee YS, Park KH, et al; Efficacy of desmopressin and enuresis alarm as first and second line treatment J Urol. 2010 Dec;184(6):2521-6. Epub 2010 Oct 18.
  11. Kwak KW, Park KH, Baek M; The efficacy of enuresis alarm treatment in pharmacotherapy-resistant nocturnal Urology. 2011 Jan;77(1):200-4. Epub 2010 Oct 13.
  12. ERIC (Education and Resources for Improving Childhood Continence)
  13. British National Formulary

Disclaimer: This article is for information only and should not be used for the diagnosis or treatment of medical conditions. EMIS has used all reasonable care in compiling the information but make no warranty as to its accuracy. Consult a doctor or other health care professional for diagnosis and treatment of medical conditions. For details see our conditions.

Original Author:
Dr Laurence Knott
Current Version:
Peer Reviewer:
Prof Cathy Jackson
Last Checked:
26/03/2014
Document ID:
2515 (v25)
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