Research & More Information
Bedwetting Treatments Offer Help
Bedwetting Treatments Offer Help
Aug. 20, 2013 — Bedwetting affects up to 20 percent of five year olds — the age when most children have learned bladder control — and can result in an array of stressful and embarrassing social, emotional and psychological problems.
For concerned parents who want to help, simple treatments are better than nothing at all, but aren’t as effective as more advanced alarm therapy or drug therapy, according to a new meta-analysis in The Cochrane Library.
“As many as two-thirds of children with bedwetting never seek help,” said lead author Patrina Caldwell, B.Med., F.R.A.C.P., Ph.D., a paediatrician at The Children’s Hospital at Westmead and senior lecturer at The University of Sydney in Australia.
Bedwetting, or nocturnal enuresis, is defined as involuntary urine loss at night with no apparent underlying medical cause. Although the condition usually resolves on its own, Caldwell knows well the emotional effects of untreated enuresis in children and adolescents who sought incontinence services at her hospital, where the waiting list time is currently 18 months.
“There’s a huge need here and elsewhere,” Caldwell said. “This condition is easily treatable and children — along with up to two percent of adults — don’t have to suffer. Part of the stigma of bedwetting is that people do suffer in silence instead of getting help.”
For their analysis, the research team ultimately identified 16 appropriate trials involving 1,643 children that tested the effects of simple behavioural interventions to treat bedwetting.
The analysis compared simple behavioural interventions, such as rewarding “dry nights” by using methods like star charts, and other interventions like lifting and waking kids to use the bathroom, fluid restriction and bladder training versus no active treatment. Such simple interventions require minimal professional involvement and have no side effects, safety issues or costs.
The researchers also compared simple behavioural interventions against one another and with more complex interventions such as alarm training. “No one single simple behavioural intervention was better than another — they were all pretty similar,” Caldwell said. “However, alarm training was clearly better than the simple behavioural strategies such as bladder training.”
Finally, they compared simple behavioural interventions versus drug treatment alone, including placebo drugs or drug treatment combined with any other intervention.
The most effective intervention is a bed-wetting alarm which detects initial drops of urine in the child’s undergarments and then sounds off, the authors noted. The second most effective intervention is typically the oral medication desmopressin or DDAVP.
The authors noted that, “The findings from this review should be interpreted cautiously due to the poor quality and small sizes of the trials.”
“I agree with the authors about the limitations of the studies they reviewed — that it’s challenging enough to do bedwetting research with large groups of children in studies, even more difficult when you have small groups that don’t have good controls,” said Howard J. Bennett, M.D., a clinical professor of paediatrics at the George Washington University School of Medicine and in private practice since 1991.
The often hidden problem affects approximately 5 million children in the United States, he said, and may stay under the radar during the doctor-parent-child conversation. “Other research shows that while 82 percent of parents want health care providers to discuss bedwetting, most parents aren’t comfortable bringing it up. Also, 68 percent of parents said their children’s doctor has never asked about bedwetting at routine visits.”
Regarding the intervention of lifting, Bennett said, “There’s not much downside, but it’s more of a temporizing measure than an actual treatment for bedwetting, and there is some discussion that lifting may actually prolong bedwetting. As to restricting fluid intake, children still tend to wet in the majority of cases. Also, if a parent restricts fluids after dinner, a child may misinterpret this as a punishment, especially if he’s thirsty.”
“The simple treatments do work, but parents should know more effective treatments are available,” said Caldwell.
Latest Research on Bedwetting
Latest Research on Bedwetting
By Laura Lyster-Mensh
There is an abundance of information available to parents about bedwetting in this era of the Internet and instant communication, but it is difficult for non-professionals to make sense of it all. With new studies coming out daily, it’s hard to stay on top of the latest health information and understand what may relate to your child.
But according to Dr. Patrick C. Friman, director of behavioral pediatrics at Girls and Boys Town in Nebraska, there isn’t much in the way of new information on the topic of bedwetting, so there’s less for you to keep up with. However, there are some studies from the past five years or so that just might be of assistance to you and your child.
It’s in the Genes
Some of the biggest news, and a big relief to parents, is confirmation through scientific study that bedwetting is not caused by poor parenting or bad discipline. Genetic studies increasingly support the hypothesis that bedwetting runs in families and is involuntary. DNA research by scientists has even identified possible enuresis genes on chromosomes 13 and 22, which would confirm anecdotal evidence of an inherited problem.
In addition, scientists are learning more about the depression and behavioral problems often associated with bedwetting. Once thought to be a cause of enuresis, studies are exploring the idea that mental disorders and bedwetting might simply both be symptoms of the same physical causes: brain chemistry gone awry.
Also important, says Dr. Friman, is the possibility that punitive and guilt-inducing ways a family reacts to a child’s bedwetting might cause stress and anxiety that can lead to emotional difficulties.
Studies also confirm the usefulness of alarm systems, especially light and vibration-based alarms. The mechanism by which the alarms do their work is still not fully understood, but it seems to center on subconscious conditioning, a learning process that is going on beneath the level of conscious thought.
Research on the use of medicines in the treatment of bedwetting is still pessimistic. The drugs most commonly used for treatment (imiprimine, desmopressin, oxybutynin) are prescribed as a stopgap measure until bedwetting stops on its own. Except for one study using two drugs simultaneously, these medicines have not been shown to "cure" bedwetting when not in use. In fact, according to a 2002 article in the British Medical Journal, the company that produces desmopressin (ddAVP) was censured in 2002 for "falsely optimistic" statistics on success rates.
Bladder capacity is also a common topic in enuresis research. A study, appearing in the May 2003 issue of the journal, Urology, found that children who wet the bed appear to have smaller bladder capacities at night.
Researchers measured the bladder capacity of children with enuresis both during the day and at night and discovered no difference from their peers in the amount of urine their bladders could hold during the day. At night, however, they found that enuretics’ bladder capacity during sleep was significantly smaller than during the day.
Such research, according to Dr. Lane Robson of the National Kidney Foundation’s Enuresis Committee, is very important. "In my view, the biggest research advancement in the last five years has been the recognition that many of the children with bedwetting have a bladder that acts small at night," says Dr. Robson. "This has many implications for treatment."
Researchers have also found some success in sharpening children’s signals of fullness through an approach that stretches the bladder’s capacity through "retention control."
The Subject of Sleep
Much of the popular literature about bedwetting discusses the role of sleep patterns, but there is debate about whether bedwetting should be classified as a "sleep disorder."
One interesting study in the journal, Sleep, in Sweden, concluded that enuretic children do not experience significantly different sleep patterns than their dry peers. They did find, however, that heart rate variability during sleep did differ in enuretics.
There are some interesting approaches on the horizon, many of which are being researched overseas. A study in the United Arab Emirates reports "markedly reduced bedwetting episodes" with the use of indomethacin, a nonsteroidal anti-inflammatory drug. In addition, Japanese researchers have seen a 40 percent improvement in bedwetting after acupuncture treatments, which increased to 47 percent after two months.
Parents seek information from many sources, but ultimately you must use your own best judgment on what advice to take.
"I’ve looked for [information] on the Internet via Web sites and discussion boards, [from] pediatricians and books on the subject," says a Susie Beck*, a mother of an 8-year-old enuretic in Wisconsin. "I trust my instincts and advice that I feel won’t negatively affect my child."
Bedwetting can be due to undiagnosed constipation, research shows
Published: Friday, January 27, 2012 – 14:35 in Health & Medicine
Bedwetting isn’t always due to problems with the bladder, according to new research by Wake Forest Baptist Medical Center. Constipation is often the culprit; and if it isn’t diagnosed, children and their parents must endure an unnecessarily long, costly and difficult quest to cure nighttime wetting. Reporting online in the journal Urology, researchers found that 30 children and adolescents who sought treatment for bedwetting all had large amounts of stool in their rectums, despite the majority having normal bowel habits. After treatment with laxative therapy, 25 of the children (83 percent) were cured of bedwetting within three months.
"Having too much stool in the rectum reduces bladder capacity," said lead author Steve J. Hodges, M.D., assistant professor of urology at Wake Forest Baptist. "Our study showed that a large percentage of these children were cured of nighttime wetting after laxative therapy. Parents try all sorts of things to treat bedwetting — from alarms to restricting liquids. In many children, the reason they don’t work is that constipation is the problem."
Hodges said the link between bedwetting and excess stool in the rectum, which is the lower five to six inches of the intestine, was first reported in 1986. However, he said the finding did not lead to a dramatic change in clinical practice, perhaps because the definition of constipation is not standardized or uniformly understood by all physicians and lay people.
"The definition for constipation is confusing and children and their parents often aren’t aware the child is constipated," said Hodges. "In our study, X-rays revealed that all the children had excess stool in their rectums that could interfere with normal bladder function. However, only three of the children described bowel habits consistent with constipation."
Hodges explained that guidelines of the International Children’s Continence Society recommend asking children and their parents if the child’s bowel movements occur irregularly (less often than every other day) and if the stool consistency is hard.
"These questions focus on functional constipation and cannot help identify children with rectums that are enlarged and interfering with bladder capacity," said Hodges. "The kind of constipation associated with bedwetting occurs when children put off going to the bathroom. This causes stool to back up and their bowels to never be fully emptied. We believe that treating this condition can cure bedwetting."
Children in the study ranged from 5 to 15 years old. The constipated children were treated with an initial bowel cleanout using polyethylene glycol (Miralax®), which softens the stools by causing them to retain water. In children whose rectums remained enlarged after this therapy, enemas or stimulant laxatives were used.
Hodges cautioned that any medical therapy for bedwetting should be overseen by a physician.
The study used abdominal X-rays to identify the children with excess stool in their rectums. Hodges and radiologists at Wake Forest Baptist developed a special diagnostic method that involves measuring rectal size on the X-ray. He said rectal ultrasound could also be used for diagnosis.
"The importance of diagnosing this condition cannot be overstated," Hodges said. "When it is missed, children may be subjected to unnecessary surgery and the side effects of medications. We challenge physicians considering medications or surgery as a treatment for bedwetting to obtain an X-ray or ultrasound first."
The study involved reviewing the charts of 30 consecutive patients treated for bedwetting. The authors cautioned that some cases may have improved on their own over time. They said a more accurate measure of the treatment’s success would be to randomly assign constipated children to laxative therapy or an inactive therapy, an approach that would identify true response from cases that would resolve over time.
Hodges’ co-author on the research is Evelyn Y. Anthony, MD, a radiologist at Wake Forest Baptist.
Source: Wake Forest Baptist Medical Center