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Enuresis

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What is Enuresis?

Enuresis (N-you-REE-sis) refers to the involuntary loss of urine beyond the age of expected toilet training. When it occurs during the daytime it is called diurnal (DYE-urn-al) enuresis; when it occurs during the night it is nocturnal (NOCK-turn-al) enuresis. Some children have only one or the other, while other children have both diurnal and nocturnal enuresis. Another word that is sometimes used to describe urinary leakage is incontinence. 

Who gets enuresis?
Approximately 15% of children still experience wetting at the age of 5. Of those who wet, it will go away in about 15% each year even without treatment. This means that by age 15 there are still about 1-2% of children who experience wetting on a regular basis. Evaluation by a doctor is aimed at identifying any factors which are causing the wetting which could put a child at risk for further problems (like urinary tract infections or kidney injury) as well as shortening the time period until the wetting resolves on its own. 

Nocturnal enuresis which occurs without any daytime urination symptoms [such as urinating frequently or the sudden need to get to the bathroom quickly (urgency)] is especially common if one or more family members (Mom, Dad, uncle, aunt, brother or sister) experienced nocturnal enuresis as a child. 

Why does enuresis occur?
Enuresis occurs for a number of reasons. In some situations an exact cause can be found, such as when the ureter (the tube which carries the urine from the kidney to the bladder) attaches in the wrong place. This, however, is a rather infrequent cause of enuresis. Often times we do not know the exact reason that wetting occurs. There are many theories that have been proposed as causes for wetting, particularly in patients with nocturnal enuresis. Some possible causes relate to the amount of urine produced during the night, sleep patterns and their relationship to bladder filling and emptying, or the bladder being "too small" for the patient's age. 

When it starts rather suddenly in a child who previously has had no problems with wetting, enuresis can be the first sign of a urinary tract infection. This deserves prompt investigation by his or her primary doctor. 

Children who have had numerous infections may have a bladder that is "small" for their age, or is more sensitive to filling, and thus experience urinary frequency and/ or urgency. This may cause them to not be able to get to the bathroom in time before they wet. Other children void so infrequently that their bladder gets over-filled (the "I'm too busy to go" syndrome!). Once they finally get the urge to go it may be too late to get to the bathroom in time. They also may not empty the bladder completely because it is too "stretched out" to squeeze efficiently. Constipation may also play a significant role in both enuresis and urinary tract infections. 

Is enuresis harmful?
When enuresis occurs without any anatomical problems in the urinary tract and without any urinary tract infections, it is not necessarily "harmful." As mentioned above, however, enuresis could be a signal of other problems with the urinary tract. Even if there is not a specific problem, however, one must also consider the effect that wetting may have on a child's self esteem, his or her relationship with peers (is he or she being teased at school? unable to go to sleepovers?), and on the family dynamics. 

Enuresis which occurs in conjunction with an anatomical problem or with urinary tract infections deserves a thorough investigation because, if left untreated, it could lead to further damage to the kidneys, bladder, or other organs. 

What can I do to help my child stop wetting?
There are a number of steps to take to help your child. First, talk with your child honestly, and find out whether it is bothering him or her. (Until he or she admits that it's a problem or a bother, it's hard to get him or her to do what you suggest, not matter how good your intentions.) 

Positive reinforcement and rewards are always a great first step. Try making a calendar or chart, then reward your child with a sticker or other prize when he or she has a dry night. Set realistic goals, then reward your child with a larger prize when he or she reaches that goal (such as a new toy for 5 dry nights in a row, etc.). 

If the problem occurs only during the night, be sure you limit the amount of fluid your child gets for 1-2 hours before bedtime. Also, be sure he or she goes to the bathroom right before bed. If your child is still wetting the bed, the next step is probably to wake your child once during the night to go to the bathroom. 

If your child only goes to the bathroom 2 or 3 times a day, that's not enough. You can help by reminding your child to void every 2 - 3 hours, and also talk with his or her teacher so that your child is reminded to void on a regular schedule at school. 

It's also important to pay attention to your child's bowel habits and be sure he or she is not constipated. 

What if that doesn't work?
If this isn't working, it's probably time to talk with his or her primary doctor about things, or see a pediatric urologist. This is especially important if your child has had a urinary tract infection. The doctor will then determine if any further tests are needed, such as ultrasound studies or X-rays of the bladder to look for things like hydronephrosis or reflux. Some patients will benefit from medications to improve bladder or bowel control. 

Another possible treatment is biofeedback. This is specialized therapy to re-train your child about the muscles involved in holding and emptying the urine. Our doctor has experience with biofeedback for children with wetting problems, and has the biofeedback program in the UAE for children with wetting problems, recurrent urinary tract infections, or reflux. During the biofeedback sessions stickers are placed on the skin (We don't use any catheters or other invasive measures!) and children, using a computer "game," are instructed in how to identify the muscles that are important for urinary control. 

Enuresis can be a tremendous problem for children and their families. While it may be considered only a bother, it may also be a sign of other problems with the urinary tract. If things don't get better with what you can try at home, your child should be seen by someone specialized in the evaluation and treatment of such problems. The good news is that there is help! You don't have to just wait for your child to "outgrow it!".

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