Bedwetting in Children

We have selected the following expert medical opinion based on its clarity, reliability and accuracy. Credit: Source: National Institute of Diabetes and Digestive and Kidney Diseases, edited by Dr Stephan A. Zderic (see below). Please refer to your own medical practitioner for a final perspective, assessment or evaluation.

Overview

Children may have a bladder control problem—also called urinary incontinence (UI)—if they leak urine by accident and are past the age of toilet training. A child may not stay dry during the day, called daytime wetting; or through the night, called bedwetting.

Children normally gain control over their bladders somewhere between ages 2 and 4—each in their own time. Occasional wetting is common even in 4- to 6-year-old children.

By age 4, when most children stay dry during the day, daytime wetting can be very upsetting and embarrassing. By ages 5 or 6, children might have a bedwetting problem if the bed is wet once or twice a week over a few months.

Most bladder control problems disappear naturally as children grow older. When needed, a health care professional can check for conditions that may lead to wetting.

Loss of urine is almost never due to laziness, a strong will, emotional problems, or poor toilet training. Parents and caregivers should always approach this problem with understanding and patience.

Children who leak urine after most classmates stay dry may have a bladder control problem. Emotional support, new habits, or treatments may help.

Do bladder control problems have another name?

Bladder control problems are also called urinary incontinence or enuresis:

• Primary enuresis is wetting in a child who has never regularly stayed dry.
• Secondary enuresis is wetting that begins after at least 6 months of staying dry.

What are the types of bladder control problems in children?

Children usually have one of two main bladder control problems:

• Daytime wetting, also called diurnal enuresis
• Bedwetting, also called nocturnal enuresis

Some children may have trouble controlling their bladders both day and night.

Daytime wetting

For infants and toddlers, wetting is a normal part of development. Children gradually learn to control their bladders as they grow older.

Problems that can occur during this process and lead to daytime wetting include:

• Holding urine too long: Your child’s bladder can overfill and leak urine.
• Overactive bladder: Your child’s bladder squeezes without warning, causing frequent runs for the toilet and wet clothes.
• Underactive bladder: Your child uses the toilet only a few times a day, with little urge to do so. Children may have a weak or interrupted stream of urine.
• Disordered urination: Your child’s bladder muscles and nerves do not work together smoothly. Certain muscles cut off urine flow too soon. Urine left in the bladder may leak.

Bedwetting

Children who wet the bed fall into two groups: those who have never been dry at night, and children who started wetting the bed again after staying dry for 6 months.

How common are bladder control problems in children?

Bladder control problems are common in children. About 1 in 10 children has trouble with daytime wetting at age. Nighttime wetting is more common than daytime wetting.

These are some statistics: Age - Bedwetting Numbers

• Age 5: About 1 in 6 children
• Age 6: About 1 in 8 children
• Age 7: 1 in 10 children
• Age 15: 1-2 in 100 children

Bedwetting often stops without formal treatment as children grow older.

Who is more likely to have bladder control problems?

Daytime wetting is more common in girls than boys.

Bedwetting is more common in boys—and in all children whose parents wet the bed when they were young. Your child’s chances of wetting the bed are about 1 in 3 when one parent was affected as a child. If both parents were affected, the chances that your child will wet the bed are 7 in 10.2

Most children with bladder control problems are physically and emotionally normal.

Certain health conditions can make a child more likely to experience wetting, including:

• A bladder or kidney infection (urinary tract infection)
• Constipation—fewer than two bowel movements a week, or bowel movements in which stool is painful or hard to pass
• Nerve problems, such those seen with spina bifida, a birth defect
• Vesicouretal reflux (VUR), backward flow of urine from the bladder to the kidneys
• Diabetes, a condition in which blood glucose, also called blood sugar, is too high
• Problems with the structure of the urinary tract, such as a blockage or a narrowed urethra
• Obstructive sleep apnoea (OSA), a condition in which breathing is interrupted during sleep, often because of inflamed or enlarged tonsils
• ADHD, or attention deficit hyperactivity disorder

Complications 

What are the complications of bladder control problems?

Children can manage or outgrow most bladder control problems with no lasting health effects. However, accidental wetting can cause emotional distress and poor self-esteem for a child as well as frustration for families.

Bladder control problems can sometimes lead to bladder or kidney infections (UTIs). Bedwetting that is never treated during childhood can last into the teen years and adulthood, causing emotional distress.

Symptoms 

What are the signs and symptoms of bladder control problems in children?

Losing urine by accident is the main sign of a bladder control problem. Your child may often have wet or stained underwear—or a wet bed.

Squatting, leg crossing, and heel sitting can be signs of an overactive bladder.

Daytime Wetting

Signs that your child may have a condition that causes daytime wetting include:

• The urgent need to urinate, often with urine leaks
• Urinating 8 or more times a day, called frequency
• Infrequent urination—emptying the bladder only 2 to 3 times a day, rather the usual 4 to 7 times a day
• Incomplete urination—not fully emptying the bladder during bathroom visits
• Squatting, squirming, leg crossing, or heel sitting to avoid leaking urine

Bedwetting

Nighttime wetting is normal for many children—and is often not considered a health problem at all—especially when it runs in the family.

At ages 5 and older, signs that your child may have a nighttime bladder control problem—whether due to slow physical development, an illness, or any cause—can include:

• Never being dry at night
• Wetting the bed 2 to 3 times a week over 3 months or more
• Wetting the bed again after 6 months of dry nights

Your child’s doctor can suggest when treatments may help control bedwetting.

When should my child see a doctor about bladder control problems?

If you or your child are worried about accidental wetting, talk with a health care professional. He or she can check for medical problems and offer treatment or reassure you that your child is developing normally.

Take your child to a health care professional if there are signs of a medical problem, including:

• Symptoms of bladder infection such as:
  • Pain or burning when urinating
  • Cloudy, dark, bloody, or foul-smelling urine
• Urinating more often than usual
• Strong urges to urinate, but passing only a small amount of urine
• Pain in the lower belly area or back
• Crying while urinating
• Fever
• Restlessness
• Your child dribbles urine or has a weak urine stream, which can be signs of a birth defect in the urinary tract
• Your child was dry, but started wetting again

Although each child is unique, providers often use a child’s age to decide when to look for a bladder control problem. In general:

• by age 4, most children are dry during the day
• by ages 5 or 6, most children are dry at night

Seek care right away

If your child has symptoms of a bladder or kidney infection, or has a fever without a clear cause, see a health care professional within 24 hours. Quick treatment is important to prevent a urinary tract infection from causing more serious health problems.

Causes 

What causes bladder control problems in children?

Bathroom habits, such as holding urine too long, and slow physical development cause many of the bladder control problems seen in children. Less often, a medical condition can cause wetting. 

What causes daytime wetting in children?

Daytime wetting in children is commonly caused by holding urine too long, constipation, or bladder systems that don’t work together smoothly. Health problems can sometimes cause daytime wetting, too, such as bladder or kidney infections (UTIs), structural problems in the urinary tract, or nerve problems.

When children hold their urine too long, it can trigger problems in how the bladder works or make existing problems worse.

These bladder problems include: 

Overactive bladder or urge incontinence

Bladder muscles squeeze at the wrong time, without warning, causing a loss of urine. Your child may have strong, sudden urges to urinate. She may urinate frequently—8 or more times a day.

Underactive bladder

Children only empty the bladder a few times a day, with little urge to urinate. Bladder contractions can be weak, and your child may strain when urinating, have a weak stream, or stop-and-go urine flow.

Disordered urination

Muscles and nerves of the bladder may not work together smoothly. As the bladder empties, sphincter or pelvic floor muscles may cut off urine flow too soon, before the bladder empties all the way. Urine left in the bladder may leak.

What causes bedwetting in children?

Nighttime wetting is often related to slow physical development, a family history of bedwetting, or making too much urine at night. In many cases, there is more than one cause. Children almost never wet the bed on purpose—and most children who wet the bed are physically and emotionally normal.

Sometimes a health condition can lead to bedwetting, such as diabetes or constipation.

Bedwetting often runs in families, where it is usually a normal growth pattern, not an illness.

Slow physical development

Between ages 5 and 10, slow physical development can cause your child to wet the bed. Your child may have a small bladder, deep sleep cycles, or a nervous system that’s still growing and developing. The nervous system handles the body’s alarms—sending signals about a full or emptying bladder—and the need to wake up.

Family history

Bedwetting often runs in families. Researchers have found genes that are linked to bedwetting. Genes are parts of the master code that children inherit from each parent for hair colour and many other features and traits.

Making too much urine

Your child’s kidneys may make too much urine overnight, leading to an overfull bladder. If your child doesn’t wake up in time, a wet bed is likely. Often this excess urine at night is due to low levels of a natural substance called antidiuretic hormone (ADH). ADH tells the kidneys to release less water at night.

Sleep disorders

Sleepwalking and obstructive sleep apnea  (OSA) can lead to bedwetting. With OSA, children breathe poorly and get less oxygen, which triggers the kidneys to make extra urine at night. Bedwetting can be a sign that your child has OSA. Other symptoms include snoring, mouth breathing, ear and sinus infections, a dry mouth in the morning, and daytime sleepiness.

Stress

Stress can sometimes lead to bedwetting and worry about daytime or nighttime wetting can make the problem worse. Stresses that may affect your child include a new baby in the family, sleeping alone, moving or starting a new school, abuse, or a family crisis.

Diagnosis

How do doctors diagnose bladder control problems in children?

To diagnose a bladder control problem, doctors use a child’s:

• Medical history
• Physical exam
• Lab tests
• Imaging tests, if needed

In addition, doctors will ask questions about:

• Symptoms
• When and how often the wetting happens
• Dry periods
• Family history of bedwetting
• Bladder and liquids diary

Before an office visit, it’s helpful to use a bladder diary to keep track your child’s bathroom habits and how much liquid your child drinks. Write down when your child uses the toilet, the amount of urine passed, and when your child leaks urine. Record the timing and amount of liquid your child drinks, too, including whether your child drinks fluids before bedtime.

Because constipation can cause wetting or make it worse, your child’s doctor may ask you to record how often your child passes stool and whether it’s hard or soft.

What tests do doctors use to diagnose bladder control problems in children?

Lab tests

Health care professionals often test a urine sample, which is called urinalysis, to help diagnose bladder control problems in children. The lab may also perform a urine culture, if requested. White blood cells and bacteria in the urine can be signs of a urinary tract infection.

Your child may need to collect a urine sample in a container. Lab tests can help diagnose the cause of bladder leaks.

Other tests

In a few cases, health care professionals may order imaging tests or tests of how the urinary tract works. These tests can show a birth defect or a blockage in the urinary tract that may lead to wetting. Special tests can find nerve or spine problems. Testing can also help show a small bladder, weak muscles, or muscles that don’t work together well.

Ultrasound: An ultrasound uses sound waves to look at structures inside the body without exposing your child to radiation. During this painless test, your child lies on a padded table. A technician gently moves a wand called a transducer over your child’s belly and back. No anaesthesia is needed.

Voiding cystourethrogram (VCUG): A voiding cystourethrogram uses x-rays of the bladder and urethra to show how urine flows. A technician uses a catheter to fill your child’s bladder with a special dye. The technician then takes x-rays before, during and after your child urinates. A VCUG uses only a small amount of radiation. Anaesthesia is not needed, but the doctor may offer your child a calming medicine, called a sedative.

MRI: Magnetic resonance imaging (MRI) uses magnets and radio waves to make pictures of the urinary tract and spine. During this test, your child lies on a table inside a tunnel-like machine. MRI scans do not expose your child to radiation. No anaesthesia is needed, but the doctor may offer your child a calming medicine or suggest watching a children’s program during the test.

Urodynamic testing: Urodynamic testing is a group of tests that look at how well the bladder, sphincters, and urethra are storing and releasing urine. These studies are not used often, but they may be helpful when simple bladder management methods are not as successful as expected.

Treatment

How can my child’s doctor and I treat a bladder control problem?

When a health condition causes the wetting—such as diabetes or a birth defect in the urinary tract—doctors will treat the health problem, and the wetting is likely to stop.

Other common treatments for wetting include bladder training, moisture alarms, medicines, and home care. Teamwork is important among you, your child, and your child’s doctor. You should reward your child for following a program, rather than for staying dry—because a child often cannot control wetting.

If your child wets both day and night, the doctor is likely to treat daytime wetting first. Children usually stay dry during the day before they gain bladder control at night.
 

Daytime wetting

Treatments for daytime wetting depend on what’s causing the wetting and will often start with changes in bladder and bowel habits. Your child’s doctor will treat any constipation, so that hard stools don’t press against the bladder and lead to wetting.

Bladder training

Bladder training helps your child get to the bathroom sooner and may help reset bladder systems that don’t work together smoothly.

Programs can include:

• Urinating on schedule every 2 to 3 hours, called timed voiding.
• Urinating twice during one visit, called double voiding. This method may help the bladder empty completely in children who have an underactive or “lazy” bladder or vesicoureteral reflux (VUR)
• Relaxing the pelvic floor muscles so children can empty the bladder fully. A few sessions of biofeedback can retrain muscles that don’t work together in the right order.

In extremely rare cases, doctors may suggest using a thin, flexible tube, called a catheter, to empty the bladder. Occasional use of a catheter may help develop better bladder control in children with a weak, underactive bladder.

Medicine

Your child’s doctor may suggest medicine to limit daytime wetting or prevent a urinary tract infection (UTI).

Oxybutynin (Ditropan) is often the first choice of medicine to calm an overactive bladder until a child matures and outgrows the problem naturally.

If your child often has bladder infections, the doctor may prescribe an antibiotic, which is a medicine that kills the bacteria that cause infections. Your child’s doctor may suggest taking a low-dose antibiotic for several months to prevent repeated bladder infections.

Home care and support

Changes in your child’s routines and behaviour may greatly improve daytime wetting, even without other treatments.

Encourage your child to:

• Use the bathroom whenever the urge occurs.
• Drink more liquid, mainly water, if the doctor suggests doing so. Drinking more liquid produces more urine and more trips to the bathroom.
• Take extra time in the bathroom to relax and empty the bladder completely.
• Avoid drinks with caffeine or bubbles, citrus juices, and sports drinks. These drinks may irritate the bladder or produce extra urine.

Children need plenty of support from parents and caregivers to overcome daytime wetting, not blame or punishment. Calming your child’s stresses may help—stresses about a new baby or new school, for example. A counsellor or psychologist can help treat anxiety.

Bedwetting

If your child’s provider suggests treatment, it’s likely to start with ways to motivate your child and change his or her behaviour. The next steps include moisture alarms or medicine.

For a bedwetting treatment program to work, both the parent and child must be motivated. Treatment doesn’t always completely stop bedwetting—and there are likely to be some setbacks. However, treatment can greatly reduce how often your child wets the bed.

Motivational therapy

For motivational therapy, you and your child agree on ways to manage bedwetting and rewards for following the program. Keep a record of your child’s tasks and progress, such as a calendar with stickers. You can give rewards to your child for remembering to use the bathroom before bed, helping to change and clean wet bedding, and having a dry night.

Motivational therapy helps children gain a sense of control over bedwetting. Many children learn to stay dry with this approach, and many others have fewer wet nights. Taking back rewards, shaming, penalties, and punishments don’t work; your child is not wetting the bed on purpose. If there’s no change in your child’s wetting after 3 to 6 months, talk with a health care professional about other treatments.

Tracking good bathroom habits may help children develop fewer wet days or nights over time. Rewards are given for effort, because a child can’t always control wetting.
 

Moisture alarms

Moisture alarms detect the first drops of urine in a child’s underwear and sound an alarm to wake the child. A sensor clips to your child’s clothes or bedding. At first you may need to wake your child, get him or her to the bathroom, and clean up wet clothes and bedding. Eventually, your child learns to wake up when his or her bladder is full and get to the bathroom in time.

Moisture alarms work well for many children and can end bedwetting for good. Families need to use the alarm regularly for 3 to 4 months as the child learns to sense his or her signals and control the bladder. Signs of progress usually appear in the first few weeks—smaller wet spots, fewer alarms each night, and your child waking on his or her own.

Medicine

Your child’s doctor may suggest medicine when other treatments haven’t worked well.

Desmopressin (DDAVP) is often the first choice of medicine for bedwetting. This medicine slows the amount of urine your child’s body makes overnight, so the bladder doesn’t overfill and leak. Desmopressin can work well, but bedwetting often returns when a child stops taking the medicine. You can use desmopressin for sleepovers, camp, and other short periods of time. You can also keep a child on desmopressin safely for long periods of time.

Home care

Changes in your child’s routines may improve bedwetting, when used alone or with other treatments.

Encourage your child to:

• Drink most of his or her liquids during the morning and early afternoon.
• Urinate regularly during the day—every 2 to 3 hours—and just before bed, which is a total of about 4 to 7 times a day.
• Urinate twice before bedtime (about a half hour apart) to fully empty the bladder and allow room for new urine made overnight.
• Avoid drinks with caffeine or bubbles, citrus juices, and sports drinks. These drinks may irritate the bladder or produce extra urine.

Children who wet the bed should use the bathroom just before bedtime.

Support

How can I help my child cope with bladder control problems?

Your patience, understanding, and encouragement are vital to help your child cope with a bladder control problem. If you think a health problem may be causing your child’s wetting, make an appointment with your child’s health care provider.

Clothing, bedding, and wearable products

For children with daytime wetting, clothes that come on and off easily may help prevent accidents. A wristwatch alarm set to vibrate can privately remind your child to visit the toilet, without help from a teacher or parent.

For children who wet the bed, the following practices can make life easier and may boost your child’s confidence:

• Leave out dry pyjamas and towels so your child can clean up easily.
• Layer waterproof pads and fitted sheets on the bed. Your child can quickly pull off wet bedding and put it in a hamper. Fewer signs of wetting may help your child feel less embarrassed.
• Have your child help with the clean-up and laundry the next day. However, don’t make it a punishment.
• Be sure your child showers or bathes every day to wash away the smell of urine.
• Plan to stop using diapers, training pants, or disposable training pants, except when sleeping away from home. These items may discourage your child from getting out of bed to use the toilet.
• Don’t make a habit of waking your child during the night to use the bathroom. Researchers don’t think it helps children overcome bedwetting.
• Easy clean-up routines may give children a sense of control while they outgrow bedwetting.

Emotional support

Let your child know that bedwetting is very common, and most children outgrow it. If your child is age 4 or older, ask him or her for ideas on how to stop or manage the wetting. Involving your child in finding solutions may provide a sense of control.

Calming your child’s stresses may help—stresses about a new baby or new school, for example. A counsellor or psychologist can help treat anxiety.

Prevention

How can I help my child prevent bladder control problems?

Often, you can’t prevent a bladder control problem, especially bedwetting, which is a common pattern of normal child development.

However, good habits may help your child have more dry days and nights, including:

• Avoid or treat constipation.
• Urinate every 2 to 3 hours during the day—4 to 7 times total in a day.
• Drink the right amount of liquid, with most liquids consumed between morning and about 5 p.m. Ask your child’s health care provider how much liquid is healthy, based on age, weather, and activities.
• Avoid drinks with caffeine or bubbles, citrus juices, and sports drinks. These drinks may irritate the bladder or produce extra urine.

About the Source

This content is provided as a service of the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), part of the National Institutes of Health. The NIDDK translates and disseminates research findings through its clearinghouses and education programs to increase knowledge and understanding about health and disease among patients, health professionals, and the public. Content produced by the NIDDK is carefully reviewed by NIDDK scientists and other experts.

Edited by: Dr Stephan A. Zderic, MD, Children’s Hospital of Philadelphia

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