Suzanne Berman, M.D.
Isn’t my child too old to be wetting the bed?
Maybe not. Here are some statistics that may give you some perspective:
- About 50% of 4 year olds still wet the bed several times a week.
- At age 10, 5% wet the bed at least once a month.
- At age 13, 2% wet the bed at least once a month.
- At age 15 and older, 1% wet the bed at least once a month. In fact, 1% to 2% of military recruits during World War II were rejected from service merely because they were bed-wetters!
Will my child grow out of this?
As you can see from the above statistics, most children do. As children get older, fewer and fewer have bedwetting accidents, even without doing any special treatment. In fact, of children who wet the bed this year, 15% won’t be routine bedwetters next year. However, there will still be some otherwise healthy adolescents and young adults who continue to wet the bed. In older children and teens, it’s much more common in boys than girls. It’s hard to predict which young children who wet the bed will grow out of it and which will continue to have the issue for a while.
Why do children wet the bed?
In general, children who wet the bed are completely normal psychologically and anatomically. While asleep, these children do not wake up when their bladders are full and start to contract. Genetics also plays a part. Children with a parent who wet the bed have a 44% chance of being a bed wetter, and a child with two parents who both wet the bed has a 77% chance.
Children who used to be dry at night but then start to wet the bed (about 30% of all bedwetters) may be under stress of some kind. For example, common stresses include a physical illness (even a bad cold), parents’ divorce or remarriage, birth of a new sibling, change of address, harsh punishments, or the death of a beloved pet or relative.
What about daytime wetting?
Again, the cause of daytime wetting (with or without nighttime wetting) is rarely the sign of something serious and overall is very common. About 25% of bedwetters also have daytime accidents.
- At age 5, 5% still have daytime accidents.
- At age 7, 4% still have daytime accidents.
- At age 12, 1% still have daytime accidents.
Four of the most common causes of daytime wetting are:
- Infrequent voiding. These children have learned to avoid using the toilet for long periods of time. They go to the bathroom voluntarily only once or twice a day, instead of four to seven times (which is usual for children.) For one reason or another, they have learned to suppress the urge to go to the bathroom. Often, they have been previously discouraged from using the toilet by a caretaker (e.g. “You just went! You’ll have to hold it”). Very timid children may be hesitant to speak up that they need to use the restroom, and will hold their urine out of shyness. Sometimes they dislike using the bathroom (e.g. if the school restroom tends to be dirty or out of toilet paper) and therefore try to avoid it. Sometimes such children are simply easily distracted from their urge to go, or are too busy playing to “bother” using the toilet. Over time, this “toilet avoidance” leads to gradual increase in the size of the bladder, but with a decreasing urge to urinate. Because their bladders have become gradually desensitized, these children may not feel the urge to go until it’s too late and they’ve already had an accident.
- Incomplete voiding. Some children let their bladders fill to near capacity, then urinate only until they get relief. When their bladders do not empty completely, they become stretched and desensitized, just as those in children with infrequent voiding.
- Vaginal reflux. This is actually not a bladder problem at all. Little girls urinating on the toilet can sometimes collect a small amount of urine in their vaginas. The amount that is present is usually very small but can be up to 15 cc (half an ounce.) The urine tends to pool in the vagina and may not leak out until after the girl has left the bathroom and has become active again.
- Constipation. If the child’s rectum is distended with poop, this doesn’t let the bladder fill and empty properly. Read more about constipation below.
Could my child’s bedwetting be caused by a bladder infection (UTI)?
Yes, occasionally. We recommend testing urine specimens for UTIs in children with bedwetting or daytime wetting at least once, particularly if it is a new problem for the child. (It is unlikely that a child who has been bedwetting or daytime wetting for years has had a single, persistent UTI.)
Even if a UTI is detected and properly treated, however, bedwetting and daytime wetting can still persist. This suggests that it is much more likely that bedwetting and daytime wetting cause UTIs, rather than the other way around. Urine collecting in a desensitized bladder which is incompletely or improperly emptied is an inviting place for bacteria to grow.
Should my child have any special tests or studies to rule out a severe problem?
As described above, a complete urinalysis and culture on children with bedwetting or daytime wetting is definitely an appropriate first step. We also like to gather the following information before taking the next step:
- When does the child have urinary accidents?
- When does the child urinate throughout the day?
- How many trips to the bathroom does the child make?
- What volume of urine does the child produce at one time?
- How much and what kind of beverages does the child consume? When?
- Does the child ever seem to have urinary urgency?
- Does the child ever seem to strain to void?
- Does the child have a constant urinary stream or urinate in a “staccato” pattern?
- Does the child take the time to empty completely, or does he “rush the job?”
- Does the child have any problems with his bowels? (soiling, constipation)
The answers to these questions help direct the therapy as well as help decide whether any additional tests are indicated. Occasionally, ultrasounds, x-rays, or consultations with pediatric specialists are warranted for children with unusual symptoms or physical findings. Again, most children do not require these tests.
You say constipation may be causing bedwetting, but my child doesn’t seem constipated.
We are frequently surprised at how common constipation is an underlying cause of bedwetting and even daytime accidents. Many times children don’t seem to be constipated — they “go poop” every day, and the BM doesn’t seem that hard — but they are not fully emptying their rectum when they go. As a result, stool builds up in the rectum over time, pressing on the bladder. A 2011 study showed that 80% of bedwetting children ages 5-15 had an abnormal amount of stool in their rectum seen on X-ray, but only 10% of parents thought the child was constipated.
How should this problem be treated?
- First of all, start at the right time. Unless the child is motivated to succeed, nothing you do will work. Trying to “treat” a 5 year old for a problem that he or she will most likely outgrow in a few years is frustrating for parents and often confuses the child. Wetting issues rarely affect a child’s social life until he or she is about 7 or 8 years old. Since most children with wetting problems spontaneously get better by age 8, we usually recommend delaying any intervention until that time. Dr. Bernard M. Churchill, a pediatric urologist at the University of California, had this to say about starting therapy for bed wetting: “At UCLA, the staff delays treatment until a child is at least 7 or 8 years old. They treat children, regardless of age, only if they are interested and committed to treatment. A child unwilling to invest time and energy, regardless of parental concern, is unlikely to respond to therapy.” (from Pediatric Clinics of North America, 48:6, December 2001.)
- Next, educate yourself. Understand that this is a common problem and that your child is not wetting himself or herself on purpose. It is easy to become frustrated with a child whose problem disturbs everyone’s sleep. You will need your child’s cooperation to succeed at dry nights. However, do not punish your child, especially with physical punishment, if he or she cannot. He or she may just not be mature enough to oblige yet.
- Begin treatment by encouraging positive behavior with a motivational program. A chart with stars, stickers, or simple treats is an inexpensive, well-received first step. “But that’s too easy,” many parents say. Most children, however, respond quite well to small, consistent, incremental goals of hourly to daily success. A promise like, “If you stop wetting for good, I’ll buy you a Nintendo,” might motivate an adult, but is just too overwhelming for most children.
- Cut out all caffeine-containing beverages. Caffeine is a diuretic and irritates the bladder. Restricting fluids overall might be necessary if your child really is drinking too much, but most children drink an appropriate amount.
- Have your child void more frequently. This helps recondition the bladder and is a good practice for both daytime and nighttime wetters.
- For children who are constipated, work on improving diet and fluid intake; ask us to recommend a stool softener if needed. Stool softeners work best when used every day.
- Nighttime wetters should wake up every 3 hours while asleep to use the toilet. This can be accomplished inexpensively with an alarm clock or with a more expensive wetting alarm that attaches to the child’s pajamas. Sometimes parents choose to wake the child themselves, but this doesn’t allow the child to take responsibility for the problem. Daytime wetters should use the toilet every 2 hours. Again, verbal reminders are okay but a method that allows the child to be in charge (an inexpensive pocket watch with alarm) is preferable.
- Children should be discreetly observed to make sure that the trip actually takes place and is appropriate in duration.
- Children who are incomplete voiders should count to 30 to ensure they have emptied their bladders fully.
- Girls who have vaginal reflux should be shown how to separate their labia, stand over the toilet, and let the urine drain completely before wiping and dressing.
PottyMD is a good resource for our families also.