Bedwetting is a common childhood disorder. Many of the modern theories about its cause place great emphasis on stress, and we have come to accept that stress is a modern phenomenon, yet bedwetting is an old problem.
The Ebers Papyrus (dated 1550 BC) has a medical treatise which mentions enuresis or bedwetting at night and in the 16th century Thomas Phaer (or Phaire) in his “Boke of Children” has a chapter “On Pyssing in the Bedde“. Toilet training with nighttime control may take place at different ages and may depend on the maturity of the child’s developing nervous system.
Most doctors don’t consider a problem exists until the child is five or six.
The majority of these children have never developed night control of their bladders. The time of stress, such as separation or the arrival of another child, is easier to see in children who have achieved night control and then relapse to a more infantile form of behavior.
Anxiety and conflict in the child, or even anxiety, over-discipline, or “smothering” by the parents, maybe factors in the development of some cases of enuresis. At the moment we are uncertain and therefore it is more rewarding to concentrate on treatment rather than on causes.
Let me just say that the later the child is toilet trained then the quicker it is learned, and the less likely it is to be lost.
This may be because the child is older and learns faster, or because the mother is less obsessional.
The parents may bring the child to the doctor at any age, depending on how much of a problem this disorder is to the child or to the family. Older children may need to see their doctor when they are being asked to stay at friends’ houses or to go camping.
Opinions differ about the frequency and which sex is more commonly affected, but to most sufferers it is a problem and to the mothers who have to wash the sheets it may be a major problem.
As with other medical conditions it is important to take a good history. This, with a complete physical examination and a simple urine test, will enable the doctor to exclude the presence of other physical diseases.
Sometimes, special tests are necessary if some other condition is suspected. Some of these children are greatly relieved to find that one or both of their parents suffered from the same trouble. They can be reassured that they are not alone and that at least one or two of the children in their class also have the same problem.
The treatment of bedwetting is now a choice between drugs and conditioning, and the latter seems more effective.
Punishing or rewarding the child has no place in management, although most parents have used these methods before consulting the doctor. Most parents have tried smacking, withholding privileges, or making the child wash the wet sheets.
Many of the emotional problems in both the child and the parents are the result rather than the cause of the enuresis.
Lifting the child each night before the parents go to bed has also been tried by most parents and is recommended by some doctors. This has been found to be of no value in treatment although it may result in more dry nights and therefore fewer sheets to wash.
Depriving the child of drinks in the evening in an effort to reduce the amount of urine is also a common and useless attempt at cure.
Many of these children appear to be heavy sleepers and drugs such as the amphetamines were used to lighten sleep. Ephedrine, which has a similar action and also tightens the sphincter muscle at the opening of the bladder, was also used.
I find it helpful for some children if they are given a calendar and asked to record their “dry” nights and bring this back to me on their next visit.
The assuming of responsibility – in keeping the record – and the institution of a direct doctor/child relationship rather than the doctor/parent/child relationship may help.
The only drugs that are effective are the tricyclic antidepressant group. These appear to work, not because of their antidepressant action but because of their side-effect, which has an anticholinergic action. This is what causes the dry mouth, blurred vision, and constipation is seen when using them to treat depression.
In enuresis they act on the bladder and relax the muscle in the wall of this organ while strengthening the action of the sphincter.
Treatment must be continued for many months and many children relapse when the drugs are stopped.
For this reason the technique of conditioning seems better. Alarm machines are used (“pad and bell”) to modify the behavior and to train the child to wake when the bladder is full so that he can rise and go to the toilet.
These can be bought or hired, but the decision to use them should be medical. The doctor should monitor their management. They are usually used for at least three months.
They rely on urine wetting a special sheet and thus completing an electric circuit that rings a loud bell and wakes the child. He then rises and finishes emptying the bladder. Eventually he learns to wake when the bladder is full and before it is involuntarily emptied.
The family doctor usually undertakes the management of children with nocturnal bedwetting.
A few children or their parents may need to see a psychiatrist if they have severe emotional problems coming from, causing or just associated with the enuresis.
Fortunately, no matter what is done, most of these children seem to grow out of the habit. In a few, it may persist into adult life.