Does bedwetting indicate a child’s emotional suffering?

When should parents start worrying about nighttime bedwetting? When should they think it's due to an emotional problem? Dr. Hadassah Troan answers the questions.

 Sleeping child (photo credit: INGIMAGE)
Sleeping child
(photo credit: INGIMAGE)

If your child wets the bed at night and you’re worried that something will happen to them, you aren’t alone. About 15% of 5-year-olds suffer from bedwetting problems, and the number of boys is almost double the number of girls.

Dr. Hadassah Troan, a pediatrician at Meuhedet's Keshet clinic in Jerusalem and a graduate of the Goshen Association for Health and Child Welfare in the Community explained that sometimes enuresis exists in children at night only and has no additional urinary tract-related symptoms. In contrast, nocturnal enuresis is marked by night urination and other symptoms related to the lower urinary system, such as wetting during the day, a feeling of frequency, difficulty urinating and other symptoms.

Can wetting go even without treatment?

Troan explained that nocturnal enuresis is a common problem in children, and it will usually go away without treatment. At the age of 5, as mentioned, 15% of children will suffer from nocturnal enuresis and every year that passes about 15% of these kids will spontaneously stop wetting at night so that when we look at the age of 12 and up, only 2% of these kids still wet at night.

Is nocturnal enuresis hereditary?

There is definitely a hereditary component to overnight wetting. "If one parent had bedwetting until late in life, then their kids have a 50% chance that they too will suffer from it; if both parents have a history, the chance of bedwetting in kids increases to 75%," explained Troan. She added that one reason parents are asked about family history is because there is a great element of shame around bedwetting and many times parents will not voluntarily tell their child their own personal experience or that of people from the extended family.

She added that when the child knows that both mother and half of the uncles had a problem similar to the one the child suffers from, it has a very calming effect - it makes it very clear that the fact that the child is still wetting doesn’t mean that the child is problematic. There is a rainbow of ages at which children stop wetting at night and there are children who mature more slowly and are still normal children. "When the child knows that the father also suffered from wetting, they experience less of a sense of failure around something really out of their control. Kids feel less unusual and have hope that just as with the father, sister or aunt, it stopped at some point, it will stop for them.”

When is medical treatment needed for nocturnal enuresis? 

Although the vast majority of children will stop wetting themselves at night if given enough time, there’s still room for treatment. "The need for treatment is when the wetting causes distress to the child or family. When a child suffers from shame and frustration around wetting then there is room to try and speed up the process," said Troan. This is also true when wetting deprives the child of age-appropriate experiences such as sleepovers with friends or going on an annual school camping trip. For teens who are still wetting, treatment is needed as at this age the chance of stopping enuresis itself decreases.

Is bedwetting a red flag, i.e. does it signal a mental problem?

According to Dr. Troan, in most cases, if there are emotional problems then it’s usually the result of the wetting itself at night. As mentioned, there are exceptions and there are cases where the wetting will appear in response to a traumatic event that happened to the child, but most of the time an event isn’t identified and so the goal in treatment is not to locate a mental difficulty that caused the wetting but to prevent the development of mental difficulties like insecurity and guilt about the problem.

Is there a connection between deep sleep and enuresis?

Usually, there is no single cause of nocturnal enuresis, but it can result from interactions between several factors, including deep sleep. In a minority of cases there are children whose enuresis is actually secondary to another medical problem, such as disturbed sleep due to upper airway obstruction. It’s important to check kids to see if they have breathing problems at night.

Why will a kid only wet several nights and not every night in a row?

There isn’t a single factor for enuresis  but it’s about the connections between different factors and some of them vary from day to day.  An example of this is the amount the child drinks and when during the day he drinks. "Sometimes just by moving most of the drinking to the morning and avoiding drinking in the hours before bed, we can help the child stay dry at night," Troan explained.

How to treat wetting in a designated clinic

At the clinic meeting, they first try to find out with the child and their parents that it is indeed a matter of wetting only at night - that is, that there are no symptoms during the day and that it’s not secondary to another factor. For starters, work on the behavioral change of moving most drinking to the morning hours and avoid drinking two hours before bed. Make sure your kid goes to the bathroom before bed.

Troan explained that kids whose behavioral measures don’t bring about the desired result actually have two treatment channels: The first is behavioral therapy with a bell. In this treatment the child is 'trained' to wake up when he needs to urinate, it’s a treatment that requires a lot of motivation and effort.This has a nice success rate. Even after finishing using the bell, a significant portion of the children will remain dry.

The second treatment is a drug called Minrin. The drug prevents urine from being produced during the night and it’s very important not to drink about an hour before taking the drug until morning. The use of the drug is effective but won’t solve the problem fundamentally because once you stop taking it the problem may return.