Bed-Wetting

Topic Overview

What is bed-wetting?

Bed-wetting is urination during sleep. Children learn bladder control at different ages. Children younger than 4 often wet their bed or clothes because they can't yet control their bladder. But most children can stay dry through the night by age 5 or 6.

Bed-wetting is defined as a child age 5 or older wetting the bed at least 1 or 2 times a week over at least 3 months. In some cases, the child has been wetting the bed all along. But bed-wetting can also start after a child has been dry at night for a long time.

Wetting the bed can be upsetting, especially for an older child. Your child may feel bad and be embarrassed. You can help by being loving and supportive. Try not to get upset or punish your child for wetting the bed.

What causes bed-wetting?

Children don't wet the bed on purpose. Most likely, a child wets the bed for one or more reasons, such as:

• Delayed growth. Children whose nervous system is still forming may not be able to know when their bladder is full.
• A small bladder. Some children may have a bladder that gets full quickly.
• Too little antidiuretic hormone. The body makes this hormone, which rises at night to tell the kidneys to release less water. Some children may not have enough of this hormone.
• Deep sleeping. Many children who wet the bed sleep so deeply that they don't wake up to use the bathroom. They probably will wet the bed less often as they get older and their sleep pattern changes.
• Emotional or social factors. Children may be more likely to wet the bed if they have some stress. For example, a child may have a new brother or sister.

Children who wet the bed after having had dry nights for 6 or more months may have a medical problem, such as a bladder infection. Or stress may be causing them to wet the bed.

How is it treated?

Treatment usually is not needed for bed-wetting in children age 7 and younger. Most children who are this age will learn to control their bladder over time without treatment.

But bed-wetting in children older than 7 may be treated if it happens at least 2 times a week for at least 3 months. It also may be treated if it affects a child's schoolwork or relationships with peers. Treatment may focus on praise and encouragement, a moisture alarm, behavior therapy, or medicine. Several of these may be used.

If bed-wetting is caused by a treatable medical problem, such as a bladder infection, the doctor will treat that problem.

What can you do to help your child?

Help your child understand that controlling his or her bladder will get easier as your child gets older.

Here are some other tips that may help your child:

• Give your child most of his or her fluids in the morning and afternoon.
• Limit caffeine from chocolate or colas, especially at night.
• Have your child use the toilet before he or she goes to bed.
• Let your child help solve the problem, if your child is older than 4. He or she can help decide which treatments to try.
• Offer your child disposable nighttime underpants. Don't force your child to wear them, but they are fine if your child is comfortable using them.
• Praise your child for dry nights.

Frequently Asked Questions

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	Should I treat my child's bed-wetting?

Cause

Almost all children who wet the bed do not do so intentionally. Most likely, several factors are involved when a child older than age 5 to 6 continues to wet the bed. Possible causes of primary nocturnal enuresis include:

• Delayed growth and development. Children with a less mature nervous system may not be as able to sense when the bladder is full.
• Small bladder capacity. Having a smaller-than-normal bladder may make some children more prone to wet the bed.
• Too little antidiuretic hormone (ADH). Levels of antidiuretic hormone (ADH), a brain chemical that signals the kidneys to release less water, normally rise at night. Some children who wet their beds may not produce more ADH at night.
• Sound sleeping. Many parents note that their child who wets the bed is a deep sleeper. These children usually wet the bed less frequently as their sleep patterns mature.
• Psychological and social factors. Bed-wetting does not appear to be a direct result of emotional problems. In fact, bed-wetting may be the cause of some emotional disturbances for children. But children living in stressful home situations or in institutions may be more likely to wet the bed.

Some of these factors may be inherited. A child is at increased risk for wetting the bed if one or both parents has a history of bed-wetting as a child.

Most cases of primary nocturnal enuresis are not caused by any medical condition. But secondary nocturnal enuresis, which is bed-wetting that occurs after a period of staying dry, is more likely to be related to a medical condition. Examples of physical causes include a kidney or bladder infection (urinary tract infection) or birth defects that affect the urinary tract . Emotional stress, such as may result from the birth of a brother or sister, can also be a factor in triggering bed-wetting.

Symptoms

Bed-wetting is not a disease, so it has no symptoms. For a child who has never had nighttime bladder control for more than 3 months, overcoming this problem is usually a matter of normal growth and development.

If a child has other symptoms, such as crying or complaining of pain when urinating, sudden strong urges to urinate, or increased thirst, bed-wetting may be a symptom of some other medical condition. A child with any of these symptoms should be evaluated by a health professional.

What Happens

Bed-wetting is common in young children. Children grow and develop at different rates, and bladder control is achieved at an individual pace. Usually, daytime bladder control occurs before nighttime control.

Children may wet the bed several times during the night, and they may not wake up after wetting.

Primary nocturnal enuresis-bed-wetting that continues past the age that most children have nighttime bladder control-will usually stop over time without treatment.

• Every year, about 15 out of 100 affected children who don't get treated will become dry on their own.¹
• Most children with primary nocturnal enuresis will stop wetting by the time they are 10 years old.²

Sometimes bed-wetting is related to emotional stress. Bed-wetting usually stops when the stress is relieved or managed. Bed-wetting in older children, especially girls, is more likely to occur with signs of emotional stress and be more difficult to treat.

But bed-wetting can be upsetting. It is more often a cause of emotional stress than a result of it, especially in children older than 6. Explaining that gaining complete bladder control is a normal part of growing up may help reassure your child.

For some children and their parents, bed-wetting is not a significant issue and is more of a minor annoyance than anything else.

But the emotional responses to bed-wetting can impact the relationship with your child. If you or your child is having difficulty with handling bed-wetting, you may wish to investigate treatment options.

If a medical condition is causing the bed-wetting, treating the condition may stop the wetting.

Treatment often does not completely stop bed-wetting, but it may decrease how often it occurs. Although bed-wetting may return when treatment is stopped, repeating or combining treatments may have longer-lasting results.

Some children who wet the bed also experience accidental daytime wetting. When wetting occurs during both the day and night, usually the factors related to the daytime wetting are explored first.

What Increases Your Risk

A child may inherit the tendency to wet the bed.³

• If both parents wet their beds when they were children, there is a 77% chance that their child also will wet the bed.
• If one parent wet the bed, there is a 43% chance that their child also will wet the bed.
• About 15% of children wet the bed even though neither parent wet the bed as a child.

Children who develop at a slower rate than other children during the first 3 years of life have an increased likelihood of wetting the bed. Boys tend to develop more slowly, so they are more likely than girls to wet the bed.

When To Call a Doctor

Call your doctor if:

• Your child has signs of a bladder or kidney infection or other symptoms, such as back pain, abdominal pain, or fever. Signs of a bladder or kidney infection include:
  • Cloudy or pink urine or bloodstains on underclothes.
  • Urinating more often than usual.
  • Crying or complaining when urinating.
• Your child age 4 or older is wetting the bed and is leaking stool. The child may have stool blocking the intestines , caused by having constipation over a period of time.
• Your child wets the bed more frequently while you are using home treatment for bed-wetting.
• Your daughter older than 5 or your son older than 6 has never had bladder control for more than 3 months in a row after trying home treatment, and it is causing problems at school or in the child's relationships with family and friends.
• Your child who has had bladder control for at least 3 months has begun to wet the bed, and this has happened more than a few times.

If your child wets the bed but exhibits no other symptoms, and you have tried home treatment without success, the doctor can recommend other methods of treatment.

Watchful Waiting

Watchful waiting is appropriate if bed-wetting is not affecting a child's performance in school or relationships with family and friends. Most children develop complete bladder control even without treatment. Home treatment may be all that is needed to help the child learn bladder control.

Watchful waiting may not be appropriate if bed-wetting begins after a child has had bladder control for a period of time. Look for possible stresses that might be causing the bed-wetting. Bed-wetting may stop when your child's stress is relieved or managed. If it does not, your child should see a health professional. For more information, see:

Should I schedule a doctor visit to discuss my child's bed-wetting?

Who To See

The following health professionals can evaluate and treat bed-wetting:

• Family doctor
• Pediatrician
• Nurse practitioner
• Physician assistant

The following specialist(s) may be required if your child has medical or emotional conditions:

• Urologist
• Psychologist
• Psychiatrist
• Developmental pediatrician

To prepare for your appointment, see the topic Making the Most of Your Appointment.

Exams and Tests

Any child beyond age 6 or 7 who continues to wet the bed may need to be evaluated by a doctor. The evaluation should include a urinalysis.

A medical history and a physical exam are also part of a medical evaluation of bed-wetting. If you are having your child evaluated for bed-wetting, for a week or two before your visit, keep a diary that lists when wettings occur and how much urine is released.

In some cases, further testing may be needed. Tests may include:

• A urine culture to find out if a bladder or kidney infection is present.
• Psychological testing, if emotional stress is suspected.

If a child has uncontrollable wetting both at night and in the day, other tests may need to be done.

What to think about

Should I schedule a doctor visit to discuss my child's bed-wetting?

Treatment Overview

Most children gain bladder control over time without any treatment. Bed-wetting that continues past the age that most children have nighttime bladder control-typically at 5 or 6 years of age-also will usually stop over time without treatment. If not, home treatment may be all that is needed to help a child stop wetting the bed. Home treatment may include:

• Monitoring when and how much your child drinks. Give your child most of his or her needed fluids in the morning and afternoon.
• Restricting your child's intake of caffeine, especially at night.
• Having your child use the toilet before going to bed.
• Reminding your child to get up during the night to go to the bathroom.
• Letting the child help solve the problem, if he or she is older than 4.
• Offering your child disposable nighttime training underpants. Don't force a child to wear them, but if you are both comfortable with using them, there is no reason not to.
• Praising and rewarding the child for dry nights.

If home treatment is unsuccessful, if the child and parents need assistance, or if the bed-wetting may be caused by a medical condition, medical treatment may be helpful. The goal of medical treatment is to decrease the frequency of bed-wetting and to increase the child's use of the toilet at night if needed. Eventually bed-wetting will stop completely, but this may not happen immediately after treatment.

• Treatment is considered successful if the child remains dry for 14 nights in a row within 16 weeks of treatment.
• Treatment is considered a complete success if the child does not have any accidental wettings for 2 years after treatment.
• Children who have an increase in accidental wettings after treatment are considered to have relapsed. A relapse is defined as more than 2 wet nights in 2 weeks. The most likely time for a child to relapse is within the first 6 months after treatment. If a child relapses after stopping a successful therapy, that same therapy usually is repeated.

Medical treatment for bed-wetting may include:

• Education for the parents and child about what is normal and expected for children as they grow and about how the urinary system works.
• Motivational therapy. This method involves parents encouraging and reinforcing a child's sense of control over bed-wetting.
• Moisture alarms, which detect wetness in the child's underpants during sleep and sound an alarm to wake the child.
• Desmopressin and tricyclic antidepressant medicines. These medicines, which increase the amount of urine that the bladder can hold or decrease the amount of urine released by the kidneys, may help some children.

Treatment for bed-wetting is based on the:

• Child's age. Some treatments work better than others for children of a specific age group.
• Child's and parents' attitudes about the bed-wetting. If gaining bladder control is seen as a normal process, it is usually easier for the child to stop bed-wetting.
• Home situation. If the child shares a bedroom with other children, certain techniques to arouse the child, such as dry-bed training or some moisture alarms, may not be practical.

Treatment for bed-wetting may be helpful if bed-wetting is affecting a child's self-esteem, performance in school, or relationships with peers.

The best solution is often a combination of treatments. Below are some suggestions for treatment options according to the age of your child.

• Ages 5 to 8: Help your child understand that wetting the bed is a normal part of growing up. Encouragement and praise may be all that is needed to help your child wake up before wetting. Children in this age group should be praised for dry nights and should take an active role in cleaning up after wetting.
• Ages 8 to 11: If your child still wets the bed, a moisture alarm may be a successful treatment option. It can be used in combination with occasional use of a medicine such as desmopressin, which can be helpful for social events such as camp or sleepovers.
• Age 12 and older: There can be significant emotional effects if bed-wetting persists at this age, so treatment can be more aggressive. If consistent use of moisture alarms does not work, the doctor may suggest medicine.

For more information, see:

Should I treat my child's bed-wetting?

What about treatment for daytime wetting?

Accidental daytime wetting may be a normal part of a child's development, or it may indicate a medical condition. If your child has any symptoms of a medical condition, he or she should be evaluated by a health professional.

What To Think About

Studies show moisture alarms to be the most effective single treatment for bed-wetting.

Medicines for bed-wetting are usually used in combination with other methods of treatment. They are not as successful as other treatments in helping children gain complete bladder control, so medicines should be used after other measures have been tried first. Medicines may be most helpful in the following situations:

• To help older children control bed-wetting for short periods of time, such as for camp or overnight trips
• To treat bed-wetting that is related to a stressful event, such as the divorce of the child's parents or the birth of a sibling

Often a child who has responded successfully to treatment will begin to wet again after treatment has stopped. But most children who relapse can be treated successfully with a repeat of the original program, especially if that program is based on behavior modification, such as using a moisture alarm.

Prevention

Learning to use the toilet is a natural process that occurs when children are old enough to control their bladder muscles and to know when they are about to wet. It is normal for young children to have accidental bed-wettings while they are learning to control their bladders.

If you are teaching your child to use the toilet, be patient. Some children are slower than others in gaining complete bladder control. Stay positive and encouraging, and learn about the normal development of bladder control. For more information, see the topic Toilet Training.

You can also help prevent or reduce bed-wetting by limiting your child's fluid intake in the evenings. Do not give any drinks containing caffeine, such as cola or tea. Also, remind your child at bedtime that he or she should get up at night to use the bathroom if needed.

Home Treatment

Most children gain bladder control over time without any treatment. A child should first be allowed to overcome bed-wetting on his or her own. But home treatment may help a child to wet the bed less frequently.

You can help manage your child's bed-wetting:

• Monitor your child's consumption of liquids. As a rule of thumb, children should be encouraged to consume 40% of their total daily liquids in the morning, 40% in the afternoon, and 20% in the evening. Talk with the doctor about how much fluid your child needs.
• Restrict your child's intake of caffeine. Caffeine is a diuretic, which means that it promotes the excretion of urine. Foods such as chocolate and beverages such as colas and tea that contain caffeine should only be consumed during the morning and afternoon hours.
• Have your child use the toilet before going to bed.
• Remind your child to get up during the night to go to the bathroom. It may help to keep a night-light near or potty chair beside the bed.
• Let your child help solve the problem, if he or she is older than 4.
• Praise and reward your child for dry nights. Involve your child in planning the reward system. You may want to use a calendar and put stars or stickers on the days that your child does not wet the bed.
• Encourage your child to take responsibility for changing clothes and linens after a bed-wetting accident. For example, use washable sleeping bags as bedding so your child can easily replace one that is wet with one that is dry.
• Offer your child disposable nighttime training underpants. Don't force a child to wear them, but if you are both comfortable with using them, there is no reason not to.
• Add 0.5 cups (125 mL) of vinegar to the wash water to get rid of the urine odor in clothing and bed linens.

If your child wets the bed, don't blame yourself or your spouse. Don't punish, blame, or embarrass your child. Your child is neither consciously nor unconsciously choosing to wet the bed. Give your child understanding, encouragement, love, and positive support.

• Be patient about changing the bed linens. Don't act offended by the smell of urine.
• Do not wake the child up at different times during the night to go to the bathroom unless it is part of a systematic treatment that the child has agreed to.
• Do not make the child feel bad. Shaming or punishing the child may make the problem worse.
• If you think your child may be feeling emotional stress, talk with a health professional about whether counseling may be helpful.

Teaching your child bladder-control exercises and techniques may help reduce the number of bed-wetting episodes.

Medications

Medicines that either increase the amount of urine that the bladder can hold (bladder capacity) or decrease the amount of urine released by the kidneys are used to treat bed-wetting.

Medicines are usually used to temporarily control bed-wetting, not as a treatment to completely stop the condition.

• Medicines work well to control accidental wetting for short periods of time, such as when children are on overnight trips or at camp.
• Sometimes medicines are used along with other treatments or for children who have not been able to control bed-wetting with other treatments. Medicines can help to encourage and motivate a child who is having trouble with other treatments by letting the child feel what it is like to have dry nights.

Medication Choices

Desmopressin (DDAVP)

Tricyclic antidepressants (imipramine, desipramine)

In a few cases, when a small bladder capacity or overactive bladder is thought to be the cause of bed-wetting, oxybutynin (Ditropan) may be used to treat bed-wetting, especially when the child also has daytime accidental wettings.

What To Think About

Medicines usually are not used to treat bed-wetting in children younger than 8, unless the medicine is known to be safe for younger children.

Most children start wetting the bed again after medicine treatment is stopped.

Surgery

Surgery may be done to fix spinal or urinary tract problems that cause bed-wetting. But this is rare.

A toilet-trained child who accidentally wets during the day (diurnal enuresis) may have a birth defect that may require surgery.

Other Treatment

Other treatments often are used alone or in combination to treat bed-wetting. These treatments usually are tried before medical treatments, such as medicines. All of these treatments involve several steps, including:

• Educating the parents and child about what is normal and expected for children as they grow and about how the urinary system works.
• Empowering the child to believe that he or she can overcome the problem in time.
• Training the child to stop wetting the bed (through behavior changes and conditioning) or helping remove the underlying cause of the bed-wetting (for example, through counseling or hypnosis if stress is the underlying cause).

Sometimes a device such as a moisture alarm is part of the training (conditioning) process.

Other Treatment Choices

• Moisture alarms help train (condition) the child to wake up and use the bathroom. The alarm wakes up a child the moment wetting has begun. Moisture alarms are often used in combination with other treatments or with medicines.
• Praise and encouragement (motivational therapy) may be successful in stopping bed-wetting when used in combination with other treatments such as moisture alarms.
• Counseling (psychotherapy) may be helpful for the child with secondary enuresis or for bed-wetting that is caused by emotional stress. Psychotherapy involves talking with a trained counselor. The counselor helps the child identify and deal with the emotional stress that may be causing him or her to have accidental wettings. The goal is to reduce or help manage the stress or to prevent stress from developing.
• Hypnosis (hypnotherapy) has helped some children who wet the bed and may be especially effective when stress is the underlying cause.

Various methods of behavior training have been used to teach a child bladder control:

• Self-awakening training involves having the child practice getting out of bed to go to the bathroom. It is mostly to be used for children older than 6 years.
• Dry-bed training consists of following a strict schedule for waking the child up at night until he or she learns to wake up alone when needed. The dry-bed training program is implemented over 7 nights.
• Bladder-stretching exercises are done to help increase the amount of urine that the bladder can hold (bladder capacity) and to teach the child to hold urine for longer periods of time.

What To Think About

• Motivational therapy requires a longer period of treatment than other treatments for bed-wetting. It is most successful for older children (older than 6) who are eager to stop wetting.
• Moisture alarms are considered the most effective treatment for bed-wetting and are often the first choice of doctors. Moisture alarms are usually used for children older than 7.
• Before hypnosis therapy is started, the child needs to be evaluated for emotional problems that may need to be treated by other methods. Psychotherapy along with hypnosis can help children deal with stressful situations.
• Even if treatment seems successful, bed-wetting will often return after treatment is stopped. Most children who relapse can be treated successfully with a repeat of the original treatment, especially if treatment includes motivational therapy and a moisture alarm.

Other Places To Get Help

Organizations

Related Information

• Growth and Development, Ages 2 to 5 Years
• Growth and Development, Ages 6 to 10 Years
• Hypnosis
• Toilet Training
• Urinary Problems and Injuries, Age 11 and Younger
• Urinary Problems and Injuries, Age 12 and Older

References

Citations

1. Kiddoo D (2007). Nocturnal enuresis, search date March 2007. Online version of BMJ Clinical Evidence. Also available online: http://www.clinicalevidence.com.

2. Tanagho EA (2008). Enuresis section of Disorders of the bladder, prostate, and seminal vesicles. In EA Tanagho, JW McAninch, eds., Smith's General Urology, 17th ed., pp. 578-580. New York: McGraw-Hill.

3. Thiedke CC (2003). Nocturnal enuresis. American Family Physician, 67(7): 1499-1506.

Other Works Consulted

• Glazener CMA, et al. (2005). Complementary and miscellaneous interventions for nocturnal enuresis in children. Cochrane Database of Systematic Reviews (2).

• Glazener CMA, et al. (2005). Alarm interventions for nocturnal enuresis in children. Cochrane Database of Systematic Reviews (2).

• Medical Specialty Society, American Academy of Child and Adolescent Psychiatry (2004). Practice parameter for the assessment and treatment of children and adolescents with enuresis. Journal of the American Academy of Child and Adolescent Psychiatry, 43(12): 1540-1550.

• Mikkelsen EJ (2007). Elimination disorders: Enuresis and encopresis. In A Martine, FR Volkmar, eds., Lewis's Child and Adolescent Psychiatry, 4th ed., pp. 655-669. Philadelphia: Wolters Kluwer, Lippincott Williams and Wilkins.

• Sadock BJ, Sadock VA (2007). Elimination disorders. In Kaplan and Sadock's Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry, 10th ed., pp. 1244-1249. Philadelphia: Lippincott Williams and Wilkins.

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