Each night in the United States at least five million school-age children wet their bed. Bedwetting is more of a problem than just running a load of wet sheets to the washer before rushing off to work. It is an annoyance for the whole family. Yet, with new insights and approaches children no longer have to suffer the embarrassment of wet nights and parents no longer have to endure years of laundry while waiting for their child to “grow out of it.” Here’s the step-by-step method of helping the nightwetter keep dry that I have used during my thirty years in pediatric practice, a time-tested approach that enables at least seventy percent of children to wake up in a dry bed.
Step 1: Keep a diary Beginning between four to five years of age record the patterns of your child’s nightwetting for one week. Identify the triggers, what is different about your child’s day on the nights he is wet or dry? Is there a relationship to food, drinks, life’s events, family events, school situations, daytime bowel and bladder patterns, or family dynamics? Try to put your finger on the triggers that lessen the number of sheets you have to change. DON’T RESTRICT FLUIDS In my experience, withholding liquids is not helpful and may be harmful. Children need to drink a lot for proper bodily function, especially during hot months. Restricting fluids may cause dehydration and constipation, which can aggravate bedwetting.
Step 2: Do a medical evaluation Your doctor will want to know the results of your diary, the correlation you have noticed and the changes you have made. Your doctor will do a complete physical examination to detect if there are any neurological problems that may affect the urinary tract, such as spinal cord abnormalities that may affect nerve supply to the bladder. Abnormalities in the external genitalia, such as a misplaced urethral opening, may give a clue to deformities inside. Your doctor may watch your child urinate and examine the force of the flow. A “stuttering stream” rather than a smooth flow may be a clue that there is a structural abnormality in the child’s plumbing. A urinalysis and urine culture may be performed as a screening test for kidney function and to exclude a urinary tract infection. To gauge your child’s bladder capacity, the doctor may also ask you to measure your child’s volume each time he urinates over a three day period to see if he has a functionally small bladder. The usual bladder capacity is a child’s age plus two ounces. So, a six-year-old should be able to hold eight ounces of urine. Finally, if an abnormality of the urinary tract is suspected, your doctor may refer you to a urologist to perform studies such as an ultrasound VCUG (an x-ray picture of how the kidneys and bladder function) to reveal possible abnormalities that could prevent your child from keeping dry all night. The good news is that over ninety-five percent of children have no urinary tract abnormalities causing the bedwetting. Once you’ve excluded a medical problem, you’re ready to begin a night- training program. In order to achieve success, your child must cooperate with the program and take responsibility for his nighttime dryness. Consider this a team approach: the doctor, the parents, and the child. After all, your child has to learn to control his bladder. You can’t control it for him you can only help. In fact, your job is to understand bedwetting, work out a night-training program, be consistent with it, and the rest is up to the child.
Step 3: Draw a diagram With the use of a picture book, such as Dry All Night by Allison Mack (Little Brown, 1989), explain to your child how his kidneys make urine and fill the bladder. Here’s how I explain it to six-year-olds: “Your bladder is like a balloon the size of a baseball, and inside the balloon are tiny nerves, like feelers, that tell you when your bladder is full. When you’re awake, you feel this pressure, but you can hold it because there is big, doughnut-shaped muscle at the end of your bladder that you squeeze shut to keep your pee inside. So, if you’re in the middle of a game and don’t want to go to the bathroom, you’re able to hold it. When your bladder gets full, these nerves tell your brain that it is full, and you go potty. But at night your brain is sleeping so deeply that it says to the bladder, ‘Don’t bother me, I’m sleeping.’ But the bladder says, ‘I’m too full, I’ve got to go,’ so out comes the pee onto the sheets. We’re going to work out some fun games that help your bladder and your brain listen to each other at night, so your brain knows that your bladder is full and says to the bladder, ‘Squeeze down and hold it’ or ‘Wake Billy up to go to the bathroom’.”
Step 4: Teach triple voiding Many children, tired and in a hurry, go to bed with a half-full bladder. Just before your child goes to bed, do some bladder-emptying techniques. Encourage him to “go three times” or “grunt, grunt, grunt” while urinating, to “squeeze your baseball-size bladder to push all the pee out.”
Step 5: Do the shake and wake Since most children wet their bed within a few hours of falling asleep, a perfect time for a second bladder- emptying session is just before you retire. Awaken your child completely. Your child must be awake enough to walk to the bathroom with assistance in order to be awake enough to sense what’s going on in his bladder. Carrying a sleeping child to the bathroom isn’t going to accomplish a complete bladder-emptying. As you approach the bathroom, let him splash water on his face or use a cool wash cloth to wake himself up and then go through the “grunt three times to push the pee out” bladder-emptying drill. If your child still wets his bed despite waking him up, do the timed nightwaking technique. The next few nights set the alarm and wake him up two to three hours later. Gradually adjust the timing of the nightwaking as the number of dry night’s increase. Once your child has a few dry nights, he will become motivated to better cooperate with these drills. Some parents in our practice achieved less disturbed sleep if they taught their seven-year-old to awaken and respond to their own alarm clocks rather than the parents taking the responsibility for waking the child.
Step 6: Do bladder-training drills Just before your child goes to bed or right after the first time you wake him up and put him back to bed, talk him through how the brain and bladder can talk to each other at night, so that he goes to bed programmed to get up when his bladder is too full. Give him phrases that imprint the actions to take: “I’m going to feel my bladder get big,” “I will get up and go to the bathroom when I feel my bladder get big,” “I will splash water on my face and grunt, grunt, grunt to push the pee out.” Try these dialogues in a fun way, so that the child is excited about getting control of his body. Have your child repeat after you many times “I will get up to go to the bathroom when my bladder is full.” He may actually drift off to sleep repeating this encouraging phrase. Do bladder-conditioning exercises during the day. These increase bladder capacity, neuro- muscular control, and awareness of bladder fullness during the day, which hopefully will carry over into the night, try these exercises: Progressive urine withholding. Encourage your child to drink large amounts of fluid and voluntarily hold his urine for increasingly longer times, even though he has the urge to go. As your child’s bladder capacity increases, like a stretched balloon, it should be able to hold more without having to empty so often. The usual bladder capacity is a child’s age plus two ounces. For example, a six-year-old should be able to hold eight ounces of urine. During these exercises, have him urinate into a measuring cup to see if he is increasing his bladder capacity. Stop and go. Advise your child to start and stop his stream many times during urination. This gives a child the awareness that he can actually control his bladder if he wants to. These exercises should not be done without the advice of your doctor, especially in girls who have a history of frequent urinary tract infections. In correct bladder training, you want to teach children to immediately listen to their bladder signals and not hold onto their urine, as this predisposes girls to urinary tract infections. But for purposes of stopping bedwetting, a few days of these exercises should help.
Step 7: Try a bladder-conditioning device If the prior steps fail to produce night dryness, this is the next step. These devices consist of a moisture-sensitive pad that the child wears inside his underwear. When one or two drops of urine strike the pad, a buzzer or vibrator awakens the child so that he can complete his urination in the toilet. I have used these devices for many years in pediatric practice and they are so successful that I rarely prescribe bedwetting-controlling drugs. My experience, and that of others, is that they are effective around seventy to eighty percent of the time if used correctly. Bladder-conditioning devices do just that – condition the child to listen to his bladder signals—which implies not just putting the alarm on the child and going to bed, but rehearsing drills with the child as to what to do when the alarm sounds. This technique operates on the principle of conditioned response. The child associates the sound or vibration with a full bladder and gets up to urinate. In time, the child subconsciously pays attention to his bladder rather than the buzzer, senses its fullness, and automatically contracts the “doughnut muscle,” “beats the buzzer,” and gets up to urinate. REHEARSING BLADDER-CONDITIONING DRILLS For these devices to be effective go through these steps: Draw a diagram. Explain to your child how the buzzer is going to work, that it’s a fun game that will help his bladder and brain listen to one another at night while he’s sleeping: “Picture your bladder filling up and your doughnut muscle squeezing down to keep the urine in. Visualize waking up and taking a trip to the toilet. Pretend your bladder is full and starting to stretch and it’s time to get up.” Empty bladder. Have him empty his bladder completely by the triple- voiding technique (“grunt, grunt, grunt to get all the pee out”) each night just before going to bed. Do the drill. As he’s lying in bed, set off the alarm (the instruction manual will show you how), and condition your child to hop out of bed as soon as he hears or feels it. Then walk with him to the bathroom, show him how to wake himself up by splashing water on his face or using a wet washcloth, and urinate three times. Do this sequence: alarm—hop out of bed— splash water on face—urinate three times. On the final run-through, place the moisture-sensitive pad in his underwear and attach the alarm to his upper shirt shoulder, as close as possible to his ear. Some alarms have soft and loud settings; most children need the loud one. These drills also help your child get used to the sound or vibration of the alarm so it doesn’t frighten him at night. As part of the drill, tell your child that the aim of the game is to “beat the buzzer,” that is, sense when his bladder is full and get up and urinate before the buzzer goes off. In our office, we actually pretend that the examining room nearest the bathroom is the child’s bedroom and I go through this drill with the parents and child, in addition to instructing them how to use the device. Initially, some parents report, “the alarm wakes up everyone else but the child.” If this family-sleep disruption continues, try an alarm that vibrates rather than sounds. You may need to camp out in his bedroom or near his bedroom a few nights, sleep in the room closest to the bathroom, or use an intercom. Also, be sure there’s an unobstructed path to the bathroom that’s clearly lit with a nightlight, otherwise you’re likely to have a wet rug in addition to a wet bed. It may take several weeks to begin noticing the number of dry nights increasing. Relapses are common after a few months, so you may need to go through another round of the device and the drills. Some insurance companies will cover the price of the alarm, providing your doctor gives you a prescription for it. Some doctors will bill the cost of the alarm into the fee for the overall office consultation, which insurance may completely cover. Parents sometimes report that the alarm they ordered out of a catalogue didn’t work. That’s because they didn’t do the drills, which are a vital part of the whole bladder-conditioning package.
Step 8: Drugs for dry nights Drugs do not cure bedwetting; they simply control it until the child grows out of it. Your doctor may suggest DDAVP (desmopressin), which diminishes the production of urine at night, similar to the natural action of the child’s own anti-diuretic hormone. Available in a nasal spray, or tablet, it’s taken before bedtime for two or three months, and then tapered off. Many children have a relapse and need another course of the medication. DDAVP works for 80 to 90 percent of children who don’t respond to other treatments. It can be especially helpful before a child heads off to camp or begins sleeping over at friends’ houses. DDAVP is safe, effective, and has minimal side effects, such as an occasional nosebleed and burning of the nasal passages. It is also expensive. (A 30-day dose costs around $100.00.) One of the oldest medications, and one which I personally do not recommend, is imipramine (Tofranil), which is basically an antidepressant. It has side effects such as blood pressure changes, irregular heartbeat, anxiety, insomnia, dry mouth, blurred vision, nausea, vomiting, diarrhea, dizziness, drowsiness, and headaches. Overdose can cause convulsions. Also, bedwetting often resumes when the treatment stops. To help these bladder-training techniques work, give reinforcements. Place a reward chart (sticker charts are packaged with the bladder-conditioning devices, or let the child pick favorite stickers) near his bed and let him chart “D” for dry nights and “W” for wet nights. After so many D’s, he gets an agreed-upon prize. (Better than a “thing” reward; try a social reward, such as a special outing at a place of his choice.) Soon you can phase out the rewards as the waking up dry and the feeling of mastery over his bladder becomes its own reward. As further motivation to listen to his bladder signals, encourage your child to spend overnights at the homes of friends and to go to camp—where he is more than likely to sleep in a cabin with at least one other bedwetter. He will soon learn that there are other members of the nighttime wet set and he is not the only one in the world who wets his bed. Parents, you are a valuable part of the controlling bedwetting team. These do-it-yourself steps are the basis of commercial programs that charge $1,000 to $1,500 to keep your child dry. Consider these steps toward dry nights as an opportunity to reconnect to your child and help him gain control over his bladder. Parenting the child through the developmental stage from wet to dry nights is another demand on your time and energy, yet the memories of your patience and understanding last a lifetime.