Factors contributing to bedwetting habit

Bedwetting by a child results from one or more factors attributing to inappropriate emptying of the bladder. This can be due to a failure of connection between the neuronal control of urination by the bladder and the child’s conscious state of mind to urinate when needed. The factors leading to bedwetting are as follows:

Genetic factors or family inheritance.

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Developmental or maturation delay.

Hyperactivity or an increase in the production of an antidiuretic hormone that controls emptying of the urine.

Disturbed sleep patterns.

Bladder capacity.

Nocturnal polyuria.

Overactivity of detrusor muscles of the bladder increases urination.

Structural blockage in the urinary system or urinary flow.

The above factors can be a primary condition or can arise from a secondary medical condition existing in a child. Secondary conditions are systemic problems leading to bedwetting in a child. They can be as follows:

Renal: Kidney diseases or stones, structural abnormality, or damage.

Urinary tract: Urinary tract infections, bladder dysfunction or stones, posterior urethral valve dysfunction, and ectopic ureter.

Gastrointestinal: Worming and constipation.

Neurological: Spina bifida, seizures, and multiple sclerosis.

Endocrinological: Diabetes mellitus or diabetes insipidus.

Hematological: Sickle cell anemia.

Sleep pattern: Obstructive sleep apnea.

Neuropsychological: Anxiety, stress, and attention deficit hyperactivity disorder (ADHD).

Management of bedwetting habit

Bedwetting habits can be multi-factorial, and evaluation should focus on identifying the root cause. The first step is to understand the bedwetting pattern in a child by a thorough history and physical examination. During history examination, one should enquire about behavioral changes, onset, frequency, and timing of bedwetting habits, bowel habits, fluid intake, sleep patterns, family history, and past medical conditions. The physical examination can include intake of vitals, palpation of lymph nodes, tonsils, abdomen, and spine, neurological examination, and perianal examination. Diagnostic studies include the following:

Urinalysis to rule out urine abnormalities and urinary tract infections.

Imaging and urine flow analysis such as bladder scans, ultrasonography, uroflowmetry, cystoscopy, voiding cystoscopy, and urodynamic studies.

Abdominal examination to rule out constipation issues.

Neurologic workup such as magnetic resonance imaging (MRI) and electroencephalogram

(EEG) to rule out seizure and neurologic conditions.

Epworth sleepiness scale and sleep studies to rule out sleep apnea.

Drug levels such as serum imipramine level to check therapeutic levels.

Treatment for bedwetting depends on the severity of the problem and the child’s age (only above seven years).

Bedwetting can cause embarrassment to the child leading to low self-esteem, depression, mood disorders, and other psychological issues. Adequate mental support and psychological counseling focusing on reassurance about reduction or cessation of bedwetting are given to improve the child’s morale. Behavioral and motivational therapy, through various interventions, aims at correcting the habit.

Bell and pad method is also followed where the child wakes up and gets up to urinate in response to a pad alarm.

Planned regular awakening while asleep is essential to make the child urinate at regular intervals.

Bladder training to rectify urinary issues such as dribbling or delay can also be done.

One can restrict fluid before bedtime to decrease urinating in the night.

Pharmacological treatment includes administering medications such as desmopressin, imipramine, anti-constipation medicines, antidepressants, anticholinergic drugs, and 5-alpha-reductase inhibitors, depending on the condition.

Surgical options to treat bedwetting include sacral nerve stimulation, clam cystoplasty for bladder augmentation, detrusor myectomy, and pelvic organ prolapsed repair.

Prognosis: The treatment panel can include specialists from urology, neurology, endocrinology, otolaryngology, psychiatry, gastroenterology, and pediatrics. Treatment prognosis is better with younger children than older children and depends upon other associated comorbidities or complications.

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