Nocturnal enuresis, commonly known as bedwetting, is nighttime urinary incontinence in children aged five or older, occurring at least twice weekly for three consecutive months. Though often dismissed as a phase, bedwetting can significantly impact a child’s self-esteem, social life, and even parental stress levels if left untreated. Approximately 5-10% of seven-year-olds experience bedwetting, along with about 3% of teenagers and 0.5-1% of adults. Each year, 15% see spontaneous improvement without intervention.

Types of Bedwetting (Enuresis)

1. Primary Enuresis: This occurs when a child has never achieved nighttime bladder control.
2. Secondary Enuresis: Develops after a child has been dry for six months or longer, often due to psychological or physical factors.

Causes of Bedwetting

Bedwetting generally results from a delayed development in typical bladder control processes. This delay disrupts the balance between nighttime urine production, bladder storage, and waking up to urinate. Key causes include:

1. Slow Bladder Maturation: Some children’s bladders develop more slowly than average.
2. Reduced Bladder Capacity: A smaller-than-average bladder can increase the likelihood of bedwetting.
3. Genetics: Bedwetting is often inherited; children with parents who bedwet as children are more likely to experience it.
4. Deep Sleep Patterns: Deep sleep can prevent a child from sensing a full bladder.
5. Low Vasopressin Levels: Vasopressin, a hormone that reduces urine production at night, may be low in children with enuresis.

Common Comorbidities in Bedwetting

Bedwetting often coexists with other health issues. Addressing these comorbidities can improve treatment outcomes:

1. Constipation: Present in 82% of children with primary enuresis. Treating constipation alone resolves bedwetting in over half of affected children.
2. Developmental or Psychiatric Conditions: Conditions like ADHD can make bedwetting harder to treat.
3. Upper Airway Obstruction: Obstructive sleep apnea (OSA) can contribute to enuresis due to disrupted sleep arousal patterns.
4. Medical Conditions and Stress: Conditions like diabetes, renal disease, and psychological stress (e.g., bullying, trauma) may also trigger or worsen bedwetting.
5. Lower Urinary Tract Symptoms (LUTS): Symptoms like frequent or infrequent urination, urgency, and incomplete bladder emptying often co-occur with bedwetting and should be managed alongside treatment.

Effective Treatments for Bedwetting

1. General Advice
Children should understand that bedwetting is not their fault. Bedwetting is involuntary, and punishment does not help. Instead, reassure the child, and avoid using scolding or negative reinforcement.

2. Behavioral Therapies

• Encourage regular bathroom visits (about six times daily, including before bed).
• Promote adequate hydration in the morning and afternoon but limit drinks, especially sugary or caffeinated ones, close to bedtime.
• Avoid using diapers or pull-ups at home, especially for older children, as this may delay the child’s motivation to get out of bed.

3. Mattress Protection
Using a waterproof sheet helps manage odor and keeps the mattress protected, reducing the stress associated with accidents.

4. Active Therapies for Bedwetting

• Enuresis Alarms: One of the most effective initial treatments, alarms detect the first drops of urine and activate a sound, light, or vibration to wake the child. This helps children learn to respond to a full bladder by waking up.
• Desmopressin: Desmopressin, an antidiuretic hormone, reduces nocturnal urine production to a level that the bladder can hold. For occasional control, such as during sleepovers or camps, intermittent use is recommended. In some cases, daily use can be beneficial for complete control, showing a full response in 30% of children and partial improvement in another 40%. Desmopressin is available as meltable or tablet forms and is given one hour before bedtime. After administration, limit fluid intake to 200 ml before bed and avoid drinks overnight to prevent risks like water intoxication or hyponatremia.

Bedwetting is common and manageable, and early intervention can significantly improve a child’s quality of life and self-esteem. Understanding and addressing the causes and comorbidities are key steps in successful treatment.


Dr. Pornroong Prutthiphongsit
Pediatrics - Pediatric Nephrology