Bedwetting / Nocturnal Enuresis

It is important to note that bedwetting is not your child’s fault.

It happens because the volume of urine produced at night is more than the child’s bladder can hold. The sensation of a full bladder does not seem to be strong enough to wake your child from sleep. As your child develops and grows, the amount of urine produced at night gets less, and they become aware that they need to wake at night if their bladder is full. So, the problem goes away eventually in most children.

Anxiety, stress, and changes in routine can all make bedwetting worse or start it up again once settled.

Do

• be patient, success may take many months of work
• give your child enough to drink during the day*
• make sure your child goes to the toilet every 2-3 hours during the day, including just before bedtime (“timed toileting” rather than waiting until your child feels the urge to empty his/her bladder)
• develop a calm, relaxing bedtime routine and switch off devices such as iPads or mobile phones an hour before bed as this will encourage the release of vasopressin (a brain hormone which acts on the kidneys to reduce the amount of urine produced)
• agree with your child on rewards for positive actions, such as a sticker for every time they take the full recommended number of drinks per day or use the toilet before bed, rather than rewarding dry nights
• use waterproof covers on their mattress and duvet
• make sure they have easy access to a toilet at night and a night light to see their way to the toilet
• check that your child is opening his/her bowels regularly as constipation can make bedwetting worse
• do not give your child drinks containing caffeine, such as cola, tea, and coffee – this can make them pee more
• do not give your child drinks in the 1-2 hours before bedtime
• do not regularly wake or carry your child in the night to use the toilet as this will not help in the long term. Lifting may be used to manage bedwetting in the short term, but you should make sure your child is fully awake and aware of why they are being woken, and walk your child to the toilet at a different time each night

Don’t

• do not punish your child – it is not their fault and can make bedwetting worse
• do not give your child drinks containing caffeine, such as cola, tea, and coffee – this can make them pee more
• do not give your child drinks in the 1-2 hours before bedtime
• do not regularly wake or carry your child in the night to use the toilet as this will not help in the long term. Lifting may be used to manage bedwetting in the short term, but you should make sure your child is fully awake and aware of why they are being woken, and walk your child to the toilet at a different time each night

Drinking

It is extremely important for children to have a good drink intake, and this can help to improve bedwetting. Children may think that drinking less in the day will help them to stay dry at night, but this is not true. Drinking less in the daytime will reduce the size of the bladder and so it will hold less.

How much a child needs to drink will depend on their age, whether they are male or female, the weather, what they have eaten and what physical activities they have been doing.

As a guide these are the suggested daily intake of drinks for children and young people:

• Age 4 to 8 years, boys & girls: 1000 to 1400ml
• Age 9 to 13 years, girls: 1200 to 2100ml
• Age 9 to 13 years, boys: 1400 to 2300ml
• Age 14 to 18 years, girls: 1400 to 2500ml
• Age 14 to 18 years, boys: 2100 to 3200ml

It is better to drink smaller volumes of fluid regularly throughout the day than to have lots in one go. Children should aim to drink:

• on waking
• with breakfast
• where permitted, during lessons
• morning break at school
• with lunch
• on getting home from school
• before the evening meal
• with the evening meal

If you have consistently used the above advice and your child is still wetting the bed, you should contact your GP who may consider prescribing medication or referring your child to the local Paediatric Bladder and Bowel Care Service.

You should contact your GP if your child has any of the following symptoms:

• pain or burning sensation when passing urine
• an increase in daytime frequency of urination
• unexplained fever or shivers
• starting to wet the bed again after 6 months of being dry

These symptoms could indicate a urinary tract infection, which should be treated quickly.

Your GP will examine your child and test a urine sample. It is helpful to bring a fresh sample of urine with you to your appointment (for instructions on collecting a sample of urine from a child, please see below)

Collecting a sample from children and young people who are potty or toilet trained

You will need:

• Clean container or foil bowl
• Urine sample bottle (yellow lid)
• Clean funnel or oral syringe (if required)
• Cotton wool or gauze
• Syringe
• Urine sample bottle or test tube as provided
• Urine collection bags
• Urine sample bottle or test tube as provided

What to do:

• Wash the genital area with water and pat dry with a clean towel
• Wash your hands with soap and water
• Ask your child to start weeing and then use the container to catch their wee
• Do not collect the first few drops – wait a second or two before starting to collect
• Pour the sample from the container into the urine sample bottle (using a funnel or syringe if needed)
• Screw the lid on tightly and put in the biological hazard bag you have been given then give to your doctor
• If it not wet, replace the nappy and wait another 10 minutes before checking. Replace the pad every 30 minutes to avoid contamination.

Collecting a sample from babies and children in nappies or pads using cotton wool or gauze

You will need:

• Cotton wool or gauze
• Syringe
• Urine sample bottle or test tube as provided

What to do:

• Wash the genital area with water and pat dry with a clean towel
• Wash your hands with soap and water
• Put a thick layer of cotton wool or gauze inside your child’s nappy
• Wait 10 minutes and check whether it is wet
• If it is wet, use the syringe provided to draw up the urine to put in the urine sample bottle or test tube
• Screw the lid on tightly and put in the biological hazard bag you have been given then give to your doctor

Using a urine collection bag

You will need:

• Urine collection bags
• Urine sample bottle or test tube as provided

What to do:

• Wash the genital area and pat dry with a clean towel
• Wash your hands with soap and water
• Attach the bag around your child’s genitals using the sticky strip
• Check the bag regularly and remove when your child has weed
• Cut the corner off the bag and pour urine into the urine sample bottle or test tube
• Screw the lid on tightly and put in the biological hazard bag you have been given then give to your doctor or nurse.

If there are any abnormal findings on the clinic test, the urine will be sent to the laboratory to check if an infection is present. Your GP may need to wait for this result before deciding if treatment is necessary.

Alarms – mattress and body worn

Bedwetting alarms can help to strengthen the signal from the bladder to the brain.

A sensor detects when a child has started to wet the bed, and this triggers an alarm to wake the child. With time the child learns to link the sensation of having a full bladder with the need to wake up and go to the toilet, and eventually will start to wake before the alarm goes off.

Alarms have a high long term success rate but need sustained effort and commitment.

It is helpful to offer your child a reward for waking up when the alarm goes off, for going to the toilet after the alarm has gone off and for returning to bed and resetting the alarm.

Early signs of a response to look out for are:

• smaller wet patches
• waking to the alarm
• the alarm going off later and fewer times per night
• fewer wet nights

Dry nights may take many weeks to achieve.

For further information on alarms and how to get hold of them, please click here.

Medications

Medications are most effective when children are drinking enough, drinking regularly, and using the toilet regularly.

Desmopressin

Desmopressin is an artificial form of the naturally occurring hormone called vasopressin and works in a similar way to decrease and concentrate urine produced at night.

Desmopressin is available on prescription for children over the age of five years in the form of a tablet or as a ‘melt’ which dissolves under the tongue. There are several important points and ‘rules’ to remember about desmopressin:

• Desmopressin does not stimulate the production of vasopressin and so when a child stops using desmopressin, they may start to wet the bed again if their own vasopressin levels are still low.
• Production of vasopressin is part of a child’s individual development, and some produce it at a later age than others.
• Desmopressin is usually taken for three months and then stopped for one week to work out whether the child now has a sufficient level of their own natural vasopressin.
• The dose of desmopressin can be increased, if necessary, after discussion with your child’s nurse or doctor.
• Desmopressin does not work for all children. Desmopressin is fully effective for about one third of children, partly effective for about one third of children and in another third of children it has no effect.
• Desmopressin may be taken for occasional use only, for example, on nights away from home. Because desmopressin does not work for all children a trial run is recommended beforehand.
• Children often take desmopressin in the form of ‘Desmomelt’; a tablet which, rather than being swallowed, is placed under the tongue shortly before bedtime as this prevents the need for a drink to help swallow a traditional tablet.
• Side-effects of desmopressin are rare. Possible side-effects may include headache, feeling sick and mild tummy pain. These side-effects are not serious and go away if the treatment is stopped.
• Children must not drink more than sips for one hour before taking the medication and until eight hours after taking it.
• Children who are experiencing vomiting or diarrhoea must not take desmopressin until their symptoms have cleared.
• oxybutynin
• tolterodine

To prevent side-effects, it is important that children take only very small drinks for one hour before taking the medication and for eight hours after (see ‘rules’ below). Full details about contraindications and side-effects are available in the product literature.

‘Rules’

• Children must not drink more than sips for one hour before taking the medication and until eight hours after taking it.
• Children who are experiencing vomiting or diarrhoea must not take desmopressin until their symptoms have cleared.

Anticholinergic medications

These medications relax the detrusor muscle that surrounds the bladder and can decrease involuntary bladder contractions and so help to enable the bladder to relax and hold more urine. The names of the two anticholinergic medicines commonly used for children are:

• oxybutynin
• tolterodine

In children with nocturnal enuresis anticholinergic medication is often used in combination with desmopressin.

Details about contraindications and side-effects are available in the product literature. Please discuss any queries or concerns you have with your child’s nurse or doctor.

What if treatments don’t work?

• Success is classified as 14 consecutive dry nights.
• Any treatment offered needs to be tried for a reasonable time before it is considered unsuccessful.
• Recording signs of progress on a chart can be helpful.
• Using alarms: If bedwetting starts again after a bedwetting alarm has previously been successful, recommence using the alarm again until there have been 14 more consecutive dry nights.
• Taking desmopressin: The dose of desmopressin may need to be increased after two to four weeks if your child is not dry. Dose changes should only be made after communication with your child’s nurse or doctor. For children for whom desmopressin works, re-assessment, via trial off medication, is needed every three months (see above).
• Taking oxybutynin: The full effectiveness of oxybutynin takes some weeks to build up and so reassessment will usually be between three and six months after your child starts to take it.
• When one treatment is considered unsuccessful an alternative, or combination of treatments, may be offered.

If you have been referred for a specialist opinion your details will be reviewed, and it may be recommended that you are seen by a hospital clinician. Information to support you in choosing your preferred hospital, including waiting times can be found using the links below.

The Paediatric Bladder and Bowel Care Service covers the whole of Devon and is based at Franklyn House, Franklyn Drive, Cowick Lane, Exeter, EX2 9HS. You will be offered an initial telephone appointment to assess the problem and offer advice. If your child needs to be seen, there are clinics held across Devon.

How long will I wait?

If a hospital assessment and/or treatment is clinically recommended your information will be sent to a specialist. Click below to find out more about waiting times for routine hospital assessment and/or treatment.

• Waiting times
• Find services near you