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  • Should enuresis be treated and when?

    When parents consider if and when they should treat their enuretic child, they should take into consideration some parameters and conditions:

    Child's age: 4 years old and up.

    Maturity: The child is mature for his age, has no infantile behavior and has the ability to understand and to concentrate suitable to his age.

    Motivation: The child is disturbed by the bedwetting . He is sad when he wakes up wet and happy when he is dry . He expresses his will to get rid of the problem.

    Bedwetting frequency: High frequency in relation to the child's age (providing that the child is not taken to urinate while he is asleep).

    Child age 4 - every night or almost every night

    Child age 6 - 2-3 times a week or more

    Child age 10 - once a week or more

    Child age 12 - over twice a month or more

    Age 16 - once every 2 months or more

    Age 18 – any frequency

    Season of the year: Bedwetting can be treated during all seasons. For children under 5 years old it is recommended to do the treatment during spring and summer.

    Unstable bedwetting frequency: Children whose bedwetting frequency is not constant and changes from time to time. These are the most difficult cases for treatment due to the instability of the phenomena. It is recommended to start treatment when the frequency is increasing.

    Seasonal bedwetting: Some children are dry or almost dry during summer and wet during winter. It is recommended to begin treatment immediately after autumn.

    Parent's readiness: The parents have a crucial role in the treatment process. They should be ready to invest a lot of time and effort during the treatment. For example, to wake up during the night, to supervise the daily tasks (exercises) and more. Treatment can fail due to a parent's lack of effort.

    Causes for bedwetting: Behavioral treatment should not be considered when there is a medical problem related to enuresis such as urinary tract infections, frequent epileptic seizures, problems related to the spinal cord such as spina bifida and more.

    Behavioral treatment should not be considered when the child is suffering from emotional stress or has psychological problems as a result of acute trauma (lose of close relative, exposure to threatening event such as physical or sexual assault, involvement in a car accident, violence within the family, conflicts between the parents and more).

    In these cases enuresis should not be treated and the treatment should be focused on the causes rather then on the enuretic symptom.

    To sum up: Enuresis can be treated when the child is at least 4 years old, with a high frequency of bedwetting, is mature for his age and is disturbed by the problem. The recommended season with this age (4) is spring and summer.

    Some parents look at bedwetting as a personal failure and they are highly motivated to treat the child when he is not ready yet and is not troubled by the problem. An attempt to force treatment on the child when he is not ready might create unnecessary tension between the child and his parents and the treatment will end in failure.

     

    Will enuresis stop without treatment?

    Most children will stop bedwetting spontaneously with no treatment. At age 4, 25% still wet the bed, at age 6 the scope of the phenomenon decreases to 15% and at age 12 only 4-5%.

    The problem is that we cannot predict if and when bedwetting will stop. When we can see decreased frequency (providing that the parent does not take the child to the toilet while he is asleep) it is recommended to wait before applying treatment.

    In cases when there is no significant decrease in the frequency, it is recommended to apply for treatment.

    When parents asks me why not wait for spontaneous dryness with no treatment, I reply with a question: "If you were promised that your child will stop wetting the bed within 2-3 years, is it justifiable to let him suffer for so long, to wake up every morning to a wet and stinking bed and to avoid sleeping away from home?". I think that the answer is clear.

    Having said that, in many cases when there is no psychological problem, it can be developed due to the bedwetting. The child's self esteem and self confidence can be affected. He invests a lot of energy answering the questions "What's wrong with me? Why does this happen only to me?" He makes efforts to conceal the problem.

    Most children who suffer from bedwetting think that they are among a very few who have the same problem.

     

    The child was treated with a buzzer but did not wake up?

    Many parents report about attempts to treat their child with a buzzer (enuresis alarm). Everyone in the house woke up except the child.

    The buzzer is activated by the first drop of urine and starts to ring. The purpose of treatment by buzzer is to create conditioning of the reflex system. The reflex system is subconscious, therefore the child self wakening to the buzzer is not a compulsory condition for treatment success. The child learns subconsciously to connect between the urination to the unpleasant buzzer response and the waking up and walking to the toilet. When the child does not wake by himself to the buzzer, the parents are instructed to do some essential activities which are essential for the learning process (the reflex conditioning).

    About 40-60% of patients will stop wetting by using the buzzer. For most patients, however, the buzzer will not be sufficient and other therapeutic techniques will have to be added.

    The treatment with the buzzer has to be short term (not longer than 5-6 months). The child gets used to the buzzer and the deterrent effect disappears. Continuation of the treatment with the buzzer means "more of the same". It causes the child frustration and disappointment and undermines the child's confidence in his ability to succeed. Prolonged failure of the treatment might affect future success. The starting point of a future treatment might be influenced by high skepticism and low motivation.

     To sum up, self wakening by the child to the buzzer is not a compulsory condition for treatment success.

     Treatment solely by the buzzer will be insufficient in most cases.

    Parents, sometimes as a result of lack of understanding or misleading guidance, wake up the child during the night and take him to the toilet. This act causes definite disruption of the learning process. It creates a delusion of success (the child wakes up dry in the morning because he was awakened by his parents) and affects the chances of success.

     

    Are there differences among various types of buzzers (enuresis alarms)?

    There are various types of buzzers. The common factors are that it rings with the first drop of urine as a result of electrical closed circuits and it is battery operated. Beyond this, there are substantial differences.

    Basically there are 2 types: Buzzers that are connected to the body and the "bell and pad" type.

     Buzzers that are connected to the body

    The alarm is attached to the child's pajamas and connected by a wire to a moisture sensor which is placed inside the child's underwear.

    It is inexpensive but has some disadvantages. Some of the buzzers are unsafe. The metal sensor can become corroded because of the acidity of the urine (ph.) and therefore may cause bruising to the skin. The child's movement in bed can also cause skin irritation due to rubbing . Some children object to wires connected to their body. Since the buzzer attaches to the body, the child can unintentionally disconnect it. The buzzer sound is not strong enough to activate the reflex system. Moreover, the bed blanket covers the buzzer and it dims its sound.

    Bell and pad

    The "bell and pad" is in two parts: an extremely sensitive control unit which uses the latest electronic techniques and a light, comfortable detector pad which is placed in the bed over a plastic sheet and under a draw-sheet. The pad is attached to the alarm by a slim wire which does not disturb the user in bed. The equipment is made ready for use by simply plugging the pad into the control unit.

    As soon as the first few drops of urine touch the pad, the alarm emits a loud humming tone which will activate the patient's reflex system. The equipment is battery operated. The "bell and pad" is 100% safe and exceeds worldwide governmental and hospital safety requirements.

     

    Is drug treatment efficient for enuresis?

    Most clinics consider enuresis a medical problem. The patient is given a comprehensive and unnecessary medical assessment with no findings. The treatment model is often drug therapy (DDAVP). We might see some progress during the drug usage but should expect a relapse (60%-90%) when the patient stops using the drug. The drugs sometimes have side effects.

     Advantages
    • Easy administration
    • When it is effective, the results are fast.

     Disadvantages
    • Limited success
    • High relapse rate after stopping drug usage
    • Possible side effects
    • The drug is expensive.

     Drug treatment is recommended in the following circumstances:
    • When the child sleeps outside his home
    • When the child is not cooperating. Drug treatment requires no motivation or effort
    • When the family is incapable of doing behavioral treatment
    • When behavioral treatment is unsuccessful, drug treatment can be combined.

     Drug treatment is not recommended before age 7-8 years.

     

    The child is a heavy sleeper. Does the treatment alter sleep depth? Will he start to wake up during the night?

    The behavioral treatment with the enuresis alarm will not alter the child's sleep patterns.

    The change will be that the child will learn, during sleep, to identify the signal from the pressured bladder to the reflex system in the brain. As a result he will act in one of two ways:
    1. Contracting the sphincter muscles during sleep with no waking up.
    2. Waking up to urinate in the toilet.

     

    The child does not wet the bed every night. Why does he wet on certain nights?

    When enuresis does not occur every night, it means that the learning system is functioning partially. When the child wets the bed every night, it means that the learning system does not function at all.

    There is more than one reason for certain wet nights. Some of the possible causes are: high fluid consumption before bedtime, time of bedtime, fatigue, weather changes, cold nights, bad mood, mental tension, illness and many more.