Posted tagged ‘enuresis’

Bedwetting in a pre-teen

August 3, 2017

The Pediatric Insider

© 2017 Roy Benaroch, MD

Josh wrote in about his 12 year old daughter – they’ve tried everything, specialists and medications, and she still wets the bed every night:

We have done everything. Waking her, withholding fluids, buzzer. She has taken the highest dosage of desmopressin allowed, to no avail. She has been to an endocrinologist and tested thoroughly, seen her pediatrician many times, had abdominal X-rays and ultrasounds, and been examined for psychological issues. Nothing. The next step our doctor suggests is a urologist. She currently wears a diaper to bed, and we are very straightforward and sympathetic with her. Only positive reinforcement, but she is frustrated with herself at this point.

Josh, about 3% of 12 year olds still wet the bed, at least sometimes (though most of those are boys). It’s not crazy-uncommon for your daughter to be doing this, but I know she wants to stop. Trouble is: bedwetting happens when you’re asleep, and what you want or don’t want doesn’t really matter. Positive reinforcement won’t hurt, but it probably won’t help much, either. What might hurt is encouraging her to “try harder” – this is something that isn’t about trying or practice or rewards. It’s about neurologic maturity.

What supposed to happen: past a certain age, even while we’re asleep we can still pay attention to signals from our bladders. When it’s full, or getting full, we tighten up our pelvic muscles to hold in the urine, without waking up. A good trick, that is, and babies can’t do it, and young children can’t do it. People who are heavier sleepers find it harder to do this, too – and that makes sense. Sleeping like a rock means it’s more likely that you’ll wake up like a, well, wet rock. And there’s not much you can do to “lighten” someone’s sleep cycle.

What *might* work – and I know Josh’s daughter has already tried some of these, but just for completeness:

Drinking more in the morning I know, the usual advice is to drink less at night – but it turns out that’s really difficult to do. If you’re thirsty, you’re thirsty, and not drinking when you’re thirsty is nigh impossible. Instead: stay well hydrated the rest of the day, especially the morning, so you don’t feel like drinking in the evening.

Don’t hold urine during the day I know, some people suggest “bladder stretching” by day to hold more at night. But the problem isn’t a small bladder – it’s that the sleeping child doesn’t notice that their bladder is full. It turns out that holding by day gets the brain “used to” the feeling of a full bladder. It dampens (sorry) the nerve signals, so you don’t get as strong a feeling of a full bladder. This is exactly what you do not want. Frequent, relaxed daytime emptying can help a child stay dry at night.

Treat constipation Constipation leads to holding which leads to less awareness of a full bladder; it also inadvertently strengthens muscles you don’t want strengthened, making it difficult to empty the bladder. At 12, if bedwetting is an issue, I suggest treating constipation even if you don’t think your child is constipated. Just try it. It might work.

Consider medication Two meds have wide use to help with bedwetting: desmopressin and imipramine. Either or both are worth a try, especially if the child is concerned about this.

Don’t make this about trying or not trying I said this before, but let me repeat it: kids don’t wet the bed because they want to wet, and don’t stop wetting the bed because they want to stop. Josh mentioned looking into psychological contributors, which may be a good idea, but don’t create a bigger problem by blaming or by implying that kids can solve this problem by trying harder. That’s not fair and won’t be helpful.

See a urologist At some point, I think it’s a good idea – to rule out very rare anatomical issues, and make sure all medical contributors have been addressed.

And, finally: Focus on the positive. I agree, Josh’s daughter has every right to be upset about this and to want it to stop. And it will stop. I’d pursue some (or all) of the ideas above, while at the same time keeping the conversation positive, non-blamey, and focused on things she does well.


A crisis for our bladders

January 30, 2012

The Pediatric Insider

© 2012 Roy Benaroch, MD

OK, listen up, people: you have to pee, at least every once in a while.

I know, I know. In elementary school, your teacher won’t let you leave class. In middle school, there isn’t enough time between classes. And in high school, well, I guess the thinking is one wouldn’t be caught dead using a toilet or something.

What happens if you don’t empty your bladder? To put in simply, Mr. Bladder doesn’t like staying full all day. Like any other muscle, if you keep it under stress it will get thick and bulky—and that’s a problem for bladders. Thick, bulky bladders can’t empty well. They squeeze too hard, and pinch off the tube that leads out. So when you finally do try to pee, you’ll get maybe just a little out. Not emptying your bladder isn’t good.

I see kids of every age in my office, every week, with these kinds of bladder issues. Running to the bathroom at the last minute, having little accidents (sometimes with laughter or coughing), pain with urination, or a feeling that you have to urinate very frequently—all of these symptoms are most often caused by a habit of not urinating frequently or completely enough. Sometimes, recurring urinary tract infections can happen, too. If you’re in the habit of holding it like a camel, you’re heading for trouble. There’s even a medical name for this: “dysfunctional voiding syndrome.”

So what should you do if you or your child is having these symptoms? Most importantly, make sure there’s unhurried time for complete bladder emptying at least every couple of hours. Don’t rush! Little kids might need something to distract them to slow them down, like a special video game that’s only played on the potty. Older children need to change their mindset: you don’t urinate just long enough to relieve the pressure. You should urinate until you’re completely done—and, to help make sure, you should probably relax and try to urinate again after you think you’re done the first time.

Schools and teachers need to rethink policies that don’t allow kids private, relaxed time to take care of their business. Four minutes between classes wouldn’t be enough time for even The Flash to get to his locker, run though the building to the one clean bathroom with working sinks, and then get back to class. Policies that keep kids squirming in their seats with their legs crossed are idiotic and unhealthy.

Make your bladder gladder. Take time to pee. Your bladder will thank you!

Frequent urination

November 28, 2011

The Pediatric Insider

© 2011 Roy Benaroch, MD

For November, I’m concentrating my writing chops on National Novel Writing Month. Fun! So I’m re-running revised versions of some classic posts. And by classic, I mean “old.” This one was originally from October, 2008—and it has been, consistently, the most-viewed “medical” article I’ve ever posted. Who would have guessed? Enjoy!

Here’s a question from AB: “Our daughter who is almost 5 years old has started a habit of wetting her pants at least once a day. She only wets a little each time and it doesn’t seem to bother her at all – she never tells us that it happened or complain about wet panties. We’ve talked to her continuously about not wetting her pants and tried all types of incentives and punishments, but nothing seems to make her stop. Could this be a medical problem? Or could it be some other behavioral issue such as an attention getter (She has a little brother who is 20 months old)? If this is only behavioral, what are your suggestions that we can use to help her stop?”

I doubt this represents a “medical” problem—she isn’t dribbling continuously or even that frequently, just once or a few times a day. And it doesn’t sound like it’s very likely to be a neurologic problem if she’s running around and otherwise acting normally. However, just to be safe, she does need to see her pediatrician for a simple urine dipstick test for infections or (far, far less likely) diabetes.

The most likely diagnosis for what’s going on is a very common problem among children called “dysfunctional voiding.” I’ve written about this before, but it comes up so often that it’s worth covering again in more detail. First, though, you should probably stop with any kind of incentive or punishment—that’s not going to get you anywhere, and may prolong the problem by making the accidents an attention-getter.

What is dysfunctional voiding?


Dysfunctional voiding is a term for an abnormal pattern of urination. The symptoms can include wetting during the daytime, urinating very frequently, rushing to the bathroom, or sometimes pain with urination. Some children who have these symptoms squat down on their heels, cross their legs or hold themselves between their legs to keep from wetting. Sometimes, children with dysfunctional voiding also start to ignore the urge to have a bowel movement.


How does dysfunctional voiding develop?


For many different reasons, children start holding their urine for a long time. They may be reluctant to stop doing fun activities for a bathroom break, or they might be embarrassed at school to ask for a hall pass. Kids who feel that the bathroom at school is dirty will sometimes hold their urine all day long! Once a child starts holding urine, the bladder wall becomes thicker and less able to empty completely. After a while, children begin to lose the sensation that their bladder is filling until it almost overflows. Though dysfunctional voiding may start because of habits, it does become a physical problem once the body begins these adaptations. Fortunately, these physical changes can be reversed by following good voiding habits.


Dysfunctional voiding with constipation


Children with dysfunctional voiding may also have constipation. When a child is constipated, the rectum may be full of hard stool and can irritate the bladder and keep it from holding as much as it should. Constipation makes the wetting problem worse. You cannot treat the problems of dysfunctional voiding unless you fix the constipation, too.


How is dysfunctional voiding treated?


The most important part of treated is regular bowel and voiding habits. These must be used together in order for this condition to be treated successfully Changing your child’s habits can take a long time. At school, children may need to be reminded to go to the bathroom.

Medicine is not usually needed to help with dysfunctional voiding. Sometimes, a stool softener can help with the constipation that often accompanies dysfunctional voiding.

Timed voiding schedules are a big help. Your child should urinate during the daytime every 2 hours (some children may need to go more often). This schedule will help train your child to empty the bladder before it gets full and begins to leak. It’s a good idea to use a kitchen timer to go off at set intervals, so a parent doesn’t have to be the “bad guy” enforcing trips to the bathroom. Make sure that the bathroom breaks aren’t perceived as a punishment, and that any fun activity that was interrupted for a bathroom break will continue when the child comes back—and doesn’t rush!


How to urinate correctly


It is very important for your child to relax when urinating. Relaxing helps the bladder to empty completely.

  • Girls should remove pants or tights completely off of one leg so that they can spread their legs far apart.
  • Girls should sit way to the back of the toilet and lean forward. Alternatively, girls can sit backwards on a toilet, facing the tank.
  • While establishing good habits, boys should be encouraged to sit to urinate. This prevents rushing.
  • Breathe deeply.
  • Relax the muscles of the head, arms, body and legs.
  • Feet should be on the floor or a footstool, not dangling.
  • Imagine urine flowing (turn water on in the sink).
  • Allow plenty of time for urination. The process of relaxing to empty the bladder takes time. Plan to spend 3-5 minutes in the bathroom.
  • For younger kids, it can be especially helpful to bring a toy. An electronic game that is only used while sitting on the toilet will keep kids sitting for a long time!

Dysfunctional voiding is a common problem encountered in a pediatrician’s office. There are no expensive tests or medicines that need to be used. It’s a matter or re-training good habits. The best way to handle this is with relaxation and good humor—you can’t force it. Fortunately, children who have developed dysfunctional voiding habits can quickly reverse this problem with some gentle support and simple steps.