Bedwetting and daytime incontinence in children.

At five years old, 10 to 20% of children are not yet toilet trained

Sandra, a 32-year-old divorced mother, is exasperated: "Christophe, my 7-year-old son, still wets the bed three or four times a week! I'm fed up with all the sheets I have to wash and I don't even want to think about what it will be like at my mother's house this summer." Annoying, certainly. Worrying, probably. However, bedwetting isn't necessarily serious, and it's actually very common. In fact, 10 to 20% of children haven't yet achieved nighttime dryness by age 5. This is still the case for 6 to 8% of 8-year-olds, and even for 1% of young adults of military service age! Indeed, bladder function, like walking or talking, requires learning for the child because this organ is subject to automatic, voluntary control, and not just reflex.

“For about two years, an infant’s bladder is completely automatic,” explains Dr. Pamela Parvex, who treats many young patients with enuresis (bedwetting) at the Nephrology Unit of the Geneva Children’s Hospital. Then, during a second phase of maturation, the child gradually becomes aware of their bladder filling and learns to voluntarily contract the sphincter that controls its opening, thus allowing urine to flow. Finally, the bladder becomes fully adult and increases in size.

So you have to be... patient. "Daytime dryness is normally achieved before the age of 4. But bedwetting until 4 or 5 years old in girls and until 5 or 6 years old in boys is not pathological," explains Dr. Parvex.

Two types of enuresis

In children, two types of enuresis are classically distinguished, the causes of which remain incompletely understood. In approximately 70% of cases, it is simply bedwetting (isolated nocturnal enuresis). This problem could be due to a deficiency in nighttime secretion of antidiuretic hormone (the hormone that retains water in the body), or to the difficulty some children have in feeling the urge to urinate while sleeping.

For the remaining 30%, bedwetting occurs during the day due to bladder immaturity. The child experiences urgency or even leakage. They frequently go to the toilet to pass a few drops of urine and have difficulty emptying their bladder. In this case, the bladder, abnormally active, contracts too frequently and uncontrollably, like that of a very young child. "It's important to look for these urinary problems during the day in a child who wets the bed, because these symptoms don't have the same treatment as nocturnal enuresis, and sometimes (though fortunately rarely) they are associated with abnormalities of the urinary tract (for example, valves in the urethra). This is why we perform some check-up tests in the hospital (urine analysis, ultrasound)," emphasizes Dr. Parvex. "The frequency of these daytime enuresis is probably underestimated," she adds.

Bedwetting: a family problem?

Isolated bedwetting often has a familial component, and it is estimated that a child's risk of developing it is 77% if both parents were affected and 44% if only one parent was. It is more common in boys, unlike daytime enuresis, which affects both sexes equally. "Before making this diagnosis, however, it's essential to verify that the child isn't simply afraid of getting up at night or getting out of bed if it's a bunk bed," notes Dr. Parvex. These bedwetting problems are often observed around the time of the birth of a sibling, a move, difficulties at school—in short, when the child is stressed.

“Managing these bedwetting episodes is less difficult than daytime enuresis,” explains Dr. Parvex. “At the hospital, we check to rule out a very rare condition, diabetes insipidus, which results from a lack of antidiuretic hormone.” Otherwise, the child should be advised not to drink too much in the evening and to urinate before going to bed. Parents can also wake the child when they themselves go to bed to take them to the toilet. After age 7 for boys and 6 for girls, desmopressin tablets (Minirin), a medication that mimics the action of the antidiuretic hormone, can be administered at bedtime. This therapeutic approach is more readily adopted if the child is suffering significantly psychologically from their bedwetting, or if they are going away for a while to summer camp.

The bedwetting alarm, which sounds as soon as a few drops of urine are released in pajamas, can have a dramatic effect on children over 9 years old and has the advantage of requiring the young patient's participation. "When you put it on, you absolutely must remove the diapers. Otherwise, it won't work!" advises Dr. Parvex.

What to do about daytime enuresis?

“Before the age of 5, we will simply use behavioral measures. For example, parents will ask the child to go to the toilet every three or four hours, even if they don’t feel the urge to urinate, after checking that the toilet is suitable (a booster seat can be helpful) and that they are not afraid of falling into the hole. Which is common,” says Dr. Parvex.
Young boys are often advised to urinate sitting down , which helps them empty their bladders. After the age of 5 or 6, and if the young patient is psychologically mature enough, rehabilitation techniques (or "biofeedback") can be prescribed to help them better control their sphincters and abdominal muscles. Anticholinergic medications are often added to reduce bladder contractions. Finally, it is important to address any associated constipation.

It is also a good idea to opt for a vibrating watch that will regularly and discreetly remind the child when they need to go to the toilet.

Tips and tricks

There's no point in scolding your child, and above all, avoid comparing them to their siblings. "Psychological factors often underlie bedwetting, and in some cases, psychotherapy can help these children. There's no need to worsen the problem by making them feel guilty," explains Andrée, who has encountered the issue as both a pediatrician and a mother. "But it's true that bedwetting is often difficult for parents, while some children suffer greatly from it, others cope more or less well."

Asking a child to wash their own sheets might seem a bit harsh, especially if they're young! However, you could help them keep a calendar of nights with and without sun. Some people are against diapers (which will be replaced by pajama pants for older children). This is something to consider (why not discuss it with your child?), as waking up wet is hardly pleasant. But of course, absorbent bed pads are essential. Remind your child to use the toilet in the evening and check that it's easily accessible and fits properly.

Why not also put in nightlights to make it easier to move around at night in the house or apartment, or install a chamber pot at the foot of the bed?

Finally, don't hesitate to talk to your doctor, especially if the problem persists or if your child experiences any difficulties during the day. They can check for any urinary abnormalities or associated infections. If the child is drinking excessively and is thirsty, a prompt consultation is necessary, as this could be a sign of diabetes.