What is the cause of nocturnal enuresis (bed wetting) in a 7-year-old child?

From the Guidelines

Bedwetting at age 7 should be addressed with a comprehensive approach that includes behavioral modifications and potentially medication, while prioritizing the child's psychological well-being and avoiding punitive measures, as emphasized by the International Children's Continence Society 1.

Initial Evaluation

When dealing with bedwetting (nocturnal enuresis) in a 7-year-old, it's crucial to start with a thorough evaluation to rule out underlying medical conditions that could be contributing to the issue, such as urinary tract infections, diabetes, or sleep apnea, as suggested by the standardization document from the International Children's Continence Society 1. A good case history is essential, focusing on voiding habits, symptoms like urgency, and any history of daytime incontinence or urinary tract infections.

Behavioral Approaches

Treatment should commence with behavioral approaches:

• Limit fluids 1-2 hours before bedtime to reduce nighttime urine production.
• Ensure regular bathroom visits before sleep to train the bladder.
• Use a bedwetting alarm that awakens the child when moisture is detected to condition the child to wake up when they feel the sensation of a full bladder.
• Implement a reward system for dry nights to encourage motivation and positivity.

Medication and Further Intervention

Medications like desmopressin (DDAVP) are typically reserved for situations where behavioral approaches are not effective or for temporary use, starting at a dose of 0.2mg at bedtime, as it helps reduce nighttime urine production 1. It's also important to address any comorbid conditions, such as constipation, which can impact the success of treatment for enuresis.

Psychological Support

Avoid punishing or shaming the child, as bedwetting is involuntary and such actions can worsen the situation by increasing anxiety and negatively impacting the child's self-esteem. Most children outgrow bedwetting naturally as their bladder capacity increases and brain-bladder communication matures. Protective underwear can help manage the situation while working on treatment, and maintaining a supportive attitude is crucial, as stress and anxiety can exacerbate the problem.

Key Considerations

• Comprehensive Evaluation: Rule out medical causes and assess for comorbid conditions.
• Behavioral Modifications: First line of treatment.
• Medication: Reserved for when behavioral approaches fail or for temporary use.
• Psychological Support: Critical for the child's well-being and treatment success. Given the emphasis on a supportive and non-punitive approach by the International Children's Continence Society 1, it's clear that addressing bedwetting at age 7 requires a multifaceted strategy that prioritizes the child's overall well-being.

From the Research

Definition and Prevalence of Bed Wetting

• Nocturnal enuresis, also known as bed wetting, is defined as nighttime urinary incontinence occurring at least twice weekly in children five years and older 2.
• Approximately 10% of 7-year-old children wet the bed regularly during sleep 3.
• The prevalence of bed wetting decreases with age, with around 0.8% of girls and 1.6% of boys aged 15-16 years wetting at least once every 3 months 4.

Causes and Types of Bed Wetting

• Bed wetting can be categorized into monosymptomatic (MEN) and nonmonosymptomatic (NMEN) forms 3.
• Monosymptomatic enuresis is characterized by nighttime bedwetting without daytime urinary incontinence 2.
• Nonmonosymptomatic enuresis is associated with dysfunction of the lower urinary tract with or without daytime incontinence 3.
• The pathophysiology of primary monosymptomatic nocturnal enuresis may be due to sleep arousal disorder, overproduction of urine, small bladder storage capacity, or detrusor overactivity 2.

Diagnosis and Treatment of Bed Wetting

• A careful clinical history is fundamental to the evaluation of enuresis 3.
• Diagnostic procedures include medical history and psychological screening with questionnaires, bladder and bowel diary, physical examination, urinalysis, ultrasound, and examination of residual urine 3.
• Treatment should begin with behavioral modification, which then progresses to enuresis alarm therapy and oral desmopressin 2.
• Enuresis alarm therapy is more likely to produce long-term success, while desmopressin yields earlier symptom improvement 2, 5.
• Children with nonmonosymptomatic enuresis should first receive treatment for the underlying daytime functional bladder problem before treatment of nocturnal enuresis 3.