Bedwetting

Disease Description (Causes and Symptoms)

• Definition: A condition in which a person cannot control urination during sleep after the age of 5 (nocturnal enuresis). Enuresis occurring at least twice a week is generally considered as a diagnostic criterion (reflecting the provided evidence).
• Classification: Primary (has never achieved urinary continence since birth) / secondary (recurs after maintaining urinary continence for at least 6 months). Most cases are primary.
• Main causes (pathophysiology summary):
  • Genetic predisposition (the incidence in children increases when there is a parental history; related gene locations have been reported)
  • Delayed bladder function (maturation) → insufficient bladder capacity at night
  • Insufficient nighttime secretion of antidiuretic hormone (ADH) → excessive urine production during sleep (nocturnal polyuria)
  • Arousal disorder (difficulty waking up) contributes in some cases
  • Rarely, structural urinary tract diseases (urethral stricture, bladder or ureter abnormalities, etc.)
• Main symptom: Inability to control urination during sleep (most cases are simple nocturnal enuresis without daytime symptoms). If daytime urinary incontinence, frequent urination, a weak urine stream, constipation, or recurrent urinary tract infections occur together, structural or complicated findings should be suspected.

Treatment Methods

• General principles: Cooperation from the family and patient is important. Punishment should be avoided, and positive reinforcement is recommended (praise and rewards). Recommended timing for starting treatment: generally after age 5 or before entering elementary school. The rate of spontaneous improvement is approximately 15% per year (based on the source data).
• Behavioral therapy (first-line recommended treatment)
  • Enuresis alarm (alarm therapy): A sensor detects moisture and triggers an alarm → formation of a conditioned reflex. Effective from around age 6–7 and older (high complete remission rate after treatment and low relapse rate). Treatment for several months (e.g., 6 months) is required. Continued cooperation from the family is essential.
  • Lifestyle habits: Restrict fluids after the evening, urinate before bedtime, manage constipation, and practice regular urination (keep a voiding diary during daily life)
  • Motivation/reinforcement: A reward system such as stickers and praise on successful days
• Medication therapy
  • Desmopressin (an antidiuretic hormone analogue): Effective for nocturnal polyuria. An effectiveness rate of 60–80% has been reported among all patients. Relapse is common after discontinuation. Fluid intake must be restricted to prevent hyponatremia.
  • Imipramine (a tricyclic antidepressant): Used in the past; reported to be effective in approximately 60–70% of cases, but the likelihood of relapse after discontinuation is high. Caution is required because of cardiotoxicity and adverse effects (including anticholinergic effects); electrocardiography is recommended, among other measures. Recent guidelines recommend cautious use as an adjunctive treatment.
  • Oxybutynin (a parasympathetic nervous system inhibitor): Mainly used when daytime symptoms (overactive bladder, frequent urination, urinary urgency and incontinence, etc.) are also present. It may cause side effects such as dry mouth, constipation, and flushing.
• Indications for detailed testing and specialist treatment
  • If complicated findings are present (daytime urinary incontinence, frequent urination, a weak urine stream, residual urine, chronic constipation, recurrent urinary tract infections, etc.), tests such as urinalysis, kidney and bladder ultrasonography, voiding cystourethrography (VCUG), and urodynamic testing are performed to differentiate and treat structural diseases.
• Complications and precautions
  • Medication side effects: Desmopressin → hyponatremia (risk of vomiting and seizures)—avoid excessive nighttime fluid intake while taking the medication. Imipramine → electrocardiographic abnormalities and adverse effects (drowsiness and anticholinergic symptoms); use cautiously in children. Oxybutynin → anticholinergic side effects.
  • Psychosocial effects: Possible low self-esteem, shame, and social anxiety—emotional support is important.
• Prognosis: High rate of spontaneous improvement (approximately 15% improve each year); approximately 1% remain affected at around age 15 (based on the source data).

Checklist Before an Outpatient Visit (Items to Bring, Records, Test Results, etc.)

• Items/documents to prepare or submit:
  • A list of medications currently being taken (including prescription and nonprescription medications)
  • Past medical and surgical history, and family history of enuresis (parents and siblings)
  • Recent urinalysis, ultrasonography, electrocardiography, and other results, if available
• Records for the patient and family to complete (recommended before the visit):
  • Voiding diary (at least 7 days): number of daytime and nighttime voids, number of days with enuresis (weekly frequency), times and amounts of fluid intake, and presence of constipation (frequency and characteristics of bowel movements)
  • Sleep pattern (bedtime and whether the patient wakes up), and response records when using an alarm
• Symptoms to tell the doctor about during the visit: daytime urinary incontinence, frequent urination, changes in the urine stream (weakness or interruption), sensation of residual urine, recurrent urinary tract infections, constipation, and signs of neurological abnormalities (such as abnormal leg function).

Examples of General Questions to Ask the Doctor

• "What are the expected effects and side effects of this medication (e.g., desmopressin)?"
• "Are there any precautions regarding the amount of fluid intake or any contraindications while taking the medication?"
• "What preparations does the family need to make to try alarm therapy? How long does it usually take?"
• "Does my child need additional tests (such as ultrasonography or urodynamic testing)? If so, why are they needed?"
• "What is the prognosis, and how high is the risk of relapse after stopping treatment?"

Examples of Disease-Specific Questions

• "What tests are used to determine whether my child produces a large amount of urine at night (nocturnal polyuria)?"
• "My child sometimes wets themselves during the day (or is constipated). If these symptoms are present, what additional tests should be performed?"