Nocturnal enuresis

Nocturnal enuresis
nighttime urinary incontinence, sleepwetting, bedwetting
Classification and external resources
ICD-10 F98.0, R32
ICD-9-CM 307.6, 788.36
DiseasesDB 4326
MedlinePlus 003144
eMedicine ped/689
MeSH D053206

Nocturnal enuresis, also called bedwetting, is involuntary urination while asleep after the age at which bladder control usually occurs. Nocturnal enuresis is considered primary (PNE) when a child has not yet had a prolonged period of being dry. Secondary nocturnal enuresis (SNE) is when a child or adult begins wetting again after having stayed dry.

Most bedwetting is a developmental delay—not an emotional problem or physical illness. Only a small percentage (5% to 10%) of bedwetting cases are caused by specific medical situations.[1] Bedwetting is frequently associated with a family history of the condition.[2]

Treatments range from behavioral-based options such as bedwetting alarms, to medication such as hormone replacement, and even surgery such as urethral enlargement. Since most bedwetting is simply a developmental delay, most treatment plans aim to protect or improve self-esteem.[1] Bedwetting children and adults can suffer emotional stress or psychological injury if they feel shamed by the condition. Treatment guidelines recommend that the physician counsel the parents, warning about psychological damage caused by pressure, shaming, or punishment for a condition children cannot control.[1]

Bedwetting is the most common childhood complaint.[3][4] Most girls stay dry by age six and most boys stay dry by age seven. By ten years old, 95% of children are dry at night. Studies place adult bedwetting rates at between 0.5% and 2.3%.[5]


The medical name for bedwetting is nocturnal enuresis. The condition is divided into 2 types: primary nocturnal enuresis (PNE) and secondary nocturnal enuresis.

Primary nocturnal enuresis

Primary nocturnal enuresis (PNE) is the most common form of bedwetting. Bedwetting counts as a disorder once a child is old enough to stay dry, but continues either to average at least two wet nights a week with no long periods of dryness or to not sleep dry without being taken to the toilet by another person.

New studies show that antipsychotic drugs can have a side effect of triggering enuresis.[6]

It has been shown that diet impacts enuresis in children. Constipation and Impacted bowels from poor diet can back up stool in the colon, putting undue pressure on the bladder creating loss of bladder control.[7]

Medical guidelines vary on when a child is old enough to stay dry. Common medical definitions allow doctors to diagnose PNE beginning at between 4 and 5 years old. This type of classification is frequently used by insurance companies. It defines PNE as, "persistent bedwetting in the absence of any urologic, medical or neurological anomaly in a child beyond the age when over 75% of children are normally dry."[8]

Some researchers, however, recommend a different starting age range. This guidance says that bedwetting can be considered a clinical problem if the child regularly wets the bed after turning seven years old.[9] D'Alessandro refines this to bedwetting more than twice a month after six years old for girls and seven years old for boys.[8]

Secondary nocturnal enuresis

Secondary enuresis occurs after a patient goes through an extended period of dryness at night (roughly six months or more) and then reverts to nighttime wetting. Secondary enuresis can be caused by emotional stress or a medical condition, such as a bladder infection.[10]

Psychological definition

Psychologists may use a definition from the American Psychiatric Association's DSM-IV, defining nocturnal enuresis as repeated urination into bed or clothes, occurring twice per week or more for at least three consecutive months in a child of at least 5 years of age and not due to either a drug side effect or a medical condition. Even if the case does not meet these criteria, the DSM-IV definition allows psychologists to diagnose nocturnal enuresis if the wetting causes the patient clinically significant distress.[11]


A review of medical literature shows doctors consistently stressing that a bedwetting child is not at fault for the situation. Many medical studies state that the psychological impacts of bedwetting are more important than the physical considerations. "It is often the child's and family member's reaction to bedwetting that determines whether it is a problem or not."[9]


Whether bedwetting causes low self-esteem remains a subject of debate, but several studies have found that self-esteem improved with management of the condition.[12] Children questioned in one study ranked bedwetting as the third most stressful life event, after parental divorce and parental fighting. Adolescents in the same study ranked bedwetting as tied for second with parental fighting.[12]

Bedwetters face problems ranging from being teased by siblings, being punished by parents, the embarrassment of still having to wear diapers, and being afraid that friends will find out.

Psychologists report that the amount of psychological harm depends on whether the bedwetting harms self-esteem or development of social skills. Key factors are:[13]

Behavioral impact

Studies show that bedwetting children are more likely to have behavioral problems. For children who have developmental problems, the behavioral problems and the bedwetting are frequently part of/caused by the developmental issues. For bedwetting children without other developmental issues, these behavioral issues can result from self-esteem issues and stress caused by the wetting.[13]

As mentioned below, current studies show that it is very rare for a child to intentionally wet the bed as a method of acting out.

Punishment for bedwetting

Medical literature states, and studies show, that punishing or shaming a child for bedwetting will frequently make the situation worse. Doctors describe a downward cycle where a child punished for bedwetting feels shame and a loss of self-confidence. This can cause increased bedwetting incidents, leading to more punishment and shaming.[14]

In the United States, about 25% of enuretic children are punished for wetting the bed.[15] In Hong Kong, 57% of enuretic children are punished for wetting.[16] Parents with only a grade-school level education punish bedwetting children at twice the rate of high-school- and college-educated parents.[15]


Parents and family members are frequently stressed by a child's bedwetting. Soiled linens and clothing cause additional laundry. Wetting episodes can cause lost sleep if the child wakes and/or cries, waking the parents. A European study estimated that a family with a child who wets nightly will pay about $1,000 a year for additional laundry, extra sheets, disposable absorbent garments such as diapers, and mattress replacement.[12]

Despite these stressful effects, doctors emphasize that parents should react patiently and supportively.[17]


Bedwetting does not indicate a greater possibility of being a sociopath, as long as caregivers do not cause trauma by shaming or punishing a bedwetting child. Bedwetting was part of the Macdonald triad, a set of three behavioral characteristics described by John Macdonald in 1963.[18] The other two characteristics were firestarting and animal abuse. Macdonald suggested that there was an association between a person displaying all three characteristics, then later displaying sociopathic criminal behavior.

MacDonald (1963) observed in his most sadistic patients a triad of childhood cruelty to animals, firesetting and enuresis or frequent bed-wetting. Such maladaptive childhood behaviors often result from poorly developed coping mechanisms. This triad, although not intended to predict criminal behavior, provides the warning signs of a child under considerable stress. Children under substantial stress, particularly in their home environment, frequently engage in maladaptive behaviors, such as these, in order to alleviate the stress produced by their surroundings. This is not to say that all children who are under stress and engage in maladaptive behaviors go on to become serial killers, but such behaviors are often observed in the childhoods of established serial killers (Hickey, 2002).[19][20]

Up to 60% of multiple-murderers, according to some estimates, wet their beds post-adolescence.[21]

The MacDonald Triad should be considered a warning sign to parents and authority figures to seek help for a child exhibiting such behaviors.[19][20]

Research has found, however, that enuresis is not associated with sociopathic behavior.[19][20] Enuresis is an "unconscious, involuntary, and nonviolent act and therefore linking it to violent crime is more problematic than doing so with animal cruelty or firesetting".[22]

Bedwetting can be connected to emotional or physical trauma. Trauma can trigger a return to bedwetting (secondary enuresis) in both children and adults. In addition, caregivers cause some level of emotional trauma when they punish or shame a bedwetting child.

This leads to a difficult distinction: it is not the bedwetting that increases the chance of criminal behavior, but the trauma. For example, parental cruelty can result in "homicidal proneness".[23]


The aetiology of NE is not fully understood, although there are three common causes: excessive urine volume, poor sleep arousal, and bladder contractions. Differentiation of cause is mainly based on patient history and fluid charts completed by the parent or carer to inform management options.[24]

The following list summarizes bedwetting's known causes and risk factors. Enuretic patients frequently have more than one cause or risk factor from the items listed below.[8]

Most cases of bedwetting are PNE-type, which has two related most common causes

These first two items are the most common factors in bedwetting, but current medical technology offers no easy testing for either cause. There is no test to prove that bedwetting is only a developmental delay, and genetic testing offers little or no benefit.

As a result, other conditions should be ruled out. The following causes are less common, but are easier to prove and more clearly treated:



Two physical functions prevent bedwetting. The first is a hormone that reduces urine production at night. The second is the ability to wake up when the bladder is full. Children usually achieve nighttime dryness by developing one or both of these abilities. There appear to be some hereditary factors in how and when these develop.

The first ability is a hormone cycle that reduces the body's urine production. At about sunset each day, the body releases a minute burst of antidiuretic hormone (also known as arginine vasopressin or AVP). This hormone burst reduces the kidney's urine output well into the night so that the bladder does not get full until morning. This hormone cycle is not present at birth. Many children develop it between the ages of two and six years old, others between six and the end of puberty, and some not at all.

The second ability that helps people stay dry is waking when the bladder is full. This ability develops in the same age range as the vasopressin hormone, but is separate from that hormone cycle.

The typical development process begins with one- and two-year-old children developing larger bladders and beginning to sense bladder fullness. Two- and three-year-old children begin to stay dry during the day. Four- and five-year-olds develop an adult pattern of urinary control and begin to stay dry at night.[1]


Thorough history regarding frequency of bedwetting, any period of dryness in between, associated daytime symptoms, constipation, encopresis should be sought.

Voiding diary

Physical examination


There are a number of management options for bedwetting. The following options apply when the bedwetting is not caused by a specifically identifiable medical condition such as a bladder abnormality or diabetes. Treatment is recommended when there is a specific medical condition such as bladder abnormalities, infection, or diabetes. It is also considered when bedwetting may harm the child's self-esteem or relationships with family/friends. Only a small percentage of bedwetting is caused by a specific medical condition, so most treatment is prompted by concern for the child's emotional welfare. Behavioral treatment of bedwetting overall tends to show increased self-esteem for children.[43]

Parents become concerned much earlier than doctors. A study in 1980 asked parents and physicians the age that children should stay dry at night. The average parent response was 2.75 years old, while the average physician response was 5.13 years old.[44]

Punishment is not effective and can interfere with treatment.


Simple behavioral methods are recommended as initial treatment.[45] Enuresis alarm therapy and medications may be more effective but have potential side effects.[45]

Condition management

Plastic pants suitable for nocturnal enuresis in larger child or small adult



Most girls can stay dry at night by age six and most boys stay dry by age seven. Boys are three times more likely to wet the bed than girls.[5][55]

Doctors frequently consider bedwetting as a self-limiting problem, since most children will outgrow it. Children 5 to 9 years old have a spontaneous cure rate of 14% per year. Adolescents 10 to 18 years old have a spontaneous cure rate of 16% per year.[56]

Approximate bedwetting rates are:

As can be seen from the numbers above, a portion of bedwetting children will not outgrow the problem. Adult rates of bedwetting show little change due to spontaneous cure. Persons who are still enuretic at age 18 are likely to deal with bedwetting throughout their lives.[56]

Studies of bedwetting in adults have found varying rates. The most quoted study in this area was done in the Netherlands. It found a 0.5% rate for 18- to 64-year-olds. A Hong Kong study, however, found a much higher rate. The Hong Kong researchers found a bedwetting rate of 2.3% in 16- to 40-year-olds.[56]


An early psychological perspective on bedwetting was given in 1025 by Avicenna in The Canon of Medicine:[57]

"Urinating in bed is frequently predisposed by deep sleep: when urine begins to flow, its inner nature and hidden will (resembling the will to breathe) drives urine out before the child awakes. When children become stronger and more robust, their sleep is lighter and they stop urinating."

Psychological theory through the 1960s placed much greater focus on the possibility that a bedwetting child might be acting out, purposefully striking back against parents by soiling linens and bedding. However, more recent research and medical literature states that this is very rare.[58][59]

See also


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