Child & Family Development Child & Family Development

March 4, 2021

Nocturnal Enuresis

Nocturnal Enuresis: Nighttime Bedwetting 

By: Sam Develli, OTR/L

Bedwetting: What is it?

Bedwetting, or nocturnal enuresis, is “the state in which a child after the age of five has no control of his/her urine for six continuous months and it cannot be attributed to any organic factors or drug use” (Salehi, Yousefichaijan, Rafeei, & Mostajeran, 2016). This condition can be broken down into two different types. Primary bedwetting refers to a child who has never remained dry throughout the night (Cleveland Clinic, 2019). Keep in mind that bedwetting is not an uncommon occurrence for children up until the age of 7 years (Case & O’Brien, 2015). Secondary bedwetting refers to a child who started wetting the bed after remaining dry for at least 6 months. Secondary is of more concern as it is more likely to be caused by a medical or psychological condition (Cleveland Clinic, 2019).

A Bit of Background

A newborn infant voids reflexively and involuntarily. It isn’t until myelination of the spinal tract in the low back occurs, that an infant gains the ability to control their bowel & bladder. Further, they learn to control sphincter reflexes for volitional holding. This typically occurs at 1 year for bowel and 1 ½ years for bladder control.

Regulated toileting with occasional daytime accidents typically occurs by 35 months. By 2 ½ years, most children will wake up dry at night. Most children can go to the bathroom independently by 3 years and achieve full independence in toileting around 4-5 years old (manage fasteners, flush, wipe effectively, wash hands, tear toilet paper, etc).

Causes

Always consult your PCP first to rule out any medical causes of bedwetting.

  • Medical conditions: This could include a hormone imbalance, infection, diabetes, sleep apnea, neurologic problems, kidney/bladder abnormalities, sickle cell disease, or chronic constipation.
  • Trauma: Emotional trauma or physical trauma can result in bedwetting. Sexual trauma may also cause nocturnal enuresis. Other signs of sexual trauma include frequent urinary tract infections, pain, itching, unusual discharge, or presence of a sexually transmitted disease.
  • Anxiety: Relationships between generalized anxiety disorder in children and nighttime bedwetting is not uncommon.
  • Stress: Bedwetting may also be caused by emotional stress caused by traumatic disruptions in a child’s normal routine (i.e. moving to a new home, enrolling in a new school, death of a loved one). These episodes typically become less frequent over time.
  • PTSD: Events resulting in post traumatic stress disorder, like after a car crash or abuse.
  • Lack of integration of the Spinal Galant Infant Reflex:
    • Primitive reflexes are typically present at or shortly after birth to assist with the birthing process and control the infant’s movement in their first few months of life in order to explore environment and develop higher-level voluntary motor & sensory skills. These reflexes should be mostly integrated (i.e. put to sleep) and replaced with higher level voluntary movement patterns by the child’s first birthday. However, sometimes these reflexes do not integrate properly and the child remains stuck in this primitive reflexive movement pattern. This sometimes occurs due to neurological conditions, but they are increasingly observed in the general population and often attributed to learning and behavioral challenges during grade school.
    • The spinal galant reflex is present at birth and integrates (replaced by higher-level, voluntary motor reactions) around 2 months. This reflex is believed to occur in order to assist the baby with positioning (such as positioning head downward) during the birth process. It also forms the basis for lateral (side-to-side) abdominal movement needed for trunk stabilization.
    • This reflex influences development such as postural control, stability, flexibility, and spine movement. Additionally, given the impact on postural control which significantly impacts vision, hearing, and attention, a lack of integration can ultimately impact daily living and classroom skills such as reading from the board. Finally, the impact on stability, control, and spinal movement then impacts bladder and bowel control, contributing to delays in achieving toileting independence.
    • Light pressure applied to the low back stimulates this reflex. Pressure from sheets or pajamas can stimulate and cause involuntary voiding while sleeping, leading to the presence of nighttime bedwetting.
  • Sensory Processing Challenges:
    • Children with sensory processing challenges often train later than other children, but may train early due to the sensations of a soiled diaper bothering them (Biel & Peske, 2009)
    • Interoception- identifying and interpreting internal body awareness such as when your bladder is full or you are hungry
      • Typically a challenge with deep sleepers- do not awaken to signals from full bladder/have not yet learned to respond to these internal signals (Cleveland clinic, 2019)
    • Vestibular- how the body handles movement
      • helps interpret head/body orientation to maintain equilibrium- provides sense of emotional & physical security when moving in space
      • stabilizes visual field by fixing eyes as head/neck move; strongly influences muscle tone/body posture- telling muscles how much they need to contract at any given time to stay upright and move against the constant downward pull of gravity
    • Smell – oversensitive to smells in bathroom, might avoid
    • Sound – oversensitive to sound of toilet flushing or water running
    • Tactile – oversensitive to feel of urination/defecation or under sensitive and seeks input via voiding in diaper to understand body processes
  • Behaviors: Sometimes habit or fear-based behaviors can impact the continuation of bedwetting in the absence of other causes.

What can I do?

Based on the area(s) of toileting impacted by limitations, specific approaches such as behavioral approaches, routines, or addressing weakness/decreased coordination can be employed by an occupational therapist to increase toileting independence. The occupational therapist can work with you to analyze the steps of the toileting routine, identify those that are causing challenges for your child and develop a unique approach for your child to ultimately increase independence. Remember that nighttime bedwetting is not done on purpose, so never punish, scold, or ridicule a child who wets the bed!

  • Limit fluids at least 2 hours before bedtime, but ensure your child has plenty to drink during the day
  • Use the bathroom before bedtime- sometimes 2x (once during nighttime routine, once right before falling asleep)
  • Pelvic floor strengthening
  • Bladder therapy (we have physical therapist’s who specialize in this area!)
  • Waking child at set times during the night
  • Integration for the spinal galant reflex (if present) by a trained therapist
    • ‘snow angels’
    • Log rolling
  • Wearing loose clothing like cotton elastic-waist pants or boxer shorts help child realize when he/she has the urge to go- tight clothing often distracts from the need to go
  • Behavioral approach using a device called a bell and pad- pad senses wetness that triggers a bell to wake up the child
  • Double-make the bed with rubber mattress pad or sheet on the bottom

The first step to freedom from nighttime bedwetting is determining the cause! Contact our office if you are interested in scheduling an evaluation with a trained therapist to narrow down the cause of causes of your child’s bedwetting.

References:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5097340/

https://my.clevelandclinic.org/health/diseases/15075-bedwetting#:~:text=Psychological%20or%20emotional%20problems%3A%20Emotional,become%20less%20frequent%20over%20time.

Case-Smith, J., & O’Brien, J.C. (2015). Occupational Therapy for Children and Adolescents (7th Ed). Mosby.

Biel, L., & Peske, N. (2009). Raising a Sensory Smart Child: The Definitive Handbook for Helping Your Child with Sensory Processing Issues. Penguin Books Ltd.

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