By Steve Hodges, M.D.
Virtually every bedwetting patient in my clinic was assured by a pediatrician or urologist that on some magical day in the future, he or she would wake up dry, never to wet the bed again.
As the mom of a 16-year-old patient told me, “Every year, through age 5, 8, 10, 14, the pediatrician kept saying, ‘Don’t worry, he’ll grow out of it.”
Parents in our Facebook support group report receiving the same “reassurance.”
One mom posted: “Starting when my son was age 6, we were repeatedly told by two different family practitioners, “This happens. Don't worry, he'll outgrow it. A few comments that stand out in my memory: ‘When he really wants to stay dry he will." And: "Just wait till he really wants to sleep over at a friends' house. Suddenly he won't want all this attention anymore."
This boy is now 11 years old and still wetting the bed.
Another mom posted: “We were told every year at our son’s physical that he would outgrow it.
Finally, I took my son’s bedwetting into my own hands. A 15-year-old is not going to outgrow bedwetting!!”
She is right.
In fact, without appropriate treatment, even a 9-year-old is unlikely to outgrow bedwetting, research suggests — especially if the child wets nightly and has daytime symptoms.
Yet pediatricians, as well as my fellow pediatric urologists, often ignore the red flags and implore families not to worry.
But, of course, parents do worry! Because for many children, bedwetting (and daytime accidents) are a nightmare right now. These kids get teased by peers, skip sleepovers or camp, and get down on themselves. Meantime, their parents feel exhausted from the laundry and emotionally drained. Extra-large pull-ups aren’t cheap, either. These folks are tired of waiting around for that breakthrough day when their child will outgrow bedwetting.
I wish more physicians would advise parents of the reality: For some children, that day will not come. And instead of waiting to find out, families should take aggressive action now. That's the thinking behind our new free download, "Bedwetting: 4 Truths Every Parent Must Know."
Yes, it is true that most bedwetting children do spontaneously stop — eventually. But “most” is not “all.” And many children wet the bed for 4 or 5 years longer than they would have if only they’d been treated appropriately for the underlying constipation that causes virtually all bedwetting.
Let’s look at some numbers. In a study of more than 16,000 children, researchers in Hong Kong found that at age 5, 16% of children wet the bed, a finding consistent with studies conducted in other countries. (The American Academy of Pediatrics estimates 20% of U.S. 5-year-olds wet the bed.) With each successively older group surveyed, the percentage of bedwetters dropped — until it didn’t. After age 8, the drop-off was small; after age 10, it vanished. In other words, the percentage of kids wetting at age 11 — 2% — was the exact same as the percentage of adults who wet the bed.
Consider the percentage of children who wet the bed at each age:
Age 5: 16%
Age 6: 13%
Age 7: 10%%
Age 8: 6%
Age 9: 3%
Age 10: 2.6%
Age 11: 2%
Now let’s fast-forward:
Age 17: 2%
Age 18: 2%
Age 19: 2%
Two percent of children may sound negligible — the American Academy of Pediatrics downplays this data point, noting that “only 2% to 3% of children continue to have problems with bedwetting as adults.” But that translates to about 840,000 U.S. teens and tweens (bedwetting rates are pretty comparable in developed countries worldwide), not to mention well over 2 million American adults.
Physicians will tell families, “No one goes off to college wetting the bed,” but it’s just not true.
My clinic at Wake Forest is filled with kids in the unlucky 2%, and let me tell you, being a member of that group is a huge bummer. You can hear from teens themselves in “Teenage Bedwetting: Everything You’ve Been Told is Wrong.”
I find it frustrating that so many children are left untreated year after year, especially because there are signs, early on, that indicate these kids are unlikely to get better without treatment.
In this regard, the Hong Kong findings parallel what I’ve observed in my clinic: Tweens and teens with enuresis tend to have very significant symptoms. Most of them wet every night, and many have daytime accidents, too.
The Hong Kong researchers concluded, “In general, enuretic symptoms in the adolescent subjects were more severe than those in children.” At age 5, only 14.3% of bedwetting children wet 7 nights a week; among bedwetting 19-year-olds, they found, 48% wet every night.
What’s more, among the bedwetting boys age 5 to 10, 14.6% also had daytime wetting, whereas among tweens and teens, 32% had daytime accidents.
The researchers didn’t track children over time; instead, they got a one-time snapshot of children ages 5 to 19. But from their data, it’s clear that children who wet every night and/or have daytime accidents are most likely to fall into the group whose symptoms do not spontaneously resolve. And you can reasonably assume that kids who wet the bed infrequently as kindergarteners are the ones most likely to outgrow the condition.
If you do some fancy statistical math based on that assumption and the Hong Kong data, you can see that a 9-year-old who wets the bed has about a 70% chance of becoming a 19-year-old who wets the bed. Given those odds, who would want to wait around?
As the Hong Kong researchers concluded, the notion that bedwetting will spontaneously resolve with age “probably applies only to those with mild enuretic symptoms” — in other words, kids who wet the bed infrequently. Furthermore, they wrote, bedwetting children with more severe symptoms have a “significantly greater chance of persistent [bedwetting] in adult life.”
These researchers argued that bedwetting children with “very severe symptoms” should begin active treatments “at a much earlier age.” Based on my own clinical experience and research, I would take that recommendation up a few notches: I think all children who wet the bed should receive aggressive treatment starting at age 4.
Furthermore, any toilet-trained child who has daytime accidents — and any child who struggles with potty training — should receive aggressive treatment for constipation. Accidents in toilet-trained children are absolutely not normal, despite the insistence to the contrary of many pediatricians. Both pee and poop accidents, as well as extreme urgency and frequency, signal trouble to come.
Nobody wins when families wait it out. As one mom in our Facebook support group posted: “Our younger son has been wet through the day and night since age 3. We were told it was normal that he was wetting multiple times per day, every day. When he was 4.5, his doctor referred us to a pediatric urologist, and we are still struggling with his daytime wetting 4 years later.”
Treat Bedwetting Early and Aggressively
One reason physicians advocate waiting is that they aren’t familiar with what really causes bedwetting and daytime accidents. They’ll tell parents a child’s “bladder hasn’t caught up to his brain,” that it’s just a genetic problem, or that the child is being “lazy” or stubborn.
If you believe these explanations or others advocated by the American Academy of Pediatrics, then naturally you will assume there’s nothing to do but wait. Problem is, these explanations don’t hold water.
Based on studies involving X-rays and anal manometry, it’s clear that nearly all bedwetting and daytime accidents have the same cause: chronic constipation. Yes, genetics may play a role, but my patients whose parents wet the bed are shown by X-ray to be severely constipated — same as children whose parents have no history of bedwetting. It may well be the tendency toward constipation, rather than the bedwetting itself, that is genetic.
At any rate, since the most effective bedwetting treatment — daily enemas for at least 30 days before tapering (the Modified O’Regan Protocol, aka M.O.P.) — requires no drugs, has a high success rate, and is not costly, at least compared to years of pull-ups, I see no reason for families to wait it out.
By contrast, there is very good reason to attack the problem immediately, since the longer a child’s rectum remains stretched and bladder nerves remain aggravated, the harder it is, generally, to resolve the constipation and the wetting.
Many parents are stunned when X-rays show their tweens and teens remain constipated even after months of daily enemas. Yes, months. (And yes, daily enemas are safe.) Several families I work with have had to switch from enemas to the Peristeen pump, a prescription “anal irrigation system” that is essentially an enema on steroids. This device was designed for children with neurogenic bowel, meaning they lack the nervous-system control to poop on their own, due to spina bifida, spinal cord injury, or other condition. It takes a lot of persistence to get insurance to cover this device when your child has no anatomical abnormality — just a propensity toward severe constipation.
The older children I treat tend to have a long history of constipation that went either unrecognized or was inadequately treated, typically with endless doses of Miralax. I feel certain that if they’d been aggressively treated at age 4, they would not be struggling with bedwetting and accidents in 9th grade.
But few doctors are willing to treat 4-year-olds for bedwetting. Most won’t even consider treatment until at least age 7. As one mom in our support group posted: “A pediatrician told my 7-year-old not to be concerned until age 11 or 12 because there are such great pull-up-type products available nowadays.”
Why Some Kids Don’t Outgrow Bedwetting
Naturally, these unlucky families wonder: Why do some kids outgrow bedwetting while others don’t?
It’s impossible to know for sure, but I believe some kids’ bladders are inherently more sensitive when squished by a stretched, poop-stuffed rectum. In other words, one child’s bladder may spasm and empty when her rectum is stretched to 4 cm, slightly beyond the normal measurement of less than 3 cm) whereas another child may not experience wetting unless her rectum is stretched to 7 cm and is more severely encroaching upon the bladder.
The child with the less sensitive bladder may stop wetting with minor improvements in constipation that happen naturally, as children mature and start going to the bathroom when they need to. Maybe a child gets accustomed to using the school bathroom or has a teacher with a more liberal bathroom policy. Maybe with age she becomes a less picky eater. Who knows? There are lots of reasons kids might become less constipated and therefore less prone to bedwetting.
Bottom line: Whether bedwetting stops better sooner or later, I believe, depends on how much the rectum is stretched and how sensitive the child’s bladder is to that stretch.
Even if a child is genetically “programmed” to quit wetting at age 7 or 8, it is clear that with treatment such as M.O.P. he can stop wetting before kindergarten.
While it’s not fun for anyone to implement a daily enema regimen, the process quickly becomes routine, kids feel so much better, and, most importantly, the wetting stops. So again, why wait?
I work with many families who wish they’d been alerted earlier that outgrowing accidents and bedwetting is not a sure thing. As one mom in our support group posted:
“Right before my daughter turned 4, she started having daytime urgency and accidents that she hadn't had since she had potty trained the year before. The doctor assured me it was normal and said she was probably stressed about something. He even had the nerve to ask me how often I was yelling at her. It took me nine more months before I really started looking into it and discovered the problem. It would have been so much easier to fix back then.”