By Steve Hodges, M.D.
I have a Google alert set for “bedwetting” so I can stay current on how nocturnal enuresis is described in the media. In general: not accurately!
As a result, parents are steered in the wrong direction, and kids miss out on bedwetting treatments that will actually resolve the accidents.
The other day, Google sent me an article I found particularly disheartening, because it advocated treatments that aren’t just useless but typically do more harm than good. These strategies, based on a faulty understanding of enuresis, include “rewarding dry nights” and “bladder training.”
Below, I explain why these and other common treatment approaches can backfire and what to do instead.
Rewarding Dry Nights
Sticker charts, extra screen time, and even praise for dryness are problematic because the underlying message to the child is: Staying accident-free is within your control.
But it’s not!
Parents would never reward their children for, say, overcoming asthma or the flu. It’s obvious that children cannot control what allergens or germs waft in their orbit or how their bodies react to these invaders. So, it would be silly to incentivize kids for something they have no power to achieve. Rewards would just set kids up for failure.
That’s exactly what happens when parents try to incentivize kids for staying accident free. Kids get the message they have failed and need to try harder. In response, some children feel extra shame and try to hide the accidents from their parents.
In reality, accidents are not caused by a lack of effort to stay dry but rather by an overactive bladder, a condition driven by chronic constipation. More specifically, the child’s clogged rectum stretches to the extent that it encroaches upon the bladder and aggravates the bladder nerves.
As a result, the bladder randomly and forcefully contracts, emptying without warning. When this happens overnight, it’s called nocturnal enuresis; when it happens during the daytime, it’s called diurnal enuresis. Either way, children cannot prevent these accidents any more than they can prevent a hiccup or sneeze, so rewards accomplish nothing.
After all, overactive bladders do not respond to the promise of extra screen time or treats!
It’s important for parents to reinforce to their children that enuresis is not their fault and to explain why the accidents are happening, as I do in my children's books Bedwetting and Accidents Aren't Your Fault and Emma and the E Club.
Another useful tool is an abdominal x-ray — called a KUB, for kidneys, ureters, and bladder — which will clearly show that the child’s rectum is clogged and stretched.
One mom in my private Facebook support group posted that viewing her son’s x-ray persuaded her to stop rewarding her son for dry nights. In turn, her son stopped hiding his wet underwear form her. “We all have better attitudes, as we view the wetting as a medical issue. Now he doesn’t have to feel disappointment for not earning a reward.”
Instead, the family began focusing on the treatment that does work: cleaning out the rectum so that it shrinks back to size and stops bothering the bladder nerves.
According to the article Google sent me, increasing the amount of time between bathroom visits helps the child “develop better bladder control.”
As a pediatric urologist, I can tell you this is false! In fact, holding pee can thicken and irritate an overactive bladder, exacerbating enuresis.
A healthy bladder is one that fills and empties on a regular basis. I advise my patients to pee more often, not less often — ideally about every 2 hours. Many of my patients wear vibrating watches to school to remind them to pee frequently.
And yet this old-school “bladder training” idea persists. A while back, first-grade teachers in Las Vegas sent parents a letter stating that “students are wasting valuable learning time on bathroom breaks” and asked parents to help their children “increase bladder endurance” by overriding their urges to pee. The principal eventually backed down but incident demonstrated a common misunderstanding about bladder health.
Limiting Fluids Before Bedtime
If bedwetting were caused by fluid over-consumption, then cutting back on fluids would be a logical remedy. But again, it’s an overactive bladder, not excessive beverage intake, that triggers accidents. Kids with healthy, stable bladders can drink a glass of water right before bed and not need to pee all night.
Restricting fluids can make matters worse by irritating the bladder and contributing to constipation, the underlying culprit.
Children should drink plenty of water throughout the day, and there’s no need to restrict beverages in the evening. One mom in our support group worried that when her son’s soccer coach challenged the players to drink 1 gallon of water per day, the boy might start wetting the bed again. Much to her surprise, he didn’t. Another mom chimed in: “When my daughter started drinking a lot more, we saw a huge reduction in overnight wetting.”
The article that prompted this blog post stated that counseling or therapy may “help the child deal with any emotional or psychological issues that may be contributing to the bedwetting.” Now, I’m certainly in favor of counseling for children who are dealing with emotional issues, but let’s be clear: Enuresis is not caused by psychological or emotional distress.
It’s absolutely true that many children with enuresis suffer from anxiety, low self-esteem, even depression because of their condition. But that’s because enuresis causes distress, not the other way around.
Of course children with enuresis are stressed out — especially teens and tweens. These kids are missing out on sleepovers, they’re terrified their friends will find out they wear pull-ups to bed, and they fear their accidents will persist until college. They shoulder loads of shame and blame — all because of a medical condition that has gone untreated.
Unfortunately, the myth that enuresis has psychological origins is pervasive in popular culture and in the psychology and psychiatry literature, as I explain in Enuresis and Encopresis Are Not “Mental Disorders” and our free download, The Mental Health Professional’s Guide to Enuresis and Encopresis.
Enuresis rates an entry in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), published by the American Psychiatric Association (APA) and countless entries in online resources for therapists and parents.
Yet enuresis is no more of a mental disorder than is influenza or a urinary tract infection. No amount of counseling or art therapy will stop an overactive bladder from contracting in the middle of the night or during math class.
Taking Pull-Ups Away
Many parents perceive pull-ups as a “crutch” and assume children with enuresis pee in their pull-ups out of convenience or laziness. Other parents just figure removing pull-ups is part of "night training" their child — that as soon as the pull-ups go, the child will be dry.
For example, a mom recently emailed: "My little girl is 3 years and 3 months old. We daytime potty trained her when she was 2.5, and once she was 3, we removed the night time nappy. Since then, she’s been waking us up to take her to the toilet once a night and occasionally went through the night dry. However, in the last two weeks she’s been wetting the bed once or twice a night."
We do not advise removing pull-ups overnight until a child is reliably dry. Simply taking them away at a specific age will not accelerate dryness. If a child is not dry by age 4, we recommend treatment.
Some physicians reinforce advise parents to withhold pull-ups on the theory that the discomfort of wet sheets will provide incentive for the child to use the toilet in the middle of the night. But the prospect of wet sheets won’t calm an overactive bladder. Removing pull-ups just causes discomfort while disrupting the child’s (and parent’s) sleep. This strategy also sends the erroneous message that accidents are within the child’s control.
With appropriate treatment for chronic constipation, the child’s bladder will stop spasming and the child won’t need pull-ups. Until then, my advice is to let the child sleep comfortably. And if you’re tired of paying for pull-ups, that’s all the more reason to take an aggressive approach to treating the underlying constipation, with a regimen such as the Modified O’Regan Protocol (M.O.P.).
What About Bedwetting Alarms and Medication?
In the Google-alert article I received, bedwetting alarms and medication are included among the list of effective bedwetting treatments. My take: both are of limited value because they do not address the root cause of enuresis, chronic constipation.
Bedwetting alarms can solve the problem of wet sheets by training the child to wake up before peeing in bed. However, it’s typically a lengthy and exhausting process for the parent and child, and often the child just sleeps through the alarm. I generally recommend families invest their energy in resolving the underlying constipation.
However, in certain situations, alarms can be a helpful adjunct to constipation treatment, as I explain in the M.O.P. Anthology.
As for medication, I discuss the three categories of enuresis drugs in the Anthology. In general, the drugs prescribed by urologists typically don’t fix enuresis; they just cover it up. However, in some cases, medications that limit overnight urine production or calm an overactive bladder can be helpful in conjunction with an aggressive bowel-emptying program such as M.O.P.
For example, if a child’s abdominal x-ray shows the child’s rectum is empty, or nearly so, but the rectum remains stretched, medication can sometimes get the child over the hump until the rectum heals and stops bothering the bladder.
I often prescribe medication as a stop-gap measure for sleep-away camp. However, I emphasize to families that unless the rectum remains empty, accidents almost certainly will return when the child stops taking the medication. Drugs are not a long-term solution, but in cases where the bladder nerves remain aggravated after the rectum has been fully emptied, two surgical procedures — bladder Botox and the InterStim device — are highly successful.
Enuresis is a highly fixable condition. All children with nighttime or daytime accidents can be successfully treated. However, it takes significant time and persistence for the underlying constipation to resolve and for the rectum to retract and heal.
Bedwetting remedies like rewards and “bladder training” may sound logical and easy, but when it comes to treating enuresis, there simply are no shortcuts.