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Bedwetting: Don’t Confuse “Common” with “Normal”

By Steve Hodges, M.D.

It’s hard to imagine a medical condition more misunderstood than bedwetting, aka nocturnal enuresis. I have a Google Alert set for “bedwetting,” and every day I read articles from around the world that are well meaning but jam packed with erroneous information. Articles like these send families down the wrong treatment path, prolonging the child’s distress.

The latest article I read, Soggy sheets, embarrassed kids: Tips for overcoming bed-wetting, hits all the usual notes, perpetuating several damaging myths. Below, I separate fiction from fact, so you’ll be better equipped to help your child resolve a highly treatable condition.

FICTION: “[Bedwetting] is a normal part of child development.” “Bed-wetting up to age 7 is common and not a concern.”

FACT: This article confuses “common” with “normal.”

Certainly, bedwetting is common, but that is because chronic constipation, the cause of virtually all enuresis, is common.

When children delay pooping, as they commonly do, stool piles up in the rectum. Now, the rectum is not designed as a storage facility; it is decidedly not normal for poop to accumulate there. What’s “normal,” and healthy, is for the child to sense the arrival of poop and poop right away. But when that doesn’t happen, stool collects, and the rectum stretches. The enlarged rectum, in turn, aggravates the nearby bladder nerves, triggering the bladder to contract and empty without warning. Ergo, wet sheets.

The article does list constipation (last) among “possible causes” of bedwetting but never explains how constipation causes enuresis and never explains that resolving constipation resolves bedwetting.

As for the contention that “bedwetting up to age 7 is not a concern,” I address this in two blog posts: Treat Bedwetting at Age 4, Not Age 7 and Don’t Assume Your Child Will Outgrow Bedwetting.

FICTION: “There are two general types of bed-wetting: primary bed-wetting and secondary bed-wetting.”

FACT: Primary and secondary bedwetting are the same condition, caused by the same scenario (a bladder gone haywire due to an enlarge rectum) and warranting the same treatment (resolving constipation).

The health professions make a big deal out of distinguishing between primary bedwetting (when a child has never been dry at night) and secondary bedwetting (when bedwetting recurs after a dry period of at least six months). The American Academy of Pediatrics emphasizes this distinction, stating that “stress” is “one of the most common reasons for secondary enuresis."

There is literally zero evidence to support this contention and also zero evidence for the AAP's theory that “treating the stress can stop the bedwetting.” I discuss the origins of the mythical stress-bedwetting connection in Enuresis and Encopresis Are Not “Mental Disorders.” Let’s Remove Them from the DSM-5.

How can I be sure primary and secondary enuresis are the same condition? Because I x-ray all my enuresis patients. The x-rays of my patients with secondary enuresis show the same thing as the x-rays of my primary-enuresis patients: an dilated, clogged rectum.

When accidents return after a dry period, it’s because the rectum of a child who was constipated to begin with has filled back up. In many kids, constipation is a chronic condition that comes and goes, for many reasons. Children with a bladder that is sensitive to rectal stretching are going to start having accidents again when the stool pile-up reaches critical mass.

Incidentally, many health professionals also make a big distinction between nocturnal enuresis (bedwetting) and daytime enuresis (daytime pee accidents). But these conditions, too, are one and the same, as I explain here.

FICTION: “Possible causes [of bedwetting] include . . . urinary tract infection, deep sleeper, small bladder or bladder nerves slow to mature.”

FACT: In a child with an intact spinal cord — in other words, a child who does not have spina bifida, tethered cord syndrome ,or other rare neurological conditions — bedwetting is almost always caused by chronic constipation. The article mentions diabetes, and indeed, once in a blue moon, the wetting is caused by undiagnosed type 1 diabetes. In 15 years of treating enuresis, I have come across this scenario exactly one time.

But the other “possible causes” listed simply do not cause enuresis.

Many girls with chronic urinary tract infections do have enuresis as well, but the UTIs are just another symptom of chronic constipation, not a separate cause of the bedwetting. I explain this in “Why 1 Million Girls a Year Get UTIs.”

Deep sleep does not and cannot cause a bladder to be overactive. See “Nope, Deep Sleep Does not Cause Bedwetting (It’s Impossible). The “slow to mature” bladder nerve theory is pure nonsense. As for the “small bladder” idea, well, sometimes the rectum becomes so enlarged with stool that it practically flattens the bladder, decreasing its capacity to hold enough urine overnight. You can see the flattened bladder on an x-ray. But again, that happens because the rectum is clogged, not because the bladder is underdeveloped. I debunk all these theories in depth in The M.O.P. Anthology: A Guide to the Only Proven Way to STOP Bedwetting and Accidents in Toddlers Through Teens.

What about heredity? The article states that “most likely, [bedwetting] is a familial gift passed down by one of the parents.” Well, it’s true that bedwetting runs in families, as I explain in About That Bedwetting Gene. But that’s because a tendency toward constipation runs in families, and some kids’ bladders are just more sensitive to rectal stretching.

Practically speaking, the fact that bedwetting runs in families is irrelevant. In fact, emphasizing this point is harmful because it gives families a reason to put off treatment even further. Whether a child has one parent, two parents or zero parents with a history of bedwetting does not matter. That child should still be treated — now, not later.

FICTION: “Treatment usually isn't necessary for primary bed-wetting or children under 7. A watch-and-see approach is usually the best option.”

FACT: While it’s true that with age, most kids do outgrow bedwetting, a substantial portion do not, and that “wait-and-see approach” is the reason I have a large caseload of teenage patients. If you are tempted to keep waiting to treat your child, I recommend reading Dear Bedwetting Teenagers: Your Condition is 1.) Common, 2.) Not Your Fault, and 3.) Totally Fixable.

FICTION: To resolve bedwetting, children ages 7 and older should be advised to “avoid high-sugar or caffeinated drinks during the evening” and “restrict drinks within two hours of bedtime.”

FACT: Soda drinking does not cause enuresis, and limiting soda and other beverages will not resolve this condition! A child with a healthy bladder can drink water 5 minutes before bed and still wake up with dry sheets. It is not liquids that cause bedwetting; it’s an overactive bladder.

To resolve enuresis, you must address the root of the problem: the clogged rectum.

When the rectum is cleared out, day after day for several months, this organ will eventually shrink back to its normal size and stop aggravating the bladder nerves. That’s when bedwetting will stop.

I appreciate that this article urges parents not to “purposely embarrass your child” and to “remember, bed-wetting isn't anyone's fault” and that “your child isn't lazy and isn't doing it on purpose.”

All true! But the rest? Not so much


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