Nighttime urination (Enuresis Nocturna) is a very common childhood disease worldwide. Although there is a high rate of spontaneous recovery with advancing age, it is important because of the social and psychological problems it causes and often requires treatment.
Normally, as the child approaches the age of two, families begin to toilet train their children. This training starts with holding the child to the toilet from time to time to urinate and poop. Parents should educate the child in an encouraging and rewarding manner to let them know when they urinate or poop. With such training, toilet training is usually completed between the ages of 2-3 and the problem of wetting the bed at night is resolved. However, despite all efforts, this problem may continue until the age of five in some children.
Incidence: Wetting the bed at night; It occurs in 15-25% of five-year-old children. With the advancing age of each year, this rate decreases to 4% in girls and 8% in boys in the 9-10 age group. In the adolescence period, the rate is around 1-3%.
At adult ages; It has been reported that the rate of peeing on the bed at night is between 0.5% and 2.3% in different studies. While peeing on the bed at night is more common in boys, it is more common in women in adults.
Primary Enuresis Nocturna: It is used for children who are more than five years old after birth, but often wet the bed at night.
Secondary Enuresis Nocturna: In children who do not wet the bed at night for at least 6 months; It is used in cases where the child starts to pee on the bed again due to reasons such as stress, family death, violence in the family, fights, problems encountered at school, urinary tract infections, diabetes.
The Most Common Risk Factors for Bed Urination at Night:
1. Neurological Developmental Retardation: It is the most common cause of nocturnal urination. It is the delay in the child’s acquisition of the ability to stay dry at night.
2. Genetic Factor: The genetic factor is very important in urination on the bed. At least 15% of such children have a history of prolonged childhood enuresis nocturna in one of their parents. If such a story is present in both the mother and father, studies have shown that the rate rises to between 44-77% in children. Genetic studies have revealed that the genes in the 13g and 12g chromosomes are the causative agents.
Although the above-mentioned two factors are the main causes of enuresis nocturna in children, other factors may also play a role. For this reason, the physician, who is competent in the subject, should also consider the following factors.
● Infection/Diseases: Urinary system infections and other related urinary system diseases, especially secondary enuresis nocturna and daytime urinary incontinence play an important role as 5%.
● Some urinary system anomalies (the first of which is the small capacity of the bladder), excessive and prolonged contraction of the bladder muscles causes a decrease in the capacity of the bladder and enuresis (incontinence).
● Insufficient secretion of anti-diuretic hormone (ADH): Some of the children who wet the bed at night are due to insufficient secretion of antidiuretic hormone. This hormone regulates the urinary function of the kidneys. This hormone, which is released at night, ensures that the kidneys make less urine. In children with insufficient ADH secretion, the kidneys continue to produce as much urine as the daytime amount at night. The amount of release (diurnal difference) of this hormone during the day and at night cannot be measured in a healthy way before the age of 10.
● Psychological Causes: Death in the family, violence, sexually abnormal behaviors, humiliation of the child by his friends and exposure to violence can be encountered as both primary and secondary causes of bed urination. In such cases, the child may need psychological support.
● Constipation: The pressure of the poop accumulating in the large intestine due to chronic constipation to the urinary bladder may cause enuresis.
● Hyperactivity: The resulting lack of attention is the cause of urination at night 2.7 times more than enuresis due to antidiuretic hormone deficiency.
● Caffeine: Caffeine increases urine production.
● Alcohol intake: Drinking alcohol increases the amount of urine.
● Mental growth retardation: In children with mental growth retardation; Urination on the bed at night is up to four times more common than in mentally normal children.
● Apnea during sleep: Respiratory arrest due to upper respiratory tract obstructions during sleep may cause nighttime urination. Snoring during sleep and tonsillar size or enlarged adenoids are potential causes of sleep apnea.
● Sleeping state: Getting out of bed before the child wakes up and walking around the house is another reason for peeing at night. When the child, whose bladder is full of urine, enters one of the halls or rooms while asleep, he may think that it is a toilet and urinate.
Although it is less common, conditions that cannot be shown to cause nighttime peeing, but many researchers have shown as factors:
● Deep and heavy sleep: Parents of children with enuresis often complain that their child’s sleep is too heavy. Some researchers have shown the existence of a relationship between sleep disorders and the release of antidiuretic (ADH) hormone. It is stated that insufficient secretion of antidiuretic hormone (ADH) makes it difficult for even children who are in a light sleep to wake up.
● Stress: Stress is not a primary (primary) cause of nighttime voiding, but may be a secondary (secondary) cause of nighttime voiding. With the disappearance of stress, night urination improves.
● Food allergy: Although it is said that food allergy is also a factor in night urination, this situation has not been demonstrated well.
● Poor and insufficient toilet training: Another factor that is blamed for peeing on the bed at night is inadequate toilet training. This education should be given to the child with love and without violence. Toilet training is often insufficient in families with low socio-economic levels.
TREATMENT: If this situation continues from the age of 4 in a child who wets the bed at night, it would be beneficial to have an experienced physician examined. Doctor with a detailed history; In addition to revealing the reason for the child’s bedwetting, it also informs the family about the details of toilet training that the family will give to the child and how the child should be treated.
In such cases, a cover is placed on the child’s bed to prevent the urine from passing to the lower layers and to absorb the urine. This provides convenience for the family in terms of cleaning the urine.
In cases of bed wetting at night, the doctor, child and parents must be in full coordination.
Approach to the Child Wetting the Bed at Night: In such cases, the child is in a state of panic and deep embarrassment. Parents should not be angry with the child because of this situation and should not use violence. Behaving like this only serves to make the child wet the bed at night for a longer period of time. It would be appropriate for the parents to say that this situation of the child is temporary and will definitely improve after a while.
Laboratory and Radiological Examinations: Following the extensive family history, the doctor should have the necessary urine, blood analyzes and radiological examinations done according to the reasons he thinks. These tests are very useful in terms of giving an idea about urinary tract infections, metabolic diseases (such as Diabetes mellitus, Diabetes Insipidus) and urinary system anomalies (especially secondary enuresis).
Physician examining the child; He should comfort and encourage the child by telling him that this situation will definitely improve, but that he can be treated in a short time if he obeys what his parents say. First, it says that the child should stop fluid intake at least two hours before going to bed.
Before going to bed, parents are required to wake the child and take him to the toilet to urinate.
Thus, the parents should inform the doctor about the developments related to the child who is under the doctor’s follow-up. Meanwhile, if there is a night where he does not wet the bed, the child should be rewarded and encouraged by his parents.
If the child’s bed wetting still continues even though he is five years old, the following treatment methods should be applied.
● Wake-up Programs: The child should be awakened at least four hours after falling asleep and urinated. This four-hour period is continued by decreasing it by twenty minutes once a week and it is checked whether the child’s bottom remains dry at night.
● Desmopressin Treatment: It is a synthetic form of the hormone released from the body and reduces the nocturnal urine production of the kidneys. Tablets or nasal sprays are available. It can be very beneficial when applied with the child’s water restriction at night.
● Alarm Treatment (Figure 1): The child usually does not empty the bladder, which is full at night, in one go. First, he wets his panties with a small amount of urine. In alarm treatment; An alarm system, which can be placed in the child’s underwear, one end is fixed to the child’s shoulder and the other end is inside his panties (containing a low current that will not cause any harm to the child). The alarm system can be ringing or vibrating.
This system, whose figure is shown below, provides 65% benefit.
● Attention Deficit Due to Hyperactivity: Such children may need the help of a child psychiatrist or psychologist to wet the bed at night.
All treatment method changes must be made under the control of a doctor.
