CHILDHOOD BED-WETTING:  CAUSE FOR CONCERN?
By Dixie Farley

During grade school, Patsy (not her real name) never asked friends to spend 
the night.  When invited to birthday party "sleep-overs," she declined.  She
worried about the possible lingering odor in her room.  And she hated the 
plastic sheet that accompanied family vacations.  Then, shortly after 
entering middle school, Patsy no longer had her "problem": bed-wetting. 

Fourteen percent of 5- to 13-year-olds wet the bed, according to a recent 
population study.  For many such children, like Patsy, the consequences are 
humiliation and damaged self-esteem.  Fortunately, this common childhood
affliction, known medically as "primary enuresis," usually disappears on its
own, and proper treatment can often hurry it on its way.

Bed-wetting is considered normal up to age 5.  When the problem persists, 
however, a visit to the doctor is in order.  Bed-wetting rarely signals a 
health problem, but daytime wetting--which often occurs with bed-wetting yet
may be overlooked if it's only a dribble-- can represent serious illness. 
Indeed, if the wetting disorders known as dysfunctional voiding (see "When
Potty-Training Goes Awry") go untreated, kidney failure--even death--can
result. 

Delayed Development and Other Causes

The precise cause of bed-wetting is unknown.  Most cases appear to be due to
delayed physical development.  Bladder capacity may be less than half what is 
considered normal for the child's age.  Bed-wetting is up to three times more 
common in boys than girls--linked, perhaps, to boys' slower rate of 
maturation.  Some researchers, in fact, have argued that boys aren't normally 
dry at night until age 8. 

Several studies point to a genetic link in enuresis.  When both parents had 
the problem as youngsters, 77 percent of the children in these studies
developed it.  But the figure dropped to 44 percent when only one parent had
wet the bed in childhood.  By contrast, when neither parent had enuresis, 
only 15 percent of the children did.

A frequent cause of bed-wetting is constipation.  In fact, treatment of 
constipation in enuretic children often resolves the wetting, report Sean 
O'Regan, M.D., and others of the Pediatric Research Center, University of 
Montreal.  In the March 1986 American Journal of Diseases of Children, they 
explained that, in chronically constipated children, the rectum is probably 
never empty so the rectal sphincter muscle remains contracted to hold back
stool.  This, in turn, can dilate the rectum, which then presses on the 
small, immature bladder to cause the enuresis.

Attempts to hurry toilet training may backfire and actually contribute to 
bed-wetting; experts advise letting a child develop bladder control at his or 
her own pace.  Other contributing factors include hospitalization (especially 
between ages 2 and 4), arrival of a baby, loss of a parent, and entering
school. 

In rare cases, emotionally disturbed children may respond to their illness
with loss of bladder and bowel control, according to Gordon McLorie, M.D.,
and D.A.  Husmann, M.D., of Toronto's Hospital for Sick Children, in the
October 1987 Pediatric Clinics of North America.  But in other cases, they
wrote, "emotional disturbances may be primarily a result of the enuresis."

Urinary tract infection also can result in bed-wetting.  These infections 
often cause additional symptoms, such as painful urination, foul-smelling 
urine, and daytime wetting. 

Diaries and Other Diagnostic Tools

Diagnosis at the Center to Assist the Regulation of Enuresis (C.A.R.E.) in
Chicago involves use of a diary.  Before the first appointment, parents 
complete a psychological questionnaire and keep a three-day record on their 
child's diet and wetting pattern (times, duration and volume of daytime 
urination and times of bed-wetting).  The record may suggest a wetting
pattern abnormality, recurring urinary tract infection, or unrecognized 
constipation. 

"I do not believe that all children with these complaints merit a full scale
urodynamic evaluation," wrote C.A.R.E.  director Max Maizels in the April 
1982 Journal of Urology.  (Urodynamic tests use electrodes and flexible thin
tubes called catheters to gain information about urinary tract flows, muscle
movement, and pressure changes.  See "When Potty-Training Goes Awry.") A
"hands off" approach is how Maizels describes C.A.R.E.'s diagnosis and
treatment.  "I have been content with eliciting a detailed history, 
performing a physical examination of the genitalia, and observing the voided
stream to guide the need for .  .  .  urodynamic evaluation." 

What can a patient's history reveal? Compared with youngsters with normal 
bladder control, bed-wetting children are more likely to have experienced 
problems while still in the womb, such as maternal illness or bleeding or,
after birth, colic or jaundice (skin yellowing from bile pigment buildup in 
the blood), according to Maizels.  "Perhaps these .  .  .  are stresses that
later lead to the 'maturational delay' believed responsible for primary 
enuresis," Maizels and Diane Rosenbaum wrote in the December 1985 Primary 
Care. 

A thorough physical examination includes inspecting the rectum for impacted 
stool, checking the gait and reflexes of the legs and feet for nerve defects, 
and gently feeling the abdomen, genitals, buttocks, anus and spine for
abnormalities.  Observing the child's urination is important because
different problems may be reflected by the nature of the stream, which may be 
weak, unusually forceful, intermittent, continuous, spraying, or painful. 
Intermittent flow, for instance, suggests obstruction.

Flow-rate measurements show how many ounces or milliliters of urine are 
passed in how many seconds.  Ultrasound examination (a painless procedure,
made by applying sound waves to the skin) may be needed to check the size and 
shape of the kidneys and to see how well the bladder empties.  Laboratory 
analysis of urine screens for diabetes, kidney disease, or other disorders. 

Among the candidates for further examination with more complicated tests are
patients for whom conventional treatment has failed and those with recurrent
urinary infection, wetting day and night without an obvious cause, coexisting 
loss of bowel control, and suspected dysfunctional voiding.  Parents should 
ask questions to be sure they understand why a particular test is recommended 
and what is involved. 

To Treat, or Not

But if the diagnosis is that the nighttime wetting is simply due to an
immature bladder, the examination will probably end there.  Physician and 
parents can move on to discussions about treatments.  It's reasonable to
consider doing no more than being patient and supportive until the child is 
older.  Still, for families facing great stress over the problem and for
children feeling shame and low self-worth, there are potentially effective
therapies.  The choice of therapy and effectiveness of individual treatments
depend on the severity of the problem, the child's age and emotional
maturity, and the level of commitment of the child and parents.  Certainly, 
scolding and punishment are ineffective and inappropriate.

Behavior Modification 

For behavior modification to be effective, child and parents must be highly 
motivated to follow the physician's instructions exactly and to persist long
enough, which may mean several months.  It's very easy to become lax or give
up.  Rewards alone--no punishments--are used.  Among the techniques:

Responsibility reinforcement training.  The child takes charge of making one
last trip to the bathroom, changing and laundering soiled bed linens, and 
charting progress (dry nights earn rewards).  These responsibilities should 
help improve the child's feelings of self-worth and prevent parental anger
over a wet bed.  Hints from the Mayo Clinic: Use a plastic mattress pad and 
pillowcases, and buy lots of inexpensive sheets and blankets for storage in a 
tightly sealed plastic bag for weekly washing.

Urinary alarm.  Wetting sets off the battery-powered alarm; the child wakens, 
turns off the switch, and finishes urinating in the bathroom.  Eventually,
the child is supposed to learn to wake before wetting.  Lightweight pajamas 
are best because thick ones slow down the time between the first drops of 
urine and the sounding of the alarm.  It's a good idea to replace batteries 
at set intervals because weakened ones may not trigger the alarm and may
damage the device.  The success rate with the alarm is as high as 75 percent, 
but the relapse rate can be as high as 30 percent.  Maizels says that, by 
combining the alarm with other therapies, he and his colleagues can correct 
about 80 percent of wetting within the first month or two, with a relapse 
rate of only around 13 percent. 

Another treatment often reported involves retaining urine to enlarge bladder
capacity.  But Terry Allen, M.D., urology professor at Southwestern Medical 
School in Dallas, says "this is bad policy because it puts undue pressure on
the urinary tract." 

Drugs Have Drawbacks

The Food and Drug Administration has approved one drug as safe and effective
for bed-wetting: imipramine (Tofranil), an antidepressant.  It can
immediately produce dry nights, but there are drawbacks.  It can cause a
number of side effects, including blood pressure changes, irregular 
heartbeat, anxiety, insomnia, dry mouth, blurred vision, nausea, vomiting,
diarrhea, dizziness, drowsiness, and headache.  Bed-wetting often resumes 
when treatment stops.  And, while the drug is safe at recommended dosages, an 
overdose can cause convulsions, coma and death.  "One third of the physicians 
who use the drug do not recognize its toxic potential," wrote Betsy Foxman of 
the University of Michigan School of Public Health, Ann Arbor, and others in
the April 1986 Pediatrics.  The researchers were commenting on the results of 
the Rand Health Insurance Experiment, a population study.  "We suggest that 
physicians explore less hazardous alternatives before relying on
pharmacologic [drug] treatment for this generally benign condition," they 
concluded.  The April 1987 Mayo Clinic Health Letter advised: "We rarely
recommend this drug for children with enuresis."

If the decision is nevertheless made to use imipramine, parents should take 
extreme care to give it exactly as prescribed, to keep it in a locked cabinet 
out of reach of children, and to seek immediate medical help in case of 
overdose.  Any substance potentially poisonous to a child should be labeled 
with warning stickers, such as "Mr.  Yuk." These are available from regional
poison control centers (not emergency rooms), listed with emergency numbers 
at the front of the telephone directory.

Physicians are investigating enuresis treatment with oxybutynin chloride
(Ditropan).  The drug is approved by FDA for certain nerve-related bladder
disorders, but its safety and effectiveness for bed-wetting remain unproven.

Counseling and Other Treatments 

Some physicians may recommend psychological counseling or hypnosis.  In the 
C.A.R.E.  program, fluids are not restricted at bedtime, but patients are 
advised to drink nectars, apple juice, cranberry juice, and water rather than 
carbonated drinks.  "As these beverages may be less interesting," says
Maizels, "children tend to drink more for thirst than for recreation."

Dealing with bed-wetting can be frustrating, even traumatic.  It might help 
to keep in mind that nearly every child will outgrow the problem. 
                                    

                        WHEN POTTY-TRAINING GOES AWRY 

Sometime between ages 1 and 2, a toddler first senses bladder fullness and, 
so, starts to hold back urine by contracting the sphincter muscle of the
urethra, the urinary tract opening out of the body.  As the bladder gradually 
stretches to hold more urine, increased inner pressure causes the bladder's 
powerful detrusor muscle to contract to expel its contents.  By age 4 or 5, 
most children learn to suppress detrusor contractions so they can retain
urine and to relax the urethral sphincter during detrusor contractions so 
they can pass urine.  Daytime dryness usually comes before nighttime control. 

Certain children, however, get stuck in this transition with a condition
known as dysfunctional voiding.  Some don't learn to coordinate the urinary 
muscles; others learn coordination, but so persist in holding back urine that 
the bladder greatly overstretches.  In both abnormal patterns, the contained
urine becomes stagnant and infected.  Dysfunctional voiding reflects neither
disease nor physical defect but, rather, a hitch in the child's beginning 
efforts at bladder control.  Such children make up about 40 percent of the
outpatient practice of pediatric urologists.

With early detection and muscle retraining, dysfunctional voiding is often
cured.  Allowed to progress, this abnormal wetting can lead to permanent
damage to the urinary tract--even kidney failure and death. 

Why do these abnormal wetting patterns develop? 

"In a lot of cases, no clear cause can be found," says Terry Allen, M.D., who 
teaches urology at Southwestern Medical School in Dallas.  Allen has studied
dysfunctional voiding extensively.  "Quite often," he says, "it's related to
a broken home, alcoholism, child abuse, or other stress.  But it occurs in
stable families, too.  Some children hold back their urine all day because
they've decided the school bathroom is dirty, or they're so hyperactive and 
busy they don't take time to go.  Some fear the potty because they've fallen
into it.  One child was terrified of the toilet because his father had a
bowel disorder and the son associated it with the toilet. 

"Also, trying to force children to urinate can push them into a wrong 
pattern.  They aren't clear on what to do so they tighten the wrong muscles.
We recommend letting children decide on their own when they want to be
potty-trained.  The fundamental effect, though, is the same: The child gets 
into this mode of holding back, instead of learning to relax and empty the
bladder completely at regular intervals." 

An abnormal wetting pattern can result in several serious problems, says
Allen.  "As the detrusor and the urethral sphincter strain against each 
other," he says, "the weaker sphincter eventually fails, so that the bladder
can squirt out urine." Meanwhile, the straining builds very high pressures
within the bladder.  The detrusor reacts by contracting and, like any muscle
given daily workouts, increases in size and strength.  Ever stronger
contractions become ever harder to control, causing abdominal cramps and more 
leaking.  The bladder fails to empty completely, causing the child to have
repeated urinary tract infection.  The pressures inhibit urine flow from the
kidneys to the bladder, causing the ureters and kidneys to overstretch, which 
in turn can be damaging.

The overstretched kidneys work hard to push the urine through the ureters 
into the bladder, but high pressure there provides resistance.  So, while the 
valves at the ureters momentarily open to let urine into the bladder, this
excessive pressure may push the urine back up into the kidneys.  Over time, 
the abnormal urine flow can enlarge and distort the valves until they no
longer work but allow the urine to move freely back up into the kidneys.  To
ward off this dangerous situation, proper diagnosis and treatment are vital.

Following are tests that may be used in diagnosis:

Intravenous urography (also called I.V.  pyelogram)-- to rule out anatomical
defects.  This X-ray study is made by injecting dye into a vein, filming the
movement of the dye, and watching it progress through the kidneys, ureters, 
bladder and urethra until it is excreted from the body. 

Voiding cystourethrogram-- also to rule out anatomical defects.  Another
X-ray study, this procedure is done by filling the bladder with a dye and 
filming the dye in the bladder and as it moves along the urinary tract out of 
the body while the patient urinates.

Cystoscopy-- to confirm suspicion of serious urinary tract damage or to 
determine why the child hasn't responded to outpatient treatments.  The 
inside of the bladder and ureters are examined via a lighted, thin tube 
called a cystoscope that is threaded through the urethra.  Some doctors use a 
general anesthetic for this examination.

Urodynamic testing-- to evaluate how well the urinary tract works by
examining pressure changes, flow rate, and muscle movement.  The physician
uses catheters (thin, flexible tubes) to measure bladder pressure and 
electrodes to measure activity of the urethral sphincter.  With the catheters 
and electrodes attached to a recording monitor, the child urinates into a 
special receptacle or "potty chair" connected to a flow meter.  Thus, bladder 
pressure, sphincter activity, and flow rate are recorded simultaneously.
This takes about an hour and a half.

If the problem is detected before damage requires surgical correction, the
child begins a simple retraining program that centers on urinating
frequently, completely, and in a relaxed manner.  This may require months or
even years.  The child goes to the bathroom at two-hour intervals, tries to 
maintain a continuous stream by remaining completely relaxed, and then tries
to urinate again and again until unable to pass any more urine.  Some 
investigators suggest intermittent catheterization (a catheter is threaded
through the urethra into the bladder for complete emptying) and the use of
any of a number of drugs: the tranquilizer diazepam (Valium) to relax the 
sphincter, the antidepressant imipramine (Tofranil) to help control wetting,
and the antispasmodic oxybutynin chloride (Ditropan) to decrease bladder
pressure. 
                                 
                              DEFINING ENURESIS 

Primary enuresis (EN-you-REE-sis) is the medical term commonly used for 
bed-wetting in someone over age 5 who has never gone at least a year without
wetting the bed.  Secondary enuresis is bed-wetting in a child who has had
bladder control.  These terms do not apply to wetting problems due to 
physical illness or anatomical defect.  Enuresis is diagnosed in 5- and 
6-year-olds who have two or more monthly episodes and in older children who 
have one or more episodes a month, according to the American Psychiatric
Association.  The APA definition includes daytime wetting not due to disease
or defect.  But, generally, "enuresis" is used solely for wetting during
sleep, so that is how it's used here.  For every child with daytime wetting,
it's reported there are six who wet at night. 

Typically, bed-wetting occurs during the first third of sleep.  When it takes 
place in REM sleep, the child may remember dreaming about urinating.  (Rapid
eye movement, or REM, accompanies the stage of sleep when most dreaming 
occurs.) It was once believed that wetting took place only during very deep 
sleep or when sleep moved from one stage to another.  Recent studies, though, 
show wetting occurs in all sleep stages in proportion to the time spent in
that stage and without relation to arousal patterns.

Some bed-wetting children walk in their sleep or have coexisting sleep terror 
disorder, in which nightmares waken them to great fearfulness.

Enuresis affects some 20 percent of children at age 5, 5 percent at age 10, 
and up to 2 percent at age 15.  Only about 1 percent of adults have wet the 
bed since childhood.