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Vol. XXV
No. 1

In This Issue

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by Dr. Rodger Sayre
- disclaimer -
The Scourge of Soggy Sheets

It was 11 p.m. My 6-year-old son stood in front of the toilet, swaying back and forth on locked legs. His head was cocked slightly back and to the side, eyes closed, mouth wide open.

“Daddy wants you to go potty,” I whispered in his ear several times, hoping that somehow a subliminal message would trigger the desired bladder response. I managed only to convince myself that I really had to go. (The power of suggestion worked, just on the wrong person!)


Finally, after a few futile minutes, I decided on a different tactic. I spun him around, slipped down his pajama bottoms, and sat him on the cold potty seat. That did the trick! But my satisfied smile quickly faded when I realized that, somehow, he had found the crack between the seat and the bowl. Too late, I realized that he was wetting all over his pajamas and the floor. Oh well, better the bathroom floor than the bed again.

Yes, the scourge of bedwetting has visited the Sayre household!

Bedwetting can be such a pain in the neck! Day after day, struggling with fitted sheets on a bottom bunk…trying to figure out what to do with the new feather pillow that got “just a little bit damp.” A child who has never been able to consistently make it through the night without wetting the bed, but has no trouble with urinary leakage during the day, is said to have Primary Nocturnal Enuresis (PNE). This is the most common form of enuresis (lack of bladder control) and the only form to be discussed in this article.

As a general rule, a lack of nighttime bladder control is not considered abnormal until a child reaches the age of 5. About 6% of children over 5 suffer from PNE, and boys are afflicted three-to-one over girls. As you might suspect, there is a strong genetic link. In fact, studies demonstrate that when one parent struggled with PNE as a child, his or her offspring have about a 15% chance of bedwetting, themselves. When both parents carried the diagnosis, their children have more than a 50% chance of being bedwetters! In our family, two of our six boys qualified for the diagnosis, but none of our five girls wet the bed once they were potty trained. (If you have enough kids, you can do studies of your own!)

You may ask, “What in the genetic makeup of a child predisposes him or her to being a bedwetter?” There seem to be three main inheritable factors that contribute to bedwetting. Those factors are

  • an unusually small bladder capacity,
  • increased nighttime urine production (due to the lack of the nocturnal production of a hormone known as anti-diuretic hormone, or ADH), and
  • a tendency to be a deep sleeper.

I have noticed that most children possess all three of these factors in varying proportions.

Other than a history and physical exam (and perhaps a simple urinalysis), no specific medical workup is needed to diagnose PNE. If your child is 5 or older and nighttime wetting has been ongoing since birth, it is okay to wait until the annual checkup to discuss this issue with your family doctor or pediatrician. But please note, this is not the case for other forms of bladder control problems! Since the loss of urinary control during the day in a child who was at one time potty trained has a myriad of potential causes, ranging from infection to diabetes, it is prudent to seek medical attention urgently.

Considering the factors that lead to PNE, it is obvious that a child has little control over whether the sheets are wet in the morning. So don’t take your frustrations out on your child! Disciplinary action against a child with PNE is never appropriate. In fact (and I know this runs countercurrent to popular thinking), I believe that even giving rewards for dryness is counterproductive. If you reward a child with a sticker or special treat for being dry in the morning, you imply that your child has some significant control over this issue. Your child may become unnecessarily frustrated, discouraged, or guilt-ridden by his or her inability to please you. For the vast majority of children, there is plenty of internal drive to correct this embarrassing problem, without employing either negative or positive reinforcement techniques.

So what’s a parent to do? First, give your child some ownership in the clean-up process (i.e., strip the bed and, if he’s old enough, wash the sheets). This provides additional incentive to stick to the rest of the program outlined below and helps diffuse some parental frustration. Second, restrict nighttime fluids. Caffeine or heavily sweetened beverages, such as soda, are especially problematic and should be eliminated from the diet. Third, awakening the child and taking him to the bathroom during the night (before his parents retire for the evening) is an option. Setting an alarm clock for the “wee hours” of the morning (no pun intended) will also work for many self-motivated children, although very deep sleepers may not awake. Fourth, a moisture alarm is successful in two-thirds of children, and over half of those who respond stay dry permanently. Unfortunately, moisture alarms can be very disruptive to the rest of the family and are usually the last of the non-medicinal approaches employed.

Several medications can be used to treat PNE. The most popular of these is DDAVP (desmopressin). DDAVP is very effective and can be used in those children who have failed nonpharmacologic measures, either when used alone or in combination with other measures, as discussed above. DDAVP is an analogue of the naturally occurring ADH that is lacking in many children who struggle with PNE. The downside to DDAVP is that, when used singularly, a relapse generally occurs when the medication is stopped.

There is one way to reduce the risk of a relapse, regardless of the modalities used to treat PNE. Once a child is dry for two consecutive weeks, have the child gradually increase fluid intake before bedtime. This can help reduce relapse rates by increasing bladder size. The most important message for parents is to avoid making your child feel guilty for his failure to be able to control his bladder at night. In my experience with bedwetters, the psychological trauma of the condition is its most serious aspect. The vast majority of the time, bedwetting resolves spontaneously. True, it’s a pain! But don’t take your frustrations out on your child. This too shall pass.

About the author

Rodger Sayre, MD, FAAFP, has been an HSLDA board member since 1997. He and his wife, Mary, homeschool their 12 children.