Scientific Publications

Guidelines & Review Articles about Nocturnal Enuresis (Bedwetting)

Bedwetting is a very common urologic condition in childhood, which is highly documented in published literature. Listed below is a selection of review articles & guidelines from different countries. These are all free to download for personal use. Please just follow the links. They all mention conditioning treatment with a bedwetting alarm as the first-line treatment for bedwetting. For example, this quotation by Dr. Lane Robson, Calgary, Canada (2008) is representative of what experts are saying: “Alarm therapy should be considered in every child with nocturnal enuresis. Success with alarm therapy is related to the motivation of the child and to the motivation of the parent who must participate in the therapy. A Cochrane review of 56 trials concluded that alarm therapy resulted in dryness in about two-thirds of children.” Canada: Robson  Link to the publication

  • UK: The National Institute for Health and Care Excellence (NICE) in the UK has published guidelines on their website. link to the publication.
    A shorter version based on these guidelines can also be found by O’Flynn. Link to the publication.
  • Australia: An Australian perspective is provided by Caldwell et. al.REF
  • BMJ 2013;347:f6259, doi:10.1136/bmj.f6259
  • New Zealand: Best Practice Journal provides a nice summary article by Dr. David Reith. Link to the publication.
  • United States: A US perspective is brought by Dr. Ramakrishnan. However, this article makes statements in regards to simple behavioral interventions, biofeedback, and motivational therapy that seem more favorable than most other similar publications. Motivational therapy probably has a role and should be used with a bedwetting alarm. However, on its own, it not believed to be very effective. Link to the publication
  • Singapore: No authors. Link to the publication

Bedwetting Alarms Provide a Cure for Bedwetting in 1-3 Months

Recently, a systematic review of 2861 cases treated with bedwetting alarms showed a cure rate of 76%. The child’s age did not affect the result. The mean treatment time to achieve dryness was 62.1 ± 30.8 days. Thus 1-3 months, rather than 3-4 months (as previously thought), is the time it takes to achieve dryness with a bedwetting alarm. REF

Apos te. al, J Pediatr. 2017 Dec 12. pii:S0022-3476(17)31342-2. doi: 10.1016/j.jpeds.2017.09.086. [Epub ahead of print],Enuresis Management in Children: Retrospective Clinical Audit of 2861 Cases Treated with Practitioner-Assisted Bell-and-Pad Alarm.

Bedwetting and Self-Esteem

A study from Sweden compared bedwetting children with non-bedwetting children for self-esteem before and after treatment. Children with bedwetting had significantly lower self-esteem before treatment and boys had lower self-esteem than girls. However, after 6 months of treatment, the bedwetting children who had become dry had the same levels of self-esteem as the control group. The children who had become totally dry also had significantly better self-esteem at a 6-month follow-up compared to those who persisted in bedwetting. This study is direct evidence that self-esteem is improved with treatment. REF

Hägglöf B et.al. Eur Urol. 1998;33 Suppl 3:16-9. “Self-esteem in children with nocturnal enuresis and urinary incontinence: improvement of self-esteem after treatment.

Nocturnal Enuresis – Will All Children Outgrow Bedwetting?

Many physicians are reluctant to recommend treatment for bedwetting. Their reasoning is often that the issue is self-limiting since all children will eventually outgrow the condition. However, this is not true, or at least many bedwetters will no longer be children when this happens. Children who wet their beds every single night at seven years of age have a large probability of still struggling with the condition even as young adults. Children who only have a few episodes per week have a much larger change of outgrowing the condition sooner. The chart below, from a study of 20,000 children in Hong Kong, illustrates these findings.

Link to the publication

From this graph, there is little to indicate that bedwetting will be a short-lived problem for children who wet their beds every night. These children should be offered treatment. Without treatment, these children are often missing out on social activities, such as sleepovers, school trips and camping with friends. They should not be told that they will soon outgrow the condition as this is probably false. Ask a seven-year-old bedwetter and his/her parent this question:”Would you rather we try to cure your bedwetting now, which usually takes 60 days using a bedwetting alarm or to have another 1800 days of bedwetting before it stops on its own.” (The average time to outgrow bedwetting at 15% resolution is about 5 years or 1800 days.)

Nocturnal Enuresis – Is the Bladder too Small?

A small bladder capacity contributes to bedwetting. The normal bladder capacity for children up to the age of 14 can be estimated by the formula age + 2 = volume in ounces. To get the volume in ml just multiply the result from this formula by 30. Thus, for a seven-year-old, the capacity is expected to be 7+2= 9 ounces = 270 ml. This result can be compared to the single largest amount of urine voided anytime by a child over a 2 day period. If the volume is <80% of the expected volume, the capacity is low.This may help explain wetting in some children. However, a recent article indicates that even a bladder of normal size can “act smaller” at night. The bladder capacity does not affect treatment with bedwetting alarms but this may have implications when using a medication called desmopressin. It may explain why some children respond poorly despite a reduction of urine production. REF

Borg et. al. J Pediatr Urol. 2017 Oct 27. pii: S1477-5131(17)30432-1. doi:10.1016/j.jpurol.2017.09.021.

Nocturnal Enuresis – Will Surgery Help Some Children?

There is an association between obstructive sleep disorder and bedwetting. The mechanism involved is complex but it has been suggested that sleep apnea can directly affect the amount of urine produced. Recently, a Canadian team of researchers conducted an analysis of the literature. A high portion,60%, of the patients treated with adenotonsillectomy (surgery to remove adenoids and tonsils) had an improvement in their bedwetting and about 50% were cured. This has not been confirmed in a controlled trial. The results are not transferable to the average child with bedwetting since this is a small group of children with a specific problem.However, this should be a consideration if a child has sleep apnea along with bedwetting. REF

Lehmann KJ et al. J Pediatr Urol. 2017 Sep 6. pii: S1477-5131(17)30309-1. doi:10.1016/j.jpurol.2017.07.016