Involuntary urinary incontinence at night (enuresis nocturne) is a common condition in children. It is usually seen in families with low socioeconomic status and crowded families. Most of these improve with age, children do not wet the bed.

However, in some people, bedwetting continues after puberty. In this article, I will explain the causes and treatment of bedwetting at a young age, taking into account my own experiences.

What does enuresis nocturne mean?

Enuresis nocturne (nocturnal enuresis) means involuntary leakage of urine during sleep. Sometimes both night and day urinary incontinence can occur. This condition is called enuresis diurna. It is estimated that bedwetting at night is 1-2% on average. In fact, this rate is thought to be higher because these patients are often unable to tell about their problems because they are embarrassed. This is a condition that affects both men and women of both sexes.

Bedwetting decreases in most children by the age of 4-6 as they grow up. In some children, this situation continues even after puberty, albeit to a very small extent.

How many types of bedwetting are there at night?

Bedwetting at night varies according to the onset of the disease. It is possible to divide this condition into two groups according to the onset of urinary incontinence:

• Primary enuresis: It means primary nocturnal enuresis is present in people who are incontinent and wet the bed at night for 6 months. In these patients, no urinary control could be achieved from birth.
• Secondary enuresis: If you stay dry for 6 months or more and subsequently have involuntary bedwetting at night, this is known as secondary nocturnal enuresis.

What are the causes of bedwetting at night?

There are many causes of involuntary urinary incontinence during sleep at night. We can summarize these reasons as follows:

• Hormonal causes: It is thought that a hormone called antidiuretic hormone (ADH) is deficient in these patients. This hormone decreases the production of urine from the kidneys during sleep, and in its deficiency, there is an increase in urine production. It is thought that the DH hormone is insufficient in enuresis patients, and therefore, patients leak urine at night. Bedwetting at night can also be seen as a symptom of type I and type II diabetes.
• Neurological causes: It is known that neurological, that is, neural causes, can also cause nocturnal enuresis. In these patients, bladder capacity is smaller than in normal individuals. In other words, the urine storage volume of the bladder has not developed enough. As a result, even when there is less urine in the bladder, signals are sent to the brain and the bladder contracts and urinary incontinence occurs. These patients have an overactive bladder or bladder instability. As a result, contractions occur before the bladder is filled to full capacity and urinary incontinence occurs.
• Sleep disturbance: One of the most common problems in people who wet the bed at night is sleep problem. These patients sleep much more deeply than normal people. Bladder fullness and urine sensation cannot be felt due to the depth of sleep.
• Obstructive sleep apnea: This disease is a condition that accompanies sleep disorder. It may be a cause in patients with bedwetting.
• Constipation: Constipation can cause this disease, albeit very rarely. We did not see this reason very often among our patients.
• Pelvic organ prolapse: It is a condition seen in women who have given birth multiple times and who have had a difficult delivery. Some patients may also have complaints of nocturnal urinary incontinence.
• Structural causes: This disease can also be caused by structural problems in the urinary system. It is known that there may be structural problems in the bladder, urethra and pelvis frequently. Other than these, diseases such as urinary tract infections, urinary system stones, prostate enlargement in men in advanced ages and prostate and bladder cancer can be factors.
• Stress and anxiety: Stress and anxiety can cause enuresis by disrupting the nervous control of the bladder, affecting the contraction and contraction functions of the bladder muscle.
• Genetic causes: Studies on bedwetting at night appear to be related to genetics, that is, it is a familial disease. In some studies, it has been reported that if two people in the family have a bedwetting problem, the probability of it being 77%. If one of the parents has this condition, the rate of occurrence in children is 40%.
• Diabetes: Bedwetting can be seen as a complication in long-term and poorly controlled diabetes patients.
• Medications: The problem of wetting the feet at night can also occur as a result of the side effects of some medications. At the beginning of these drugs are drugs used in the treatment of some neurological and psychiatric diseases. Diuretics can cause nocturnal urinary incontinence by causing excessive urine excretion. Although these drugs do not directly cause bedwetting in normal people, they can trigger urinary incontinence in patients with neurological and structural problems.
• Alcohol and coffee consumption: Alcohol and excessive coffee consumption, which also irritates the bladder, can also cause this problem. For this reason, we do not recommend excessive coffee and alcohol consumption to our patients with these problems.

What are the complications of bedwetting at night?

Sleep incontinence or bedwetting can cause some problems at a young age. These problems are usually psychological problems. The feeling of shame caused by the disease puts people in stress and anxiety. Usually, these patients cannot explain their problems because they are ashamed and they withdraw.

This situation creates more serious stress for those who are of marriageable age. We see that these problems are more serious, especially in our female patients. Our advice to our patients is that they consult a Urologist and seek treatment.

How is bedwetting diagnosed during sleep?

A systematic approach is required to diagnose these patients. The methods to be followed in diagnosis are:

• •Patient’s history: Questions such as detailed questioning of the patients and whether there is this disease in the family are asked.
• Examination: General urological examination is performed on the patients.
• Neurological tests: Neurological evaluation and tests can be done to reveal causes.
• Urinalysis: Urine microscopy and routine urinalysis are performed.
• Urine culture: If there is a treatment-resistant urinary tract infection, a urinary culture can be performed.
• Uroflowmetry: It is a test to evaluate urine flow.
• Residual urine: After patients urinate, no urine should normally remain in the bladder. If excess urine remains in the bladder after micturition, this should be investigated.
• Cystometry: The cystometry test gives an idea about the contraction of the bladder muscle.
• If there is an overactive bladder and involuntary contractions, it is shown on cystometry. We usually ask our patients for this examination. It is useful to do this test to start anticholinergic therapy. Although cystometry was normal in some of our patients, we achieved positive results with anticholinergic treatment.
• Ultrasound (USG): It is possible to evaluate bladder capacity with urinary system USG. It is also possible to determine residual urine in the bladder after micturition with USG.
• Cystoscopy: Cystoscopy is rarely required in these patients.

The doctor may ask patients the following questions

When patients go to the Urology doctor, the doctor may ask some questions. These are questions that will help in the diagnosis and treatment of the disease. We often ask our patients the following questions:

• Does urinary incontinence occur at night or during the day?
• What are the eating habits like?
• Is alcohol, coffee, tea consumption high?
• Are there recurrent urinary tract infections?
• Does it happen every night or intermittently?
• Do you have difficulty urinating, thin fork urination?

Treating bedwetting at night

Adult bedwetting treatment includes a wide spectrum from lifestyle changes to surgical treatment. Treatment options for these patients are:

Lifestyle changes: Lifestyle changes have an important place in the treatment of this disease. We always tell our patients about the importance and benefits of these changes. These changes are:

• Fluid restriction: Lifestyle changes come first among the treatment methods we recommend to patients with enuresis. We recommend these patients to reduce their fluid intake before going to bed in the evening, and to reduce their consumption of alcohol, coffee and tea. Also, if these patients are using diuretics and it is not essential, it is better to cut them off or use them during the day.
• Increasing bladder capacity: These patients’ increasing fluid intake during the day and prolonging the urination intervals will increase their bladder capacity over time. As a result, it will be possible to achieve improvements in bedwetting problems.
• Alarm system: By installing an alarm system at night, patients can be ensured to urinate and stay dry.
• Wake up from sleep: In these patients, sleep is deep. Waking up patients during their sleep and urinating can prevent urinary incontinence.

Medication: In the treatment of this disease, it is possible to get positive results from medication. However, it is necessary to use this medicine regularly and continuously. When the drug is discontinued, the complaint reappears.

• Antidiuretic hormone (ADH): Drugs that act like ADH hormone are preferred as drugs. In this way, urine production from the kidneys decreases and patients can stay dry.
• Anticholinergics: This group of drugs helps by affecting the contraction of the bladder muscle. Some of these patients may also have involuntary contractions of the bladder muscle or an overactive bladder problem. Anticholinergic drugs act by inhibiting muscle contraction in the presence of involuntary bladder contraction and overactive bladder. We have had very good results with this treatment in some of our patients. It is possible to achieve successful results in suitable patients.

Surgical treatment methods for bedwetting at night: Different surgical methods are used in the treatment of bedwetting in adults. These are rarely needed. These surgical methods can be applied in suitable patients who do not respond to other treatments.

• Sacral nerve stimulation: By stimulating the sacral nerve roots from which the bladder nerves exit, the contraction of the bladder muscle is reduced, as a result, the bladder expands and the bladder is prevented from pumping urine.
• Cystoplasty surgery: Some of these patients have a small bladder capacity. Therefore, surgical procedures to increase bladder capacity are effective in the treatment of appropriate patients. For this purpose, the most common surgery we do is to increase the bladder capacity with a piece taken from the small intestine. This surgery is called ileocystoplasty surgery.
• Detrusor myotomy: The aim of this surgery is to prevent excessive and involuntary contraction of the bladder. Layers are cut from the outer part of the bladder to the structure called the mucosa that covers the inner part of the bladder, and the mucosa is left intact. As a result, involuntary contractions of the bladder are prevented.

Acupuncture treatment: There is not much information in the literature about the scientific place of acupuncture in the treatment of bedwetting. There are reports of success with this method. Some of these are thought to be psychological. We do not recommend this treatment to our patients.

In summary: Bedwetting at night, which continues at young ages and does not improve, is a health problem that puts patients under stress. It is possible to get positive results with appropriate treatment. Lifestyle changes play an important role in treatment. Patients must apply to a urology specialist and follow their recommendations and apply the given treatment.

Prof. Dr. Emin ÖZBEK

Urology Specialist

Istanbul- TURKEY