Bedwetting and ‘Accidents’: Solutions for Children

If you’re up in the middle of the night putting your child’s soaked-through bed sheets and pajamas into the washing machine again, you might be wondering how long until you don’t have to do this anymore. For most children, bedwetting and daytime accidents are just a passing phase, but for some, there is an underlying urinary incontinence issue that should be checked out by a pediatric urologist.

That was the case for one 8-year-old who started having urinary incontinence issues in early grade school. And the problem was only getting worse, says her mom, Caroline, of Westbrook.

“One day my daughter had an accident on the playground but told the other children she was just sweating,” Caroline says. Despite the child’s quick thinking, the embarrassment of having urinary incontinence issues was becoming a daily struggle. Problems continued on and off for months, until the family sought medical care and learned the main problem was constipation.

This is not uncommon says Israel Franco, MD, a Yale Medicine pediatric urologist whose new program, called the Pediatric Bladder & Continence Program, helps children ages 5 to 21 gain bladder control.

“The first thing I tell parents is to make sure their child is not constipated,” he says, adding that after potty-training, many parents have no idea if their children are having regular and normal bowel movements. When a child has constipation issues, it can lead to urinary incontinence because the nerves for the rectum and bladder are close to each other in the spine, and the nerve signals can get crossed. When that happens, the bladder may be led to contract instead of the colon.

Constipation is just one of many causes of incontinence, though. Another common scenario is that a child with Attention Deficit Disorder (ADD) or Attention Deficit Hyperactivity Disorder (ADHD) who struggles with “executive function” (planning and follow-through skills) has accidents because processing signals may not work as quickly as needed to delay the need to urinate long enough for the child to get to the bathroom.

“It’s important to understand and manage executive functioning,” says Dr. Franco, noting that 20 percent of kids with ADD/ADHD have incontinence issues. It’s important to know that children who don’t have ADD/ADHD can also have trouble with executive functioning, too.

“There can be other behavioral components to voiding symptoms,” says Kaitlyn Murphy, APRN, CPNP, a clinician with the program. For instance, children with oppositional defiant disorder, anxiety, depression or autism (among other conditions) may also encounter urinary incontinence issues.

Life gets better for children when bladder issues are addressed. “Improved self-esteem, socialization and independence have been observed in children who’ve undergone incontinence treatment,” Murphy says.

Dr. Franco has reassurance to offer families struggling with this problem: “The vast majority of children who wet are going to stop.” That should come as a relief, but it’s still a good idea to get the problem checked if the incontinence issues go on for more than two months. “With many of the problems children have, the earlier we can make certain changes the better,” Dr. Franco says.

Importantly, problems with bladder control that are left untreated can progress to additional problems later in life, too. “One-third of children who wet will continue to have urinary incontinence in varying degrees for the rest of their lives,” he says. That’s especially true for girls with a type of incontinence called overactive bladder.

Urinary incontinence is diagnosed when a child involuntary releases urine during the daytime or nighttime, two times a month or more.

According to Therese Collett-Gardere, APRN, CPNP, a clinician with the program, here are the main kinds of incontinence issues children can have:

• Urge syndrome: Also called overactive bladder, children with this condition feel the need to urinate more frequently than normal.
• Dysfunctional voiding: The sphincter muscle contracts when the bladder is trying to empty, so urine is retained, causing the child to go more frequently.
• Lazy or underactive bladder: When the bladder muscle isn’t as strong as it is should be, the result can be a mix of symptoms. Some of these children urinate infrequently and others have to go often. 
• Neurogenic bladder: This is the diagnosis when bladder symptoms are associated with a neurological condition such as spina bifida, brain or spinal cord injuries.

Nighttime bedwetting issues are more prevalent in boys—especially when there’s a family history. Girls tend to have more trouble with bladder incontinence during the day. Some children achieve continence and then start having accidents, whereas others have never been fully toilet-trained to begin with. Here are some differences between daytime and nighttime urinary incontinence in children:

• Daytime incontinence: Urinary incontinence occurs in children ages 5 or older older. This problem affects up to 8 percent of all children.
• Nighttime incontinence: Called enuresis (or nocturnal enuresis), bedwetting is usually not treated until age 7 because staying dry all night can take longer to achieve than staying dry during the day. Nighttime incontinence is a problem for about 18 percent of 6-year-olds, 10 percent of 7-year-olds, 3 percent of 12-year-olds, and 1 percent of 18-year-olds. A tiny percentage will continue to have problems into adulthood.

Beyond constipation (mentioned above), any number of factors—or several—can underlie a child’s wetting issues. Among the common problems behind childhood incontinence are:

• Delayed maturity: Some children's brains mature more slowly, compared to their peers, but eventually catch up on their own.
• Incomplete or early toilet training: Sometimes potty-training when a child is not ready will cause children to push when urinating, which is not the correct way to do it. (The correct way is to let urine release naturally.) Pushing, in turn, leads to lack of relaxation of pelvic floor muscles and eventual problems with urination.
• Bladder overactivity: An overactive bladder means the child’s bladder may involuntarily contract and release urine before it’s full.
• Not waking up: When a child doesn’t wake up from deep sleep to use the bathroom, bedwetting can become a problem.
• Parental history: If either or both parents had urinary incontinence (day or night) issues growing up, their children are more likely to as well.

• Recurrent urinary tract infections (UTIs): Wetting accidents can go hand-in-hand with bladder infections.
• Severe stress event: Urinary incontinence issues can develop after a traumatic experience.
• Developmental issues: Children with developmental delays or who struggle with executive functioning for other reasons may have urinary incontinence.
• Other medical conditions: As mentioned earlier, another medical condition or disease could be causing incontinence such as type 1 diabetes, ADD, anxiety, depression, oppositional behavior, compulsive behaviors, cerebral palsy or spina bifida, for instance. 

Just about all causes of childhood incontinence can be effectively treated. “We can pretty much stop anybody from wetting,” says Dr. Franco. “It’s just how far you want to go with treatments.” He notes that some parents are reluctant to use certain treatments, such as medication, for example.

At Yale Medicine Urology Pediatric Bladder & Continence Program, the following treatments are available:

• Urotherapy: The first step is to teach the child proper voiding and bowel management techniques. In up to 50 percent of the cases, this can solve the problem without further intervention.
• Transcutaneous Electrical Nerve Stimulation (TENS): This noninvasive treatment is pain-free and well tolerated by children of all ages. At home, the child or parent applies an inexpensive, handheld device to the lower back in the sacral area, as instructed by the clinician. The device sends an electrical signal through the nerves to the brain to help interrupt reflexes that are preventing the bladder from functioning normally.
• Biofeedback: Special sensors are placed on the skin near the anus to measure the strength of the pelvic floor muscles. Pelvic floor muscles support the bowel and bladder and are used to stop the flow of urine. Using computerized graphics and sounds, biofeedback therapy can help children identify where their pelvic floor muscles are and learn how to relax them when urinating. Unlike in adult biofeedback, where patients learn to tighten their muscles, children need to learn to relax these muscles when they urinate. 
• Medications: We only prescribe medication when medically necessary to address bladder issues. Antibiotics can be used to treat frequent UTIs, but we prefer to treat the underlying cause of UTIs rather than prescribe antibiotics when possible.
• Counseling: Our team collaborates with experts at Yale Medicine Child Study Center. Cognitive and behavioral therapy can sometimes help children to modify behavior in order to manage the problem. In some cases, cognitive behavioral therapy can be a better method to treat overactive bladder. Counseling can also help children cope with social embarrassment that can occur at sleepovers, home and school.
• Clinical trials: Drug trials, such as one using Botox for children with severe urinary urgency issues caused by bladder overactivity, are available at Yale Medicine. Another trial will soon be available for patients with neurogenic bladders and overactivity. 
• Surgery: Rarely, there is an anatomical problem needs to be corrected surgically by a urologist.

One or a combination of treatments can help a child who is struggling with daytime or nighttime wetting issues. Though well-meaning friends or family members (or even your pediatrician) may offer reassurance that “this is normal,” don’t ignore the problem. “Just don’t believe it if people say it’s okay if your child wets every day, or four or five days a week,” says Dr. Franco. Founder of the new Yale Medicine program, he has made pediatric urinary incontinence his life’s work.

“I see my patients as interesting intellectual puzzles. They’re so complicated, and it’s rewarding trying to figure out where the problem lies,” says Dr. Franco. That means you don’t have to go it alone to help your child stay dry, both day and night.

For more information about Yale Medicine Urology's Pediatric Bladder & Continence Program, call 203-785-3588.