Bedwetting and Voiding Disorders

NIGHTTIME BEDWETTING (NOCTURNAL ENURESIS)

If a child who has turned five continues to wet during nighttime sleep, this is called bedwetting (nocturnal enuresis). Bedwetting at night before the age of five is not considered abnormal. Bedwetting is more common in boys, and its frequency decreases with age. About 15% of five-year-old children have a nighttime bedwetting problem. Its frequency decreases by 15% each year, falling to about 1% by adolescence. This suggests that nighttime bedwetting results from a delay in the child's normal developmental process.

CAUSES OF NIGHTTIME BEDWETTING

Genetic predisposition plays a major role in this problem. If the mother or father has a history of bedwetting, the child has a 44% chance of bedwetting; if both parents had this problem, the chance is 77%.

Increased nighttime urine production: If there is a problem with the release rhythm of ADH, a hormone released at night that reduces urine production by causing the body to retain water, nighttime urine production increases and results in wetting.

Deep sleep and waking problems: These children are unable to sense that the bladder is full, or are unable to wake up even when they sense it.

Involuntary bladder contractions: This condition, which usually also causes daytime urinary symptoms, can also cause wetting at night.

Psychological causes: Underlying psychological causes are found in 5-10% of children who wet at night.

Organic problems: In a small proportion of cases, around 2-3%, problems such as urinary infection, hyperthyroidism, diabetes mellitus, voiding dysfunction, urethral valves or sleep apnea underlie the bedwetting.

Sometimes children who did not have a nighttime wetting problem may develop wetting later due to psychological causes such as the arrival of a sibling, parents' divorce, loss of a family member or mistreatment.

TREATMENT OF NIGHTTIME BEDWETTING

Behavioral Therapy: Explaining the problem and giving detailed information to the child and family is very important for the success of treatment.

First of all, children's fluid intake should be restricted starting 2 hours before bedtime. They should always be made to urinate before going to sleep and should be woken 1-2 hours after falling asleep to urinate. Salty foods should be avoided at dinner. Fluid intake should be spread evenly throughout the day. If there is constipation, it must be resolved. A high-fiber diet and adequate fluid intake are essential for this.

Regulating urination is also very important. The child should go to the toilet every 2-3 hours at home and at school and urinate regularly. For the child's pelvic floor muscles to relax and the bladder and bowels to empty completely, the child needs to sit in a proper position on the toilet with feet flat on the floor, with a support placed under the feet if needed.

The child should be asked to record wet and dry nights. A reward system used here will motivate the child. However, punishment should be avoided.

Medication: The most commonly used treatment is a hormone analog (desmopressin) that reduces the amount of urine at night. The aim is to replace the deficient ADH hormone with desmopressin, increasing the body's water retention during sleep and reducing urine output.

The greatest advantage of this treatment is that it starts working from the first dose and is easy to use. Its most important disadvantage is that bedwetting may start again after the medication is stopped. Although there is a common misconception that this medication causes infertility, no such effect has been reported in the literature.

In addition, depending on the underlying disorder, there are also medications that regulate the nighttime waking problem or prevent the bladder from being overactive at night.

Alarm Therapy: This is a treatment method recommended particularly for children who have difficulty waking up. The main aim is to create a conditioned reflex in the child. Woken by an alarm that sounds at even a single drop of urine, the child involuntarily contracts the bladder sphincter muscle and holds the urine. The goal is for the child to learn, over time, to wake up when the bladder is full before wetting. This is a long-term treatment, and the child must be taken to the toilet every time the alarm sounds. It should be used for at least 6-8 weeks to assess its effectiveness, and if there is a response, it should be continued for 3-6 months.

DAYTIME WETTING AND VOIDING DISORDERS

Voiding disorders such as daytime or nighttime wetting, frequent urination, sudden urgency, holding urine and difficulty starting urination are seen in about 20% of children over the age of five. These problems often result from inadequate bladder development as the child grows. But first, neurological (nerve-related) and anatomical (structural) causes that may lead to this condition must be ruled out, because serious neurological or anatomical disorders that can lead to kidney failure if left untreated may underlie voiding problems.

TREATMENT

First, a detailed history and examination along with a few simple tests are performed to understand the source of the child's voiding problems and whether there is an underlying disorder. The child is asked to keep a voiding diary for a certain period to understand the severity of the problem.

The child and family are given practical instruction on how regular and correct urination should be done, proper voiding posture, avoiding urine-holding maneuvers, preventing constipation, controlling fluid intake and adjusting lifestyle.

In addition to voiding training, wetting in children can be treated, depending on the severity and type of the voiding problem, with medication, pelvic floor muscle training, the biofeedback method (through play) or interventional (surgical) methods.

A Solution with the Biofeedback Method (Through Play)

"Urotherapy", which aims to teach children how to use their urinary control muscles, is defined as a bladder training and rehabilitation program aimed at correcting bladder filling and emptying disorders.

Following the voiding recommendations, a 6-week hands-on training program is given that teaches the child how to use the pelvic floor muscles with the help of a number of computer-assisted games. In this treatment method, which we call "biofeedback", applied once a week with each session lasting about 30 minutes, various computer animations are used.

In this program, the child is asked to move a fish or a bird seen on the computer screen and try to help it escape from dangers (a wolf, a snake, etc.). To do this, the child needs to contract or relax the urinary control muscles sufficiently. Through this fun program and short exercises given to do at home, the aim is to teach the child to control the urinary control muscles on their own.

This treatment program, which has been used for years in Europe and America, has in recent years also begun to be used and gain popularity in our country. Scientific studies on the results of this program report a success rate of over 90% at the end of the 6-week treatment period, without the need for medication.