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Raising the Alarm on Enuresis
(by Doctor Anthony Page)
| Introduction
The latest research on bedwetting shows that between 10% to 20% of children around the age of 5 yrs of age wet the bed at night (1,15,18). Bedwetting runs in families, too, and recently a genetic marker has been found in those who have primary enuresis (the kind where the child has never been dry at night) proving that it is not the fault of the bedwetter. Most bedwetters do not have psychological problems, although it is a good idea to look for any emotional upsets or perhaps an illness if the child has been dry then starts to wet the bed. Bedwetting is caused by an illness in only about 1% to 2%, a urinary tract infection being the most common - though it is always sensible to have a patient checked over by a doctor.
Treating the problem
Quick fixes that don't
Medication: one common form of medication is the tricyclic antidepressant - a drug type which is traditionally used as a treatment for adult depression. With an initial cure rate of 25%, and a relapse rate of 50% (2) these drugs have a rather disappointing success rate of 12%. As well as the low success rate there is also the concern that tricyclic antidepressants cause side-effects such as rashes, loss of appetite and irritability, as well as being responsible (according to a study in the UK) for poisoning more children than any other drug. Dr Schmitt (3), a paediatrician in the Department of Paediatrics at the University of Colorado School of Medicine, and an expert in enuresis, refers to "...newer studies which demonstrate tricyclic antidepressants raise the resting pulse rate and diastolic blood pressure..." and concludes that there are "...grave doubts that these drugs should be prescribed for any child at all". Dr Rauber and Dr Maroncelli (16) noted that few general practitioners seemed aware of the toxicity of tricyclic antidepressants in overdose, and were adamant that other modes of treatment should be explored rather than turning to what they termed "the more hazardous pharmacologic alternatives". And finally, Dr Black (14) tells us that "...drugs should never be used as a first line of treatment because of their side-effects and the danger of toxicity in overdose".
Another medication, Desmopressin, is a synthetic pituitary hormone which helps to reduce the amount of urine produced when a patient is asleep. At first glance, it looks like a very useful alternative because it does stop bedwetting in a significant number of users. But for all that, Dr Wille (19) reports that most children return to wetting the bed after they stop using it, and Dr Houts and his colleagues (17) find a success rate of just 21% when the relapse rate is taken into consideration. In addition, these types of medication have side effects such as headaches and stomach aches and can interfere with electrolyte levels (the proper balance of the body fluids). Lister-Sharp et al (1997) (21) of the University of York reviewed the treatment studies and showed that there was no conclusive evidence that drugs had any useful effect after treatment had ceased. At best they are useful only when being taken and for short term relief (Houts et al (17), Steele, (18)).
The Enuresis alarm - the best long term cure
Mode of operation: An enuresis alarm works by emitting a loud, high-pitched beep when a child begins to pass urine. Obviously, this causes the child to wake up; but more importantly, it causes an automatic contraction of the external bladder sphincter (the muscle which controls the bladder neck). No sooner has the child begun to urinate and the reflex to do so is suppressed. Over a few weeks, most children develop an increased sensitivity to subliminal bladder contractions during the night. They learn to inhibit the reflex to pass urine - ultimately without having to wake up or wet the bed at all.
Enuresis alarms
Research into the effectiveness of enuresis alarms has been going on for over 50 years - a fact which is made clear by Dr Forsythe and Dr Butler (15). Throughout that period, success rates have risen to 90% (6,13) - as more refined electronic models have been introduced. Of the 90% who are cured, around 20% may relapse, but most of these return to dry nights with another course of the alarm. In the University of York Review Lister-Sharp et al (1997) showed that an enuresis alarm is nine times more effective in preventing relapse than the drug Desmopressin. And so, it will come as no surprise to discover that Dr Houts and co (not to mention many other authorities) have described the enuresis alarm as the most successful treatment of bedwetting to date (15,17), and as the modern treatment of choice (7,12, 18). These glowing references are further reinforced by Professor Hjalmas (20) of the Department of Paediatric Surgery and Urology at Gothenburg who says that "the alarm should be the first line of treatment because [it] is the only method proven to have cured the problem." Also of interest in Dr Houts' study are the following: (i) The finding that increased length of treatment with medication decreases its effectiveness, while increased length of treatment with an enuresis alarm increases its effectiveness. (ii) The discovery that children who have finished the treatment have much higher self esteem levels than before (12).
Treating the child
The first few times the alarm rings, the child is unlikely to wake up until the bladder is completely empty and the bed is as soaked as ever. As time goes by, however, the child learns to wake up sooner. As a result, urination can be partly inhibited for as long as it takes to walk from the bedroom to the bathroom where the draining process can be completed. Eventually the child learns to recognise the feeling of a distended bladder before the alarm rings. As a result, the bladder can be controlled before it is too late or the child can choose to wake up and deal with the situation in a mature way. This process - of an effective treatment leading to a three week period with no bedwetting and no alarm activation - may take as little as a week or as long as a couple of months to achieve.
Disclaimer
Medical science is always changing and while the information presented in this website has been checked with reliable sources, it can not be guaranteed against human error from those or other sources used, or change of understanding by medical science which may occur as research proceeds.
References
1. Schmitt, B.D. Nocturnal Enuresis: An Update on Treatment. Pediatric Clinics of North America, 1982; 29:21
2. Ibid. P.27
3. Ibid. P.27
4. Ibid. P.22
5. Ibid. P.27
6. Ibid. P.26
7. Ibid. P.25
8. Ibid. P.25
9. Ibid. P.26
10. Ibid. P.21
11. Grellis, S.S. etal Current Pediatric Therapy, 1976, Volume 17. B. Saunders, Philadelphia.
12. Schirky, H.C. Pediatric Therapy, 1980, 6 Ed.Mosby, St Louis, Missouri.
13. Baller, W.R. Bed-Wetting: Origins and Treatment, 1975, Pergamon, New York.
14. Black, Dora. Psychotropic drugs for problem children. British Medical Journal, 1991; 302: 190-191.
15. Forsythe, W.I. and Butler, R.J. Fifty years of enuretic alarms. Archives of Diseases of Childhood, 1989; 64: 879-885.
16. Rauber, Albert and Maroncelli, Regina.Prescribing practices and knowledge of tricyclic antidepressants among physicians caring for children. Pediatrics, 1984; 73: 107-109.
17. Houts, Arthur C., Berman, Jeffrey S., and Abramson, Hillel. Effectiveness of Psychological and Pharmacological Treatments for Nocturnal Enuresis. Journal of Consulting and Clinical Psychology, 1994; 62: 737-745
18. Steele, Brian T. Nocturnal Enuresis: Treatment Options. Canadian Fmily Physician, 1993; 39: 877-880
19. Wille, S. Comparison of desmopressin and enuresis alarm for enuresis. Archives of Diseases of Childhood, 1989; 61: 715-726
20. Hjalmas, Kelm. GP Weekly News,1994, 23 March. Nocturnal Bedwetting is in the genes.
21. Lister-Sharp, D et al. A Systematic Review of the Effectiveness of Interventions for Managing Childhood Nocturnal Enuresis. NHS Centre for Reviews and Dissemination, University of York, 1997.
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