Bedwetting: is it time to seek medical help?

If you're worn out by battles over bedwetting, take stock and see whether you need to chill out or seek medical help, writes Dr Melanie Woodfield.

So you've followed Stoppard, Spock and Supernanny, and your little ray of sunshine is still wetting the bed? Months of effort, rewards, enthusiastic praise for weeing in the potty seem to have gone straight down the toilet and you may be frustrated, exhausted, bored or accepting, but should you be worried?

It's perfectly normal to expect some ups and downs on the path to toilet- training a child. Your child might be dry during the day but have the occasional "accident", or might be still wetting at night while being dry during the day. It's also normal to take a long time for a child to become dry: three to five months on average, if you start when a child is two years old. Some children in particular just take that little bit longer. If your child is prone to being anxious or stressed out or has a developmental disability, toilet training might take a little longer, and that's perfectly okay. Big events in the family's life, such as the birth of a new baby, moving house, earthquakes or parents separating, can also contribute to children slipping back to bedwetting for a while. Although it can be frustrating, it's important to view toilet-training in context: most children stop wetting the bed by about age four, and most of those who don't will stop within a year or two.

Did you know...

Bedwetting is very common. According to www.continence.org.nz, it affects 15% of five year olds, 5% of 10 year olds and 2% of 15 year olds. That means the mothers of several other kids in your child's primary school class are rinsing sheets in the morning too.

Bedwetting runs in families, especially in male relatives. Kids who wet the bed for extended periods often have a close relative who did too, and children of bedwetters are much more likely to be bedwetters themselves, especially if both parents wet the bed."

There is a link between "behaviour problems" (conduct issues) and wetting the bed. Also, children who have ADHD and other similar conditions wet the bed more often. This is not to imply that this group of children are deliberately wetting the bed - just that the two issues are linked in research studies.

Should I be worried?

Around the world, the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) is used by professionals to identify when wetting ("enuresis") and soiling ("encopresis") could be cause for concern. You might be interested to know that a child needs to be at least five years old, and wetting twice per week for three months (or be very distressed or disadvantaged by the wetting) before coming close to meeting criteria for  a "disorder". Similarly, with encopresis a child needs to be at least four years old and soiling themselves at least once a month for at least three months.

Let's look at some examples: Definitely seek help if you have a five year old still in nappies who has never been dry. The cause is most likely medical. However, a four year old still having accidents when out and about is unlikely to need medical help as it's common for children to fail to notice bodily cues when they're playing.

However, a three year old who has been toilet-trained and who suddenly starts wetting himself again for no obvious reason may well have a medical problem. In the absence of any possible causes it's worth visiting the GP to exclude possibilities such as a urinary tract infection (UTI).

Sometimes there are psychological or emotional issues at play. A rather anxious child who suddenly starts having accidents when she starts school may still benefit from a trip to the doctor. There are effective techniques to help children manage anxiety. It's worth getting on top of the issue, as "holding on" for extended periods of time can distract children from school work and may contribute to a urinary tract infection.

There is a wide range of "normal" in this area. In my work as a caregiver of children in the past, I've changed many a wet sheet of a seven, 10 or even 12 year old. Encouragingly, at these later ages, there is quite a substantial remission rate of about 10% per year - in other words, 10% of children per year with wetting issues who are over five years old will just sort themselves out, without intervention.

But what should we do with those children who keep wetting or soiling and are heading into their primary school years? Try this plan of attack: 

• Make sure you've tried all the usual toilet training techniques such as star charts, descriptive praise and rewards.
• Visit your GP to exclude the possibility of a medical issue, such as a UTI.
• If your child is healthy but still wetting, consider using a bedwetting alarm. See the information below for where to hire alarms in New Zealand. 
• If an alarm isn't successful, and your child is school aged and/or distressed by the wetting or soiling, visit your doctor again. It may be that a referral to a medical specialist is in order. Or you may be eligible for free services from a child and adolescent mental health service and your GP can facilitate this. Alternatively, your doctor may be able to help find a professional in private practice who can help (expect to pay between $120 and $300 per hour). 

Bedwetting can be very embarrassing for children and can stop them attending sleep-overs or school camps, for fear of being different to other children. In some cases, doctors can prescribe medications such as Desmopressin, which is a nasal spray to temporarily stop a child wetting the bed. Once the medication stops, however, bedwetting usually resumes.

Dr Melanie Woodfield is a child and adolescent clinical psychologist in Auckland, and mother of two preschoolers.