Sleep Enuresis

What Causes Sleep Enuresis?

Sleep enuresis in older children and adults may be caused by many different medical issues. In general, the condition occurs when a person experiences greater than normal urine production, has problems with bladder control, or has a condition that makes it difficult to arouse from sleep to go to the bathroom.

Conditions sometimes associated with sleep enuresis include:

• Smaller than typical bladder size or other structural problems of the urinary tract
• Nerve dysfunction that interferes with bladder control
• Chronic constipation
• Diabetes
• Lower than normal levels of anti-diuretic hormone (ADH)
• Sleep apnea
• Urinary tract infections (UTIs)
• Sickle cell disease

Sleep enuresis may also be associated with mental health-related issues such as attention-deficit/hyperactivity disorder (ADHD), bipolar disorder, or autism spectrum disorder.

Is Sleep Enuresis Hereditary?

Research suggests that there is a strong genetic component to sleep enuresis. Many children affected by bed wetting also have a close family member who has also experienced the condition.

Scientists have not yet identified a gene or genetic mutation associated with sleep enuresis. Likely, some people are genetically predisposed to experiencing the disorder, but some external environmental factors may trigger the problem.

How Is Sleep Enuresis Detected?

Bed wetting is common in young children and is generally not a cause for concern in children younger than five. Most children will develop consistent bladder control between the ages of five and seven. However, frequent bed wetting (at least twice a week over three consecutive months) that occurs past the age of seven is a reason to consult a doctor. In addition, bed wetting that develops in older children, adolescents, or adults after a period of normal night-time bladder control is also a reason to consult a doctor.

How Is Sleep Enuresis Diagnosed?

Doctors may take several different diagnostic steps when a patient is experiencing sleep enuresis.

• Physical exam. A basic physical exam will screen for indications of medical conditions that could be causing the bed wetting.
• Blood tests. The doctor may order laboratory blood tests to rule out conditions, such as diabetes or infections, that may be causing the problems.
• Imaging exams or x-rays. These exams may be used to look for evidence of structural problems or medical conditions that can cause incontinence.
• Sleep diary. Your doctor may ask you to keep a sleep log over two weeks to look for patterns in your sleep and urination behavior. You may also be asked to track other habits impacting your sleep, such as caffeine use.

PLEASE CONSULT A PHYSICIAN FOR MORE INFORMATION.

How Is Sleep Enuresis Treated?

In many cases, bed wetting symptoms resolve on their own without treatment. Improving sleep hygiene may help, as well. In cases where the symptoms are caused by an underlying condition such as sleep apnea or constipation, treatment of that condition may relieve the problems with bed wetting.

When enuresis does not respond to other treatments or lifestyle changes, doctors may prescribe treatments to directly address the incontinence, including:

• Medications, most often desmopressin (DDAVP), to decrease urine production
• Medications such as oxybutynin to aid bladder control
• The antidepressant imipramine for adults who do not respond to other treatments
• Moisture alarms to help wake the person at the first sign of urination

How Does Sleep Enuresis Progress?

Although the underlying conditions that cause bed wetting are often not serious or life-threatening, the emotional and psychological impact of the problem can be severe.

Untreated sleep enuresis can lead to a wide variety of quality-of-life complications and mental health-related issues, including:

• Risk of physical or emotional abuse of children by parents or caregivers
• Bullying
• Social isolation
• Low self-esteem
• Problems at work or school
• Relationship difficulties
• Anxiety or depression

How Is Sleep Enuresis Prevented?

There is no known way to prevent bed wetting, but good sleep habits and a healthy lifestyle can help to moderate the symptoms in many cases. Steps you can take to ensure better sleep include:

• Stick to a regular sleep schedule (even on weekends)
• Don’t eat or drink close to bedtime
• Avoid stimulating activities (e.g., watching TV, using electronics) 30 minutes before bedtime
• Use your bedroom only for sleep
• Keep your bedroom dark and cool
• Get plenty of exercise
• Limit consumption of caffeine and alcohol
• Quit smoking
• Don’t take naps
• Try meditation or relaxation techniques

Sleep Enuresis Caregiver Tips

Some people with sleep enuresis also suffer from other brain and mental health-related issues, a condition called co-morbidity. Here are a few of the disorders commonly associated with sleep enuresis:

• Attention-deficit/hyperactivity disorder and sleep enuresis are commonly associated with one another.
• Children with oppositional defiant disorder are at increased risk of sleep enuresis.
• Autism is also commonly co-morbid with sleep enuresis.
• People with bipolar disorder or other mood disorders are at increased risk of sleep enuresis.

Sleep Enuresis Brain Science

Researchers are currently working to understand how atypical changes in brain development or function might lead to the symptoms of sleep enuresis. Areas of recent research include:

• Some studies have suggested that developmental delays in specific brain areas lead to small structural differences in those areas. The minor abnormalities may, in turn, affect a child’s ability to store and eliminate urine during the night. Brain areas implicated in these studies include the frontal lobe, the anterior cingulate cortex, the insula, and the thalamus.
• Other studies have suggested atypical development of the paraventricular thalamus (PVT) may impact a child’s ability to normally transition from sleep to a waking state. The problem may cause the child to remain asleep when they need to urinate during the night.

Sleep Enuresis Research

Title: TENS Treatment for Bedwetting

Stage: Recruiting

Principal investigator: Adam Howe, MD

Albany Medical College

Albany, NY

Children referred to the pediatric urology clinic for primary nocturnal enuresis will be screened for enrollment. Patients who fail will next be offered therapy with a bedwetting alarm device or a TENS unit as an alternative, and those who chose TENS therapy will be included in the study. The patients will be randomized into three groups of 20 patients each. Group 1 will be the long frequency set at 2 Hz (hertz). Group 2 will be the moderate frequency set at 10 Hz. Group 3 will be the short frequency set at 150 Hz. The patients will be provided with a TENS unit and electrode pads with caretakers instructed on how to use the apparatus.

The child’s TENS unit will be set at a frequency determined by randomization, a pulse width of 260 seconds, and the intensity to be determined in the office based on when the child feels sensitive to the TENS unit. The child will be randomized and will place the electrodes along the posterior tibial nerve on the medial ankle each night before bedtime for 15 minutes for a total of 30 days. Diaries, including nighttime incontinence episodes and a “wet sheet” scale (dry, damp, wet, soaked) will be recorded, along with any adverse reactions to the TENS unit. Patients will be followed up after one month of TENS with evaluation, including the Pediatric Urinary Incontinence Questionnaire, a validated tool for measuring quality of life in children with bladder dysfunction; this questionnaire will be filled out before starting TENS treatment to compare the effect of treatment on QOL. The data will be collected at different time points (baseline and after 1 month of treatment) for each group by itself, and the groups compared against each other using statistical analysis.

Institutional review board approval was obtained. Children ages 5-18 years old referred to the pediatric urology clinic for primary nocturnal enuresis will be screened for enrollment. Behavioral modification (limiting evening drinking, double voiding before bedtime, bowel habits, and social anxiety factors) will be utilized first. Patients who fail will next be offered therapy with a bedwetting alarm device or a TENS unit as an alternative, and those who chose TENS therapy will be included in the study. Patients who have previously tried pharmacologic treatment for nocturnal enuresis or alternative therapy for urologic disorders within the past 30 days, daytime incontinence symptoms, known “high volume” voiders (determined from history), bedwetting episodes on the average of less than one time per week, medications predisposing to incontinence (e.g., Lithium for bipolar disorder), other known voiding or neurologic disorders (e.g., overactive bladder, myelomeningocele), secondary etiologies for nocturnal enuresis (e.g., cystitis, obstructive sleep apnea, urinary fistulae), prior use of a TENS unit or other neuromodulation for bedwetting, and any contraindications to the usage of a TENS unit such as having a pacemaker will be excluded. Patients who have previously tried the bedwetting alarm will not be excluded from the study.

The patients will be randomized into three groups of 20 patients each. Group 1 will be the long frequency set at 2 Hz. Group 2 will be the moderate frequency set at 10 Hz. Group 3 will be the short frequency set at 150 Hz. There is no sham group in this study as the investigator has previously found posterior tibial TENS to be effective and lasting, and as such, all patients will be treated. The investigator will aim to recruit 20 patients per group for a total of 60 patients. A detailed explanation of the purpose of the study, along with the risks and benefits of TENS will be given to the patient and caretakers by a provider before obtaining informed consent for enrollment into the study. The patients will be provided with a TENS unit and electrode pads and caretakers instructed on how to use the apparatus.

Parents/patients of enrolled patients will fill out nightly voiding diaries, recording nighttime incontinence episodes and subjective “wet sheets” scale per night (dry, damp, wet, soaked) for 30 days before randomization into the treatment arms. The TENS sessions will be performed at bedtime for 15 minutes for 30 days. TENS units will be set at a frequency of 10Hz, and intensity will be determined in the office by the sensitivity threshold of the patient. Voiding diaries will be kept each night while on TENS therapy. A voiding diary will also be completed 30 days before TENS treatment; patients and families will fill out the Pediatric Urinary Incontinence Questionnaire (PIN-Q), a validated tool for measuring quality of life in children with bladder dysfunction. Patients will follow up on day 30 and as needed (worsening symptoms, adverse reactions, concerns, and questions regarding usage of TENS). Patients who record 2 wet nights per week (a total of 8/30=27% wet nights) will be eligible for the TENS study. Those who record less than 2 wet nights per week will be ineligible for the TENS study but will be offered therapy using a bedwetting alarm device or other treatment.

Title: Investigation of Brain Mechanisms Involved in the Urinary Continence Mechanism Associated With Aging

Stage: Recruiting

Principal investigator: Becky Clarkson, PhD

University of Pittsburgh

Pittsburgh, PA

Urge urinary incontinence (UUI) is a common problem in older people, which vastly reduces quality of life, yet the cause and mechanism of the disease are not well understood. This study will characterize brain control of the bladder in young and old continent individuals and age-matched incontinent counterparts. This will expand the investigators’ current knowledge of how the brain controls the bladder, how that control changes with age and disease, and suggest new targets to guide the development of better treatment.

Current data suggest that bladder control comprises 3 cerebral circuits that maintain continence by suppressing the voiding reflex in the midbrain. In the UUI phenotype that responded to BFB (Biofeedback assisted pelvic floor muscle therapy), the mechanism involved enhancing deactivation of the first brain circuit (medial prefrontal cortex, mPFC), which resulted in less activation of the second circuit (which includes the midcingulate cortex). In the phenotype that was resistant to BFB, no brain changes were observed. Although the investigators have an emerging picture of the brain’s role in UUI, the investigators have only a rudimentary understanding of what is ‘normal,’ i.e., how the brain normally controls the bladder. Moreover, the investigators do not know whether this control mechanism is the same across the lifespan, or whether it changes owing to the impact of aging. Thus, the investigators’ aims are to characterize the brain’s normal role in bladder control in both young and older people, to determine the changes in brain structure and function that lead to bladder control failure (UUI), and to examine how such changes differ between young and old individuals. To address the aims, the investigators will utilize detailed neuroimaging to evaluate 80 asymptomatic women and 80 women with UUI, each group divided into young (18-45) and old (65+ years) individuals. The study will enable the investigators to define the brain’s key structures, functional activity, and mechanisms involved in normal bladder control, and to identify the differences in these elements among those with UUI, both young and old.

By elucidating the mechanisms that mediate the brain’s control (and loss of control) of bladder function, the proposed study should enhance the investigators’ working model, deepen the understanding of the impact of aging, and identify better targets for the treatment of UUI. In addition, it may enable scientists to develop novel and more effective new therapies based on the revolution in neuroscience and more hope for UUI sufferers.

Title: Enuresis Alarm – Is a Manual Trigger System Beneficial?

Stage: Recruiting

Principal investigator: Gina Lockwood, MD

University of Iowa

Iowa City, IA

This study aims to evaluate whether the bedwetting alarm trigger activated by parents to wake their child, in addition to the moisture alarm, will improve treatment success compared to the moisture alarm alone.

Nocturnal enuresis is a common issue in children, and the use of bedwetting alarms has shown the best long-term success. However, using alarms is very time-intensive, often taking months before yielding results. Therefore, researchers in the division of pediatric urology are initiating a randomized controlled study comparing a standard bedwetting alarm with a newly developed technology, with the hope that the new alarm will result in better, more rapid, and easier treatment for bedwetting.

Children between the ages of 5 to 15 years old who have issues with bedwetting after successful toilet training may qualify for the study.

Participants must first be evaluated by a pediatric urology specialist.