ENURESIS (BED WETTING)

DEFINITION:
Enuresis refers to bed-wetting occurring at least several times 
per month in children at least 5 to 6 years old. There is a wide 
variation in the age at which nighttime urinary continence is 
achieved, thus, normal preschool-age children who wet the bed are not 
viewed as having enuresis but rather considered to have 
developmentally appropriate night wetting. Bed-wetting is considered 
normal up to age 5. When the problem persists, however, a visit to 
the doctor is in order. Bed-wetting rarely signals a health problem, 
but daytime wetting, which often occurs with bed-wetting yet may be 
overlooked if it's only a dribble, can represent serious illness. 

DIAGNOSIS 

The first thing that needs to be established is the type of enuresis 
your child is suffering from; PRIMARY or SECONDARY. A history of the 
child's pattern of wetting will determine this. If he has wet 
consistently with few, or, short-lived periods of dryness then a 
diagnosis of primary enuresis will be given. Children with primary 
enuresis have never gone for a significant period--at least six 
months--without wetting the bed. Secondary (or acquired) enuresis is 
bed-wetting that occurs in a child who has previously demonstrated 
nighttime bladder control for six months or longer. The distinction is 
important because children with secondary enuresis will more often 
have underlying medical or psychological problems: structural 
abnormalities or infection of the urinary tractor significant 
emotional trauma. Over 90% of bed wetters, however, have primary 
enuresis. Is there a family history of enuresis? Genetic 
predisposition is extremely prominent. A positive family history of 
enuresis can help allay the child's shame, the parents' fears, and 
your suspicion of an organic etiology. 

If, on the other hand, the child begins wetting after a long 
period of dryness or begins wetting after no prior history of enuresis 
then it's secondary enuresis. 

PHYSICAL CAUSES: 

Bedwetting may be a symptom of another problem. This is why a 
thorough history is the next step including a history of toilet-
training methods, and sleep habits is needed. Even complications at 
the time of delivery, birth weight and milestones can be important. 
There is not one cause that encompasses all enuretics. 

1. Genetic Predisposition. The one factor that does seem to play a 
role in enuresis is heredity. For example, while it is estimated 
that only 15% of all children are enuretic, this figure increases 
to 45% when one parent was enuretic and 75% if both parents were 
bed-wetters. One possible explanation may be a genetic 
predisposition for insufficient productions of Antidiuretic Hormone 
(ADH). Results of a study announced by a Danish investigator, Dr. 
Jens Norgaard, demonstrated that 80-85 percent of his bedwetting 
cases in the past nine years were due to insufficient production of 
antidiuretic hormones (ADH). ADH production, which ordinarily 
increases during sleep, apparently remains unchanged during both 
day and night in bed wetters. 

2. Smaller functional bladder capacity; that is, the enuretics can 
hold less volume in their bladders before feeling the urgent need 
to urinate. Over 75% of enuretic children have small functional 
bladder capacity. Enuretic children often talk of a real urgency 
whenever they need to urinate. These children may also experience 
stronger and more frequent contractions of their bladder. 

3. Obstruction. Does the child ever experience daytime incontinence? 
A positive response would increase your suspicion of obstructive 
uropathy or of structural anomalies such as an ectopic ureter. A 
child with either of these problems will be almost constantly wet: 
He or she will have damp underwear during the day and a wet bed 
each night. (Diurnal incontinence may also be associated with 
emotional disturbances.) Stool impaction is a rare cause of 
enuresis that is always accompanied by fecal soiling. Severe 
impaction can impinge on the bladder by reducing its storage 
capacity or distorting the neck of the bladder and reducing control 
over urination. 

4. Urinary Tract Infection. (UTI). Does the child have symptoms of 
urinary tract infection (UTI) such as urgency, frequency, burning 
pain on urination, or fever? Does the urine have a foul odor? 5% to 
10% have UTI. 

5. Tonsillar obstruction. (Breathing difficulties at night can cause 
enuresis. These children tend to be groggy in the morning and 
easily irritated. They will often be mouth breathers and snorers). 

6. Neurogenic Bladder. Does the child also have fecal soiling? 
Enuresis accompanied by encopresis may indicate a neurogenic 
bladder. ( It may also be present in children with severe emotional 
problems. 

7. Urethral Meatal Stenosis. An uncommon cause of enuresis, urethral 
meatal stenosis seems to be physiologically significant only if it 
results in an abnormally thin and turbulent urinary stream, when it 
can produce retrograde pressure, urethral inflammation, bladder 
distention, and incomplete bladder emptying. 

8. Diabetes mellitus or insipidus. A thorough exam is particularly 
important in children with secondary enuresis, because of the 
greater likelihood that their problem has organic causes. 

PSYCHOLOGICAL CAUSES 

Because psychogenic factors may weigh more heavily in children with 
secondary enuresis, such children may need a more thorough 
psychosocial evaluation than children with primary enuresis. Possible 
causes include: 

1. Psychological Stress. Have there been recent significant stresses 
or crises in the family--births, deaths, marital discord, a move to 
a new home? Has the child changed schools? Has there been a change 
in his or her school performance or in relationships with friends? 
Has the child been ill or in the hospital recently? Is this a sign 
of regression in response to some recent trauma. This could be the
cause, particularly in an older child, who at one time was 
enuretic, has had a long period of being dry, and begins to wet
the bed after some life crises. 

2. Inhibition of impulses. How does the child handle his anger? You 
might ask this question of the parent(s) and then rephrase it and 
direct it at the child later in the interview: "What do you do when 
you get angry?" or "How would Mom and Dad feel if you got angry and 
said something to them?" Inhibition of expression of affects such 
as anger is sometimes a factor in enuresis, though it's more often 
implicated with encopresis of daytime incontinence. If the history 
suggests that an enuretic child is suppressing a significant amount 
of anger or rage, whether because of guilt or fear, you may wish to 
discuss this issue with the parents and the child, focusing on the 
verbal expression of anger, expression through permissible motor 
actions, and the constructive use of anger to resolve conflicts 
rather than create them. 

3. Secondary Gain. Occasionally, the child will unconsciously wet as
a means of getting back at a family member (usually the mother). 
Another of these secondary gains may be the intense involvement of 
the family in the enuresis problem. Effective management of bed-
wetting sometimes hinges on deft manipulation of the impact the 
condition is having on the rest of the family. Who gets up when 
the child wets the bed and how is the situation handled? Who's 
responsible for stripping the bed and washing the soiled items? 
Is the child ever left to sleep in a wet bed, or is any other form 
of punishment administered? How do siblings react to the situation? 
How do the parents behave toward the child on "wet mornings" and on 
"dry mornings"? Does the child wish to solve his problem? Is he 
embarrassed or ashamed? A child who seems to be unconcerned about 
wetting the bed may be deriving secondary gains from it and may 
consequently be quite difficult to treat unless you succeed in 
arousing some concern or in helping parents minimize the secondary 
gratifications of wetting the bed. 

3. Toilet Training. When toilet training was initiated, how it 
proceeded, and how well it worked can also be a factor. Although 
a harsh toilet training regimen more often results in daytime 
urinary or bowel incontinence, a child sometimes develops enuresis 
in the context or unrealistic parental expectations in this 
area. At the opposite extreme are parents who have been overly 
lax about their child's impulse control (weaning and toilet 
training late, for example) and who at first may not even have 
spoken with the child about the bed-wetting. This exaggerated 
permissiveness sometimes results in an impulse-ridden child who may 
not only wet the bed but also have difficulty dealing with other 
societal norms that frustrate the immediate gratification of 
impulses. 

PSYCHOLOGICAL TREATMENT 

Bedwetting itself is a rather benign disorder. In fact, it is not the 
wetting itself that causes parents to seek out treatment, but rather 
the hassle and embarrassment of wet sheets and the frustration and 
emotional scarring that are associated with the wetting. If your 
child got up in the middle of the night to use the toilet he would 
hardly be brought in for treatment. When considering whether to seek 
treatment, consider these factors: Does your child request treatment? 
Is your child's urination more frustrating to you or him? Is your 
relationship with your child suffering from this disorder? Is your 
child suffering emotional repercussions be cause he is wetting the bed 
(ie teasing, low self esteem, social restrictions)? 

Spontaneous resolution is generally the conservative rule if the child 
and parent are willing to wait. The spontaneous cure rate for 
enuresis is 15% per year after age 6 and that very few individuals are 
still enuretic after puberty. If not, taking your child to his doctor 
for a through medical examination to rule out the possibility of 
Primary enuresis. 

Enuresis is a common, often misunderstood condition that affects 
millions of children. Preventing psychological repercussions is an 
important consideration when deciding whether to seek treatment. Look 
at the stress on your child and yourself before deciding to pursue a 
treatment plan. Often just knowing that the condition is not unusual 
and that treatment is available is enough to alleviate a child and a 
parent's anxiety. 

Psychological Treatments for children with enuresis without an evident 
cause are varied. Most doctors agree that a combination of these work 
best. An excellent behavior modification described by Nathan Azrin, 
PhD, of Nova University, includes 4 basic principles: 

1. Alarm system 

2. Cleanliness training (putting dirty sheets into hamper and remaking 
the bed) 

3. Nightly waking schedule to urinate 

4. Positive practice (at bedtime lying down on the bed counting to 50 
then getting up to urinate, repeat 20 times). 

Enuresis Alarms: 
A "new generation" of enuresis alarms has rendered obsolete the older 
"bell and pad" alarm, which required the child to sleep on a 
cumbersome system of bed sheets and conducting mats that were attached 
to a rather large alarm. At least 10 mL of urine was required to 
complete the circuit and set off the alarm. The new enuresis alarms, 
typified by the Wet-Stop, are lightweight, portable, transistorized, 
and inexpensive ($35-$40). They're activated by even a few drops of 
urine, so the child has a much better chance of being awakened in time 
to finish urinating in the toilet. Moreover, they eliminate the need 
for conducting mats. The Wet-Stop, for example, features a small 
cotton flannel strip that is sewn to the outside of the child's 
underwear. A plastic insert with two metal strips fits into a pocket 
in the strip and is attached by wire to a tiny buzzer held in place by 
a patch of hook-and-loop tape (Velcro) sewn near the collar or 
shoulder area of the child's pajama top. 

When the alarm is activated by a few drops of urine, the child stops 
the buzzer by pulling the plastic insert out of the cotton pocket and 
shaking or wiping it dry. There is no possibility of electric shock 
because the unit is operated by tiny hearing aid batteries. The 
pockets and patches can be washed and dried by machine along with the 
pajamas and underwear to which they've been sewn. Four of each are 
provided with each alarm. 

The enuresis alarm gradually conditions an enuretic child to recognize 
subliminal bladder contractors during sleep. Children with small 
bladders often learn to awaken and void in the toilet instead of 
urinating in bed. Children with normal-sized bladders also may 
develop an increased awareness of bladder contractions during sleep 
but often learn how to inhibit the micturition reflex without the 
necessity of awakening to go to the bathroom. With both types of 
enuretic children, the ultimate goal is to have them gain control over 
the enuresis without the help of the alarm. 

Enuresis alarms are slow in effecting cures, often requiring three or 
more months of conscientious use. The child typically needs 4-6 weeks 
to master waking up promptly at the sound the buzzer and contracting 
his or her bladder sphincter so as to prevent a complete emptying of 
the bladder in bed. Another 4-6 weeks are usually required for the 

child to begin anticipating the alarm and awakening spontaneously upon 
bladder distention or to begin successfully inhibiting the micturition 
reflex. When the child has gone three weeks without wetting the bed, 
he can discontinue use of the alarm. 

Despite the lengthy time enuresis alarms take to cure bed-wetting, 
they have the highest cure rate of any therapeutic modality currently 
used for childhood enuresis, averaging about 70%. The relapse rate is 
approximately 10%-15%, but a short second course of treatment with 
alarms is usually successful. Relapse rates have sometimes been 
dramatically reduced by the use of over learning techniques, such as 
urging the child to drink as much fluid as possible in the hour before 
bedtime. 

What about the 30% of enuretic children for whom enuresis alarms fail? 

Roughly half of these children use the alarm improperly, 
inconsistently, or not at all, and the other half fail to awaken at 
the sound of the buzzer. Some of these hard-to-wake children may be 
helped by keeping a night-light on in the bedroom. It's not true, 
however, that enuretic children generally spend a greater amount of 
time in deep sleep than other children. Successful use of an enuresis 
alarm depends on your thorough and careful explanation of its purpose 
and functioning to the patient and his parents. After your 
instructions, the child should be able to set up the alarm system 
every night, use it correctly, and take care of its components on his 
own--though he may need some parental help with responding to the 
alarm quickly during the first week of therapy. 

Tell the child that the purpose of the enuresis alarm is to remind him 
to wake up when he has to urinate during the night. As such, he can 
consider it a backup system for his self-awakening program if he has a 
small bladder. Once the child understands how to operate the device, 
suggest that he give himself a nightly "pep talk" before going to 
sleep. This self-exhortation might run as follows: "I'm going to try 
to beat my alarm tonight. I'm going to wake myself up when In feel 
that I have to urinate. If the alarm goes off, I'm going to stop the 
flow and finish urinating in the toilet." 

Have the child continue to keep a record of his "dry nights," while 
using the enuresis alarm, and urge the parents to continue providing 
praise, encouragement, and rewards for his success. Schedule follow-
up visits or phone calls monthly for the duration of treatment. The 
best approach to using medications for childhood enuresis is a 
cautious one. The efficacy of drugs in permanently curing enuresis is 
not impressive, and there is currently no safe, effective drug for 
treating enuresis in children. 

An enuresis alarm for nighttime use may be indicated in a child who: 

1. Is age 8 or older 

2. Has a small bladder capacity that has responded neither to bladder 
stretching exercises nor to the various self-awakening techniques 

3. Has intense motivation to try the alarm and to use it correctly, 
consistently, and independently of parental aid (at least after the 
first week). 

4. Children with normal sized bladders who have failed in their 
regimen of positive reinforcement and stream interruption exercises 
may also be candidates for an enuresis alarm, again provided 
they're older than age 8 and strongly motivated to try this 
technique. 

Psychological Counseling: 

With counseling It's crucial to establish an optimistic setting for 
therapy and a positive outlook in the patient and the parents. 
Remember that the problem will eventually resolve itself, even in the 
absence of treatment: The spontaneous remission rate for enuresis is 
15% per year after age 6. Also make sure the parents understand that 
a punitive approach to bed-wetting will only exacerbate the problem 
and delay its resolution. 

Once everyone is confident that the child can master the problem, try 
to enlist the child's help--if he is old enough--in selecting a 
treatment program. The more a child feels that a certain modality 
will work for him, the greater are its chances of success. He will 
also be more motivated to work on his problem if he feels like a 
partner in therapy instead of its passive object. From the child's 
perspective, the parents have been trying to solve his problem for 
him--and have failed to do so. Now you are explaining certain things 
that can be tried but leaving it up to him--the patient--to select the 
right combination of choices. This shift in the "ownership" of the 
problem, making it incumbent on the child to do something for himself, 
may prove to be an entirely novel motivating factor for him. 

In general, use the same criteria for referral to a mental health 
professional as you would for a non-enuretic child. Refer if: 

1. The child--or the family situation--is obviously and severely 
disturbed. 

2. The child's emotional and behavioral problems are chronic and 
pervasive, adversely affecting peer relationships as well as 
interactions with parents and school officials. 

3. The child displays an unusually low level of self-esteem or a high 
level of depression. 

4. The older child whose enuresis is causing him significant shame, 
embarrassment, or secondary social problems--or whose parents are 
over pressuring him because of the bed-wetting 

6. The child who exhibits daytime incontinence exclusively, in the 
absence of a medical explanation 

Bear in mind that the incidence of severe emotional problems is 
probably no higher in bed wetters than in the age-matched 
population at large. It's estimated that 5%-10% of all children 
need professional counseling, so there's going to be some 
overlap between disturbed children and enuretics.

Parental expectations can exert a significant influence on the 
treatment program of an enuretic child. Some parents may simply 
require reassurance that their child's enuresis is a benign 
condition. This is often true of parents who were enuretic 
themselves or who have had prior experience with another enuretic 
child. 

Initial treatment options for enuresis in which an underlying medical 
or psychological disorder is not suspected include: counseling of the 
child and parents, positive reinforcement/behavior modifications, 
fluid restrictions, bladder exercises, self-awakening, and 
hypnotherapy. 

Behavior Modification: 

Positive reinforcement/behavior modification A popular way of 
motivating enuretic children involves the use of a calendar or chart 
posted in a conspicuous site in the home. On dry mornings the child 
puts a star over the date, draws a smiling face, or writes the word 
"dry." Make sure the parents and older siblings understand that they 
should respond positively to a dry morning, whether by verbal praise 
or by a hug--something that will show the child how proud and pleased 
they are with his progress. Material rewards--a dime or a small gift-
-can also be profiled, though most children are sufficiently motivated 
simply by knowing they have the entire family's support. Most 
children also respond eagerly to a "points system," whereby a certain 
number of dry mornings earns them a trip to the movies or some other 
privilege. An older child can keep a record of his progress in a 
diary instead of on a chart. Parents can provide a small reward when 
the child demonstrates increased bladder capacity and offer praise and 
encouragement when he at least matches his current record. Children 
younger than age 6, however, sometimes have difficulty complying with 
this exercise regimen. Keep in mind, however, that this or any other 
form of behavior modification is more likely to cure enuresis over the 
short term than over the long term. 

In using motivational counseling and behavior modification, it's 
a common mistake to assume that success in stopping enuresis without 
completely resolving an underlying emotional problem that may be 
contributing to it will cause the problem to surface in another area 
of the child's life. On the contrary, if a child with low self-esteem 
can be led to resolve his enuresis by whatever means, his ego is 
enhanced, and his heightened sense of self-worth in this area may well 
extend to other aspects of his psychological functioning. 

Other Adjunct Measures: 

1. Fluid restriction: 
Have parents limit the fluid intake of their enuretic child after 
dinner, and warn them not to give beverages containing caffeine, 
because they increase diuresis. Make sure, however, that this 
common sense recommendation abut evening fluid intake doesn't result 
in conflicts between over vigilant parents and a thirsty child. 
Remind the child to urinate immediately before going to bed, even 
if he feels no sense of bladder fullness. 

2. Cleaning bedclothes: 
Involving the child in cleaning the bedclothes is another way to 
help motivate him--one that also reduces parental frustration or 
anger. A young child may be made to feel that he's helping to 
clean up even if the parent is actually doing all the work. After 
about age 6, the child can be responsible for doing all the 
cleaning himself. This task can be simplified if he sleeps in his 
underwear on a large towel, so that neither bed linen nor pajamas 
have to be washed. In fact, if the towel and underwear are rinsed 
out in the morning, they don't have to be thoroughly washed more 
than once a week. 

3. Bladder exercises:
Although a enuretic child should restrict his evening fluid intake, 
he may benefits from increasing his daytime fluid consumptions and 
attempting to prolong the interval between urinations. By drinking 
approximately 1 cup/h during the day--especially in the morning--
and voiding only when the feeling of urgency has reached a high 
level, the child can increase his bladder capacity by as much as 1 
oz/mo. 

4. Stream interruption exercises can help children with normal bladder 
capacity learn to withstand bladder spasms and achieve greater 
control over the urinary sphincter. Every time the child urinates, 
he should interrupt the steam when his bladder feel half empty, 
count to 10, and then complete the voiding. 

5. Self-awakening Before going to bed, the child rehearses actions to 
perform in the middle of the night when his or her bladder is full. 
You can introduce the program to the child in the following way: 
"The most urine your bladder can hold is oz, but your kidneys make 
at least oz during the night. The only way you can be dry at night 
is by waking yourself up. There are a number of ways to do that, 
but here's one way that might work. Every night at bedtime, before 
you've urinated, lie down on your bed and close your eyes. Pretend 
it's the middle of the night and you feel your bladder is full. 
Then get out bed, go to the bathroom, and start to urinate--but 
just before the stream starts, hold back and don't let the urine 
out. Go back to bed and start all over again. Do this five times. 
On the fifth practice run, empty your bladder. And say to yourself 
every time you practice, 'This is what I'm going to do in the 
middle of the night.'" An alternative to this active rehearsal 
involves the use of visual sequencing, whereby the child lies on 
the bed, closes his eyes, and pictures himself waking up during the 
night, getting out of bed, going to the bathroom, and urinating. 
Discourage the parents from waking the child before they retire for 
the night. This practice prevents the child from assuming 
responsibility for his problem and may delay the age at which he is 
able to wake himself. 

6. Hypnotherapy: 
You may want to consider using it as part of the self-awakening 
program for children age 5 or older. One researcher claims to 
achieve a 77% cure rate by using relaxation techniques with 
enuretic children and having them practice self-hypnosis every 
night before they go to bed. The posthypnotic suggestion can take 
the following form: "When I feel that I have to urinate, I will 
wake up, go to the bathroom, urinate in the toilet, and go back to 
bed." As with all other forms of therapy for enuresis, the child 
being considered for hypnotherapy must be motivated not only to 
solve his bed-wetting problem but also to do so by means of the 
treatment modality chosen. 

Cure rates are not always encouraging (for example, 35% with bladder 
exercises). The greatest failure rates occur in children with very 
small bladders, in those who have never been dry at night, and in 
those with a parent or sibling who wet the bed into adolescence. In 
the case of relapse after treatment, try the successful treatment 
program again in conjunction with continuing bladder exercises. 

MEDICAL TREATMENT 

Drug Therapy

Drug therapy is probably the most widely used medical treatment 
for enuresis with imipramine being the drug most prescribed. When 
taken on a regular basis imipramine is successful in controlling 
enuresis at a rate up to 70%. However, children rarely stay dry once 
the drug is withdrawn. Considering this, the compound is often 
recommended for nights when the child really needs to stay dry such as 
going to camp or sleeping at a friends. Often just knowing that they 
can have a dry night when necessary helps to ease the feeling of 
helplessness bedwetting can create. 

The drug most frequently used for enuresis is imipramine HCL 
(Janimine, SK-Pramine, Tofranil, etc.). Its initial success 
rate in controlling enuresis may reach as high as 50%-60%, 
but the permanent cure rate is only 25% because relapses occur at 
a rate of over 50% when the drug is discontinued. This 
figure may be compared with the 15%/yr spontaneous cure rate in 
children over 6 years of age and with the estimated success rates 
for other treatment modalities: motivational counseling, 25%; bladder 
exercises, 35%; enuresis alarms, 70%. Medications for enuresis work 
best in children with normal-sized bladders; the failure rate is 
high in children with small bladders--the great majority of bed 
wetters. Drugs are also generally ineffective in the treatment 
of enuretic adolescents. 

For children 8-12 years old, start imipramine HCl (Janimine, SK-
Pramine, Tofranil, etc.) at 50 mg, 1-2 hours before bedtime. In the 
absence of a positive response, consider increasing the dosage to 75 
mg after one week. Start children over age 12 on 75 mg. 

For families with unrealistic expectations, make it clear that 
imipramine does not work for some children and that, for others, it 
may merely decrease the frequency of bed-wetting. Alert parents to 


the possible side effects associated with the use of imipramine (see 
"Drawbacks of drug therapy," page 83). 

You can keep a child who shows a positve response to imipramine on the drug 
for 2-3 months. Gradually taper the drug over a period of 2-4 weeks so that 
discontinuance takes place after one month of continuous dryness. In case 
of relapse, consider another course of 2-3 months for the child. 

An antispasmodic agent sometimes used to treat childhood enuresis is 
oxybutynin chloride (Ditropan). The dosage for children age 8-12 is 5 mg at 
bedtime. This agent's anticholinergic side effects are similar to those of 
imipramine, though the drug is not associated with cardiac arrthythmia. 
Oxybutynin is the drug of choice for enuretic children with associated 
day-time wetting and bladder spasms. As with imipramine, a positive 
response, if it is to occur, will be seen during the first week of therapy. 

Promising New Drug Treatment

Therapy using a synthetic form of ADH (Desmopressin) eliminated 
bedwetting in 80 percent of children who received the drug. Of 29 
children who participated in a four-week study, 20 had total 
elimination of bedwetting with administration of intra-nasal 
Desmopressin. Four others had a significant increase in dry nights. 
The average number of dry nights for a group of 21 children followed 
for six months increased from 2.2 to six nights per week. 

An Illinois pediatrician, Dr. Kenneth Miller, reports similar results 
following a seven-year study. His work included gradually reducing 
the amount, and frequency of administration of Desmopressin. Using a 
protocol he had developed, 15 of 28 bedwetting children who had 
achieved dryness using the drug were weaned totally from the drug over 
time and remain dry. 

Desmopressin acetate (DDAVP, Rorer Pharmaceuticals), 

Physiological: Desmopressin was pressed into service after 
investigators discovered that primary nocturnal enuresis seems to have 
a physiological cause. When children who had never been able to go 
for prolonged periods of time without wetting their beds were compared 
with "normal" children, it was found that enuretics produced more 
urine than the bladder could properly contain, according to Jens Peter 
Norgaard, Institute of Experimental Clinical Research, University of 
Aarhus, Denmark. Once the bladder filled to capacity, the child would 
empty it. This pattern could be repeated several times a night. 

Upon examination, bladder function, sleep patterns, and micturition 
were all normal, Norgaard continued. So, the researchers took a look 
at antidiuretic hormone, the substance that regulates urine 
production. It turned out that levels of ADH increased at night in 
the normal children. As a result, they manufactured smaller 
quantities of more heavily concentrated urine. Because the enuretic 
children didn't experience this nightly surge in ADH, they churned out 
large amounts of very dilute urine. 

"Desmopressin is the only relevant drug to use when it's 
established that patients have a high urine output at night," Norgaard 
said. The antidiuretic, now awaiting Food & Drug Administration 
approval for treatment of bedwetting, is a synthetic analog of ADH. 
Thus, it does the job when the endogenous substance is not present in 
sufficient quantities to suppress urine production on its own. 

In one six-month study, Norgaard said, 70% of the participants 
responded to the drug completely during therapy. If used correctly, 
desmopressin can be effective after the first night of treatment, he 
added. About 15% of patients were markedly improved. The remainder 
didn't derive any benefit from desmopressin. It may be that 
nonresponders have a renal problem-that their kidneys won't react to 
their own ADH or the synthetic analog-he suggested. 

No 'cure': But the urologist is careful never to use the word "cure" 
when speaking to children or their parents. Although many will remain 
dry while on the drug, he has noted a high relapse rate once it's 
withdrawn. In those cases, patients are placed back on the drug until 
they outgrow the need for it. 

No side effect: Neither Norgaard nor Miller has seen any significant 
side effects from desmopressin. Miller pointed out that, because the 
drug is instilled into the nose, colds or allergies may inhibit 
absorption. In almost all cases, children will spontaneously overcome 
enuresis, Norgaard remarked. Although the incidence decreases with 
age, the problem can last into the teen years. For instance, 10%, to 
15%, of all 7 -year-olds may wet their beds at night; by age 16, the 
incidence drops to 2%, to 3%. 

The failure to release enough ADH at night may just be "another 
maturation problem," Miller noted. The body has an internal clock that 
regulates hormone secretion, and tapering desmopressin may allow it to 
establish a normal rhythm, he concluded. 

SOURCES: 
Drug Topics, June 19, 1989, v133, n12, p22(2), Medical Economics Co. 
Inc. 1989, 
FDA Consumer, May, 1989, v23, n4, p10(1), Food & Drug Admin. 1989, 
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