How to put an end to nocturnal enuresis?

Having addressed the subject of potty training in our previous article, we were keen to delve deeper into the subject of nocturnal enuresis. After the age of 4-5, we no longer talk about potty training, as it's considered that children should have acquired it by the time they start school for the first time. If this is not the case, the subject becomes taboo. Yet between 10% and 20% of children aged between 5 and 7 are still not toilet-trained at night. 

Everyone develops at their own pace, but as parents, we tend to put pressure on them for fear of how others will look at them and make fun of them. This worry is justified, given our society's constant comparisons of children's development. Above all, it's vital to dare to talk to your paediatrician and those around you. That's how you realize that your child is not an isolated case.

Following a personal experience with this subject, I (Natalie) felt it important to share more information about nocturnal enuresis. We met with Dr. Sophie Guillot, a pediatric specialist at the Clinique de Carouge, who answered our questions.

In this article, we hope you'll find comfort and answers to help you through this delicate phase for both children and parents.

What is nocturnal enuresis?
Nocturnal enuresis is uncontrolled urination after the age of 5, only at night. Nocturnal enuresis must be distinguished from enuresis that also occurs during the day (diurnal). Enuresis can be primary (the child has never been potty trained) or secondary (the child has been potty trained for at least 6 months).

What are the statistics on nocturnal enuresis?
In general, 15-20% of children have acquired nocturnal cleanliness by age 3, 70-80% by age 4, 80-90% by age 5 and 98-99% by adolescence. I'm not aware of any statistics that specifically differentiate between boys and girls for nocturnal enuresis. By age 3, 84% of girls have acquired daytime cleanliness, compared with 53% of boys.

Is it a hereditary problem?
It seems that there is indeed a probable genetic component, because if one of the parents has nocturnal enuresis, the probability that the child will have nocturnal enuresis is 45 to 50%; if both parents were enuretic, the probability increases to 70% or even 80%.

Parents don't talk about it, if at all, because it's a taboo subject. Why is that?
The subject is taboo, because I think it's associated with guilt, both for the parents and for the child. I think parents experience the situation as a failure, wondering if they've done something wrong or what they've "missed". Potty training is seen as one of the most important developmental milestones, just like walking or language, and the fact of not succeeding in acquiring it completely is often resented. I think there's also a lot of social pressure on both parents and children, from family and school, for example. The gaze of others is difficult to live with, and can be very problematic in certain situations, such as a camp with the class, or sleeping at a friend's house.

Should you worry about your child's nocturnal enuresis?
I'd say that, generally speaking, worrying won't help to resolve enuresis. There's no need to worry, but it's important not to ignore the subject and to discuss it with your pediatrician, who will assess the need for any further tests and provide appropriate advice on management.

Should the child be urged to remove the diaper?
Yes, it's better to give up the diaper to help with this learning process, although it can be tedious.

Is it a physical or psychological problem?
Given the growing evidence of a probable genetic origin for enuresis, I'd say that in most cases it's more of a physiological problem. It is sometimes associated with deep sleep structures. However, it's important to point out that the etiology is not yet fully understood. It is very important to discuss this with the paediatrician to ensure that the enuresis is not linked to an underlying pathology (e.g. polyuria in the context of diabetes, infection, constipation) and that it is indeed an isolated enuresis. Of course, there are also psychological factors that may come into play, not necessarily as a cause of enuresis, but rather as factors that may influence the success or failure of the measures put in place. It should also be pointed out that isolated nocturnal enuresis is not considered a disease, but rather a variation in normal bladder control, which eventually disappears.

If the child suffers from this and verbalizes it, how can we support him?
It's important to talk to him about it, to reassure him that it's a relatively frequent situation that will eventually resolve itself. You need to be understanding and patient. Communicate openly on the subject with the child. In all cases, stigmatization, threats, punishment or humiliation must be avoided. It's important to maximize self-esteem, which is often undermined by nocturnal enuresis.

How is enuresis diagnosed?
The diagnosis of nocturnal enuresis is made by means of anamnesis (questioning). There are no additional tests to diagnose enuresis. However, certain tests may be indicated to rule out the presence of an underlying pathology.

What solutions exist?
Behavioral measures are generally the first line of defence: adapting drink quantities, reducing fluid intake at the end of the day, urinating just before bedtime, avoiding wearing diapers. We can also involve the child by, for example, creating a micturition calendar with drawings or stickers, representing dry and wet nights. There is also the possibility of using alarm devices, known in Switzerland as "stop-pipi", which sound at the 1st drop of pee and encourage the child to wake up to go pee. Desmopressin, a synthetic analogue of the antidiuretic hormone, can also be used to reduce nocturnal urine output.

What do you think of "stop-pipi"? What about taking medication?
"Stop-pipi" is a fairly effective method, with a success rate of around 70% to 80% and few relapses. It is, however, relatively restrictive, with more or less frequent nocturnal awakenings, and generally has to be carried out over a period of 3-4 months. The relapse rate with this method is low, and it is considered the most effective. Medication (desmopressin) has about the same efficacy rate (approx. 70%) and is easier to administer (intranasal administration possible). However, the risk of relapse after stopping treatment is much higher. Treatment should be continued for 3 months. It can also be used for short periods for specific activities, e.g. camping, sleeping outdoors.

What tips can you use to support your child?
Tips to support your child include: distributing water intake, voiding before bedtime, a voiding calendar, avoiding diapers, why not use training pants (but I'm not sure they make much difference to sleep compared to normal pants), possibly stop-pipi or desmopressin, depending on the wishes of the parents and the child, and above all patience, listening, reassurance and support for your child.

What advice do you have for parents who are concerned about this problem?
My advice to parents is above all not to worry, to avoid any form of guilt, and to avoid putting pressure on themselves or their children. They need to bear in mind that, in the majority of cases, spontaneous maturation occurs and the symptoms disappear on their own as the child grows up. You have to trust your child, value him or her and foster good self-esteem.

Dr. Sophie Guillot
Specialist in pediatrics, member FMH
Clinique de Carouge
Av. Cardinal-Mermillod 1
1227 Carouge
022 309 45 20
www.cliniquedecarouge.ch/pediatrie