Enuresis, or bedwetting is a common condition in children and young people. However, it can be very distressing and frustrating for them and for their families. For many it causes, low self-esteem, can lead to sleep difficulties, and psychological issues and many worry about the possible embarrassment if others finding out.

What is bedwetting?

Bedwetting is a recognised medical condition that results in the bladder emptying during sleep.  It  is also known as enuresis or nocturnal enuresis.  Affected children and young people cannot help the problem. It is not caused by anything they or their family are doing wrong or are not doing.   It is not caused by laziness or naughtiness.

While bedwetting can be made worse by stress, it is not usually caused by this. Rarely it can be linked to other medical conditions. Therefore, if your child has suddenly started wetting after a period of being dry, you should ask their healthcare professional (GP or school nurse) for help and advice.

What causes bedwetting?

There are different causes for bedwetting.  If the  brain is not able to fully wake a child or young person up when the bladder signals that it needs to empty, then the bed will get wet. However, most children and young people can sleep through the night without needing to go to the toilet.

If the bladder is not working well enough to be able to hold all the urine that is made overnight, then it will need to empty during the hours of sleep. If the child or young person cannot wake, the bed will get wet.  Some children with bedwetting also have problems with bladder function when they are awake. These children may experience some urine leaking during the day: they may get damp or wet underwear. Some may go to the toilet more often than usual (frequency) or they may have to get there quickly than usual (urgency). This can appear to families as if they are leaving it to the last minute to go to the toilet, which is not usually the case: it is the bladder ‘twitching’ at any point during filling, which causes a sudden, strong and unexpected need to get to the toilet quickly.

Most children and young people can reduce urine production during the night,  so that the bladder is able to hold all that is produced while they are in bed. However, if the kidneys are making too much urine while the child or young person is asleep and they are not able to wake to the bladder signals, the bed will get very wet.

Is there anything that can be done to help with bedwetting?

Constipation can also cause bedwetting or make it worse. This is because the full bowel can put pressure on the bladder. Therefore, it is important to try to prevent constipation through a good fluid intake, and by encouraging your child or young person to eat a diet that includes plenty of fruit and vegetables. If you think they may be constipated, then speak to their healthcare professional. Constipation in children and young people does usually need to be treated with laxatives.

Drinking well during the day helps the bladder to work well. This in turn helps it to hold urine better during the day and at night. Most primary school age children should be drinking about 1.5litres of water-based drinks a day;  teenage girls should be having 1.5-2 litres and teenage boys 2 -2.5litres a day. Drinks should be divided up so that all children and young people are having a water-based drink about every two hours, or six to eight drinks a day.

Drinks that are fizzy and drinks that contain caffeine, such as tea, coffee, hot chocolate, cola and many energy drinks, should be avoided. This is because fizzy drinks and caffeine can irritate the bladder lining and increase the likelihood of being wet.  Milk is considered a food rather than a drink.

Children should have their last drink of the day about an hour before bedtime. Drinking late in the evening does not give the kidneys enough time to get rid of any excess fluid before sleep, so may make bedwetting worse. However, stopping drinks too early in younger children may make it more difficult for them to drink as well as they should during the day. Young people, who go to bed later, may stop drinks up to two hours before bedtime. 

Emptying the bladder just before settling to sleep is also important, particularly for children who play or read in bed.  Avoiding screens, such as TVs, electronic tablets, computers, phones etc,  just before sleep may also help as the type of light given out by the screens cause unsettled sleep patterns and trick the body into continuing to make wee at the daytime rate, rather than at the lower night time rate.  

A good bedtime routine may also be helpful. Some children and young people are more prone to wetting if they are very tired due to late nights, others are more prone to wetting if they go to bed early, as they are in bed for longer as their bladder may not be able to hold on for this extra time.

Are there any other treatments for bedwetting?

If the measures outlined above do not help, then medication or an alarm may be appropriate. There is a medication called Desmopressin that helps to tell the kidneys to make less urine overnight.  This is available on prescription from your healthcare professional and there is more information about it in the Bladder & Bowel UK leaflet at Understanding Desmopressin (Desmomelt) – for parents and carers.

Alarms are devices that make an intrusive noise when the child starts to wet. They can be attached to pyjamas (body-worn alarms) or have a mat that goes under the top sheet (bed mat alarms). The noise is designed to wake the child as their bladder starts to let go, so that they can get up and go to the toilet. They can take some time to be effective. While it is not clear exactly how they work, they do help some children to learn to wake to the bladder signals, others learn to hold on all night. There is more information about alarms at Using alarms as a treatment for bedwetting – for parents and carers

Some children may need other medication to help the bladder work well and some children need to have more than one treatment. Therefore, bedwetting in children over five years old should be assessed by a healthcare professional.

Why Christmas can be a good time to think about managing bedwetting?

Children and young people usually spend most of the Christmas holidays at home with their family.  Most children need support to establish good drinking and toileting patterns and this is easier when everyone has time at home.  Also, although there may be more sweets and chocolates around, traditional festive foods tend to include lots of fruit and vegetables. These can help to prevent constipation, which may make bedwetting worse.

The holidays can be a good time to start using a bedwetting alarm. The alarm will disturb you and your child or young person when they wet during the night. However, holiday times may allow you and them to catch up with lost sleep, by getting up a bit later in the morning if they do not have to go to school and you do not have to go to work.

If you have tried the initial adjustments to your child’s routine and the bedwetting is not improving and they are over five years old, then you can ask their healthcare professional for assessment and further treatment. 

Where can I find more information about bedwetting?

There is more information about bedwetting on the Bladder & Bowel UK website at https://www.bbuk.org.uk/children-young-people/resources-for-children/ and in other blogs on the Bladder & Bowel UK website at https://www.bbuk.org.uk/?s=bedwetting.  There is also information on the website at https://stopbedwetting.org/

Where can I get more advice and help?

Your child or young person’s GP, school nurse or health visitor should be able to provide more information and initial assessment. They may be able to refer your child to a local service for support.  You can also contact the Bladder & Bowel UK helpline for free confidential information and advice via the webform at https://www.bbuk.org.uk/helpline-enquiries/ or on the telephone at 0161 214 4591

For more information and resources for professionals working with bladder and bowel issues, visit our professionals’ section here. 

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Historically, continence problems (wetting and soiling) in childhood were thought to be the result of an underlying psychological, emotional, or behavioural problem. A journal article written in 1972 stated that… enuresis has long been considered a sign of emotional disturbance…

We have thankfully come a long way in the last fifty years and have a much better understanding of the causes of wetting and soiling. We now recognize that nearly all children who have these problems have an underlying medical condition, such as constipation. Wetting and soiling often result in distress, psychological, emotional or behavioural problems, rather than being the cause of them. Therefore, the correct treatment will often result in improved mental health and/or behaviour.

Often families will say that their child does not appear to be upset by the wetting or soiling and will deny they have had a wetting or soiling accident. This obviously increases the overall stress within the household. However, it is helpful if families can understand that many children are unaware of the bladder or bowel leakage when it happens. For those that are aware, or who become aware a little later, the denial aspect is a coping mechanism and the way that many children will use to help them manage and deal with the problems they are having.

A number of studies have highlighted the effect that uncontrollable bladder or bowel leaks have on the mental health and well-being of children. Therefore, it is important that families ask their child’s GP, health visitor, school nurse or other healthcare professional for help to resolve the problems.

The belief that any wetting or soiling problems will get better with time, or as the child becomes older is not accurate. Most bladder and bowel issues that cause the problems need active treatment and may get worse with time rather than better. Therefore, families should not delay seeking help.

Research in continence

In 2018 a research team interviewed young people with bladder or bowel problems as part of a study. The young people described some of the emotional issues they were going through daily. Many described how keeping the problem a secret from their peers felt like a burden and described being constantly embarrassed and frustrated that no one appeared to understand what they were going through. One young man described his problems as “not life threatening, but life ruining”. This reflects the emotional impact continence problems can have.

Other research projects have investigated the mental well-being and quality of life of informal caregivers who are looking after a family member with a bladder and/or bowel problem. They found that the mental health and quality of life of many of the carers was negatively affected by the continence issues. Those who contact the Bladder & Bowel UK helpline often relate how stressful the problem is and describe difficulty within the family when there are disagreements about how the issues should be addressed.

Continence problems can affect people of all ages

Incontinence in an elderly person is often the trigger for a move into a care home, as the stress and difficulty caused by the day-to-day issues of caring for an individual with a continence problem is often too much for the family member to bear.

Bladder and/or bowel issues affect individuals of all ages. All those involved in supporting them need to be mindful of how having an ongoing bladder or bowel problem may affect an individual’s mental health and well-being. As well as treating and managing the underlying bladder or bowel problem it is important that affected individuals are treated holistically so any associated stress, anxiety or mental health problems can be addressed. It is also important that health and social care professionals recognize that caring for an individual with a continence problem has an impact on the carer and their wider family. They should be provided with the appropriate advice and support regarding managing the individual’s problems, but also on looking after their own mental health and wellbeing.

Providing the right information and support and ensuring any bladder or bowel health issue has been assessed and the appropriate treatment put in place can go a long way in reducing stress and anxiety and improving mental health. However, it is also important that we create opportunities for affected individuals to discuss any mental health issues, by asking targeted questions in the right way, having a non-judgmental listening ear and signposting to support.

More information and support

Bladder & Bowel UK have lots of information and resources on the website at www.bbuk.org.uk to support people of all ages with bladder and or bowel difficulties.  These are all free to download and print.

Bladder & Bowel UK also have a confidential helpline staffed by specialist children and adult nurses. You can contact us by completing our web form, by email at bbuk@disabledliving.co.uk or by telephone on 0161 214 4591.

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Bedwetting remains a significant but largely hidden issue for thousands of children and families.  It causes distress, anxiety, reduced self-esteem, difficulties in relationships with peers¹ and disrupted sleep which impacts on daytime functioning².  The psychosocial impact increases with age.  Parents sometimes respond punitively¹ and quality of life is recognised as being reduced for the family as well as the child.

Myths around the causes of childhood enuresis

Myths still abound about the causes of bedwetting in children.  The assumption that it has a psychological basis compounded by stress remains. More than a decade after publication of NICE Guidance³ callers to the Bladder & Bowel UK helpline continue to report that they have been advised that it is ‘normal’, or that treatment cannot be offered until children are seven years old.

Some families are told it is self-limiting. This is despite research from the Children of the Nineties cohort finding that 41% of children who were wetting the bed at four and a half years old were still wetting when they were nine and a half. Of the latter group, those with non-monosymptomatic enuresis were twenty-three times more likely to be wetting the bed at fourteen years old than those who were dry.⁴

Popstar Keith Duffy joins the National Bedwetting Day campaign

World Bedwetting Day was introduced in 2015 to raise awareness of enuresis as a treatable medical condition. However, at Bladder & Bowel UK we are aware that bedwetting affects children, young people and families throughout the year. Bladder & Bowel UK were delighted when Keith Duffy, singer from Boyzone and actor, spoke out about his experiences of wetting the bed as a child.

Our specialist children’s nurse described how it was a privilege to join Keith on some radio interviews and live for television on GB News.  Keith also spoke eloquently on the subject during the ITN lunchtime news on 14^th September and the reach of the campaign was extended by a live feature with Bladder & Bowel UK on Jeremy Vine’s Radio Two show on 15^th September.

Raising awareness of childhood enuresis through our work

Bladder & Bowel UK will continue to work on raising awareness of the causes and treatments for bedwetting in children and provide advice and signposting via our helpline and web-based information for families and our involvement with World Bedwetting Day.  For healthcare professionals we produce an Enuresis Update electronically with reviews of recent research.

If you would like to receive this then please do email us at bbuk@disabledliving.co.uk with your name, job title, place of work and email address.

For those who are working with children who have enuresis there is still time to enter the Bladder & Bowel UK Enuresis Award 2021.  View the entry details here.

References

1. Wright A (2019) Nocturnal Enuresis: A comorbid condition Journal de Pediatria https://doi.org/10.1016/j.jped.2018.11.010
2. Van Herzeele C et al (2015) Neuropsychological functioning relatedto specific characteristics of nocturnal enuresis Journal of Pediatric Urology 11 208e1 – 208e6
3. NICE (2010) Bedwetting in Under 19s https://www.nice.org.uk/guidance/cg111
4. Heron J et al ((2017) Trajectories of urinary incontinence in childhood and bladder and bowel symptoms in adolescence: prospective cohort study  BMJ Open 2017, 7: e014238

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That patients will adhere to their prescribed therapies is something that many healthcare professionals (HCPs) take for granted. Yet, the reality is that between a third and a half of all medicines prescribed for long‑term conditions are not taken as recommended in the UK. [1] Poor adherence to to prescribed therapy – whether medication or a device (e.g., transanal irrigation) – is linked with poor clinical outcomes. By compromising the effectiveness of the treatment, poor adherence also leads to increased demand for healthcare due to lack of improvement or deterioration of the condition. The World Health Organization (WHO) considers poor adherence to treatment of chronic disease ‘a worldwide problem of striking magnitude’[2] and improvements in this area could undeniably have a significant positive impact.

What causes poor adherence?

To address the issue, we must first understand the elements that influence adherence. These can be split into intentional and unintentional causes and include: the therapeutic alliance; perceived lack of control; risk of dependence on medications; stigma associated with medication use; and lack of knowledge, education and support. Successful adherence comes from providing support to the patient throughout the entire process, from assessment to establishing long-term use of the treatment.

This is particularly important for patients with bowel dysfunction who may be reluctant to discuss their symptoms and have a tendency to ‘self-help’ and delay seeking medical help. Symptoms are often intermittent for bowel conditions, and patients may be tempted to avoid the issue when symptoms temporarily abate. Furthermore, treatment for bowel conditions can include strong medications and invasive treatments, which can interfere with some aspects of daily life and therefore discourage patients from sticking to their regime. Yet, the longer patients wait to seek treatment, the more the condition can worsen, leading to extended treatment times. This is further exacerbated by current difficulties in accessing primary and secondary care,[3] and more recently by COVID-19’s impact on waiting times to see specialists.

Tackling non-adherence

   1. Communication, time and empathy 

Crucially, non-adherence should not be seen as the patient’s fault: adherence must be a partnership between patient and HCPs. Receiving adequate support from HCPs is vitally important, especially during those first few months of beginning a new treatment. HCPs should aim to help patients make informed decisions about their own treatment and should ensure that all information is accessible. It helps to provide clear and complete information about the benefits and adverse effects of available therapies or medical devices, including alternatives to the treatment or device that is chosen. Explaining the rationale behind the selection of a treatment – such as improved symptoms – is crucial, as well as setting expectations for side effects and speed of improvement. Finally, any adjustments that may be needed during treatment should be made clear to the patient from the onset, so that they are not taken by surprise.

    2.Treatment ownership

By providing this in-depth information, patients can have a sense of ownership of their treatment and feel more motivated to adhere. Having a motivation to adhere will make patient adherence more likely than if patients are merely passive recipients of advice. This investment of time is worthwhile since informed and empowered patients are more likely to stick to their medication regime or device treatment plan. Similarly, involving patients in prescribing decisions and adapting consultation style to the individual can help HCPs to establish how involved their patients would like to be in decision making. Patients may also require some support in implementing adherence strategies, for instance setting up reminder applications or alarms on their phones.

   3.Tailored interventions

Adopting an open, no-blame approach encourages patient engagement, enabling them to discuss their concerns about treatment. In turn, this helps HCPs to understand and anticipate any factors which could stop them taking their medicine. A strategy that works for one patient may not be so effective for another so assessing each case on an individual basis is a good approach. The more tailored interventions are to the patients and their specific difficulties, the better.

   4.Follow-ups 

After initial advice and prescription is delivered, regular follow-ups should be carried out. This can be carried out more easily through teleconsultation, particularly with patients accustomed to this format due to the COVID-19 pandemic. HCPs can recommend that patients keep a treatment diary where appropriate, in which they track their symptoms and any treatment side-effects. Catch-up sessions also provide patients with an opportunity to report back on their experience and HCPs to personalise the therapy if necessary.

With healthcare systems under increased pressure due to the pandemic, strengthening adherence to improve patient outcomes and prevent condition escalation should be given more attention. HCPs can play a greater role in optimising adherence for their patients. For the strategies outlined above to work, a joined-up approach is best – whereby patients receive coordinated support from healthcare professionals and organisations. The shift to integrated care systems in the NHS will help foster this consistency throughout the patient journey. Tackling non-adherence will require some investment of time and resources from HCPs and healthcare organisations, however, the widespread benefits that stem from improved adherence will make it worthwhile from both a patient quality of life and a health economics perspective.

For further information and resources for treating bowel dysfunction, please visit https://bowelinterestgroup.co.uk/resources/

References

[1] National Institute for Clinical Excellence (NICE), Medicines adherence: involving patients in decisions about prescribed medicines and supporting adherence, 28 January 2009

[2] World Health Organization, ADHERENCE TO LONG-TERM THERAPIES: Evidence for action, 2003

[3] The Patients Association, Pandemic Patient Experience II: From lockdown to vaccine roll-out

April 2021; The Times, A record 5.45m await routine hospital treatments, 12 August 2021

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This post is promoted content by Firefly GottaGo, on behalf of Leckey.

We are all familiar with the squat posture being a great lower body exercise to target quads, hamstrings, glutes and calves. But what about squatting for function?

Some years ago, I spent time in rural Asia and was amazed at how common it was to see people of all ages squatting.  As the squat posture is rarely seen in Ireland, (except by young children and perhaps at the gym), I was fascinated. From cooking to chatting, working to relaxing, squatting was the go-to posture for many activities. That included using the toilet.

A little reading on the topic revealed that the Western raised toilet is a relatively modern invention. Initially adopted by kings and queens, a raised toilet also suited the invention of the U-bend, Therefore, so sitting on the toilet as opposed to squatting gradually became the norm for most of us.  Now, many years later, it is widely recognised within the healthcare community that the squat posture is the healthiest way to pee and poo (see National Institute for Clinical Excellence guidelines).

The link between squatting and toileting function

For me, the subject simmered in the background for some years until a unique opportunity arose for the development of a new supportive toileting seat for children. It was time to do some deeper research. I learnt about the function of the puborectalis muscle, part of the pelvic floor, which wraps around the rectum like an elastic band. This muscle, which is in a constant state of tonic contraction helps to maintain continence when we stand, lie and even sit. To be technical, it pulls the anal canal forward toward the pubis, thus maintaining a sharp angle in the rectum. That is until we squat. When squatting the muscle relaxes and the rectum straightens which lets gravity do the work for us.

Squatting also enables the thighs to put gentle pressure on the abdomen. Research indicates that people who squat report less straining and take less time to go (Sikirov, 2003).  Other studies have shown that adopting a squat position when pooing lowers abdominal pressure, suggesting this position requires less effort for bowel emptying (Tashiro et al, 2020).  A fascinating new study (Garcia-Fernandez and Emanuel Petros, 2020) has demonstrated a positive link between squatting-based exercises and reducing daytime and night-time incontinence in children.

An additional bonus of the squat posture is that it stretches the muscles around the hip joint. Adductor magnus and the proximal hamstrings (both of which are often shortened and tight in children with neurological impairment) along with the erector spinae of the lower back and gluteus maximus.

Assistance with squatting

We know that due to reduced mobility and compounding neurological issues, children with additional needs (such as cerebral palsy) frequently have chronic constipation. Their trunk control – which is linked to abdominal and pelvic control (Talu, 2018) – is often poor and slower to develop. This may cause patterns of incontinence to set in early which may be difficult to shift.  Where this is coupled with low expectations by family, education or healthcare professionals, children will not be supported to reach their potential.

But it does not need to be like this.

The squat posture can stretch tight muscles, reduce straining, and assist natural physiological function. This can promote toilet training success, which will have a positive impact on activity, participation, and quality of life for both the child and the family.  Now there is a child-sized product to support the functional posture of squatting and toileting, there is only question that remains. When are adults going to catch up?

– Dr Laura Finney PhD

This post is promoted content by Firefly GottaGo, on behalf of Leckey.

References

• https://www.nice.org.uk/guidance/cg49/chapter/1-Guidance
• Sikirov, D. Comparison of Straining During Defecation in Three Positions: Results and Implications for Human Health. Dig Dis Sci 48, 1201–1205 (2003). https://doi.org/10.1023/A:1024180319005
• Tashiro, Daisuke & Nakahara, Masami & Kitajima, Eiji & Haraguchi, Kenzo. (2020). The effects of a defecation posture, supported by the upper limbs, on respiratory function. Journal of Physical Therapy Science. 32. 332-336. 10.1589/jpts.32.332.
• Garcia-Fernandez, A. and Emanuel Petros, P. 2020. A four-month squatting-based pelvic exercise regime cures day/night enuresis and bowel dysfunction in children aged 7–11 years. Central European Journal of Urology, 73 (3), pp. 307-314.
• Talu, B. 2018. Determine the Relationship Between Abdominal Muscle Strength, Trunk Control and Urinary Incontinence in Children with Diplegic Cerebral Palsy. Urology Journal, 15 (4), pp. 180-185.

More advice on constipation

Are you concerned that you or someone else may be constipated? Speak to a healthcare professional (GP, school nurse or health visitor) for advice.

Bladder & Bowel UK publish a quarterly e-newsletter, which is full of interesting articles, suggestions and information for people affected by bladder and bowel conditions. To receive the newsletter please send an email to bbuk@disabledliving.co.uk, You can find out more on our newsletters page.

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Dehydration may cause headaches, light-hot headedness, dizziness, lack of energy and make your child more grumpy than usual. It will also cause the wee (urine) to become more concentrated and darker yellow in colour. This is because the kidneys produce less wee as the body tries to hold onto water. Poos will also become drier and harder as the bowels hold onto water. This may cause constipation.

The bladder relies on regular emptying to help prevent urinary tract infections (UTI). If children are not drinking enough, they will wee less than the usual 5-7 times a day, and this may increase their risk of getting urinary tract infections.

Some children may limit their drinks, in the mistaken belief that they will not need to go to the toilet as often (particularly in school). However, the wall of the bladder is very sensitive and can become irritated by concentrated urine. If irritated, it will be less likely to hold on to the wee for a long time and may give the child less notice that they need the toilet. Families will often think their child is leaving going to the toilet until the last minute. They may also see their child ‘dancing,’ crouching, or holding their groin just before going to the toilet. Sometimes the child may end up needing to wee more than seven times a day, or they may get wet on the way to the toilet.

Not drinking very much or passing small amounts of wee frequently, because of bladder irritation or being sent to the toilet too often to try and prevent wetting, means that the bladder does not get an opportunity to stretch properly, so it may be smaller than usual. This can affect a child’s ability to achieve night time dryness as well.

Children who become constipated may also have problems with their bladder. This is because the end of the bowel (the rectum) is normally empty. The sensation of needing to have a poo happens as the poo moves into the rectum. If the signals are ignored for any reason, such as the child being unable to get to the toilet, or not wanting to go for any reason, the poo will stay in their rectum. If they continue to ignore the signals, they will become constipated. The poo that remains in the rectum takes up space that the bladder needs and puts pressure on the bladder, which then needs to be emptied at short notice and more frequently than is usual. If you think your child has a problem with constipation ask your child’s GP for advice.

Constipation may also be one of the causes of night time wetting for some children.  Another cause may be that the bladder is not able to hold as much wee as it should, something that can happen if a child is not drinking well during the day. More wee will be made at night if the child is drinking most of their drinks in the evening. This is one of the reasons why a good fluid intake, evenly spread out throughout the day is so important.

What should children be drinking?

Children (and adults) should be drinking enough water-based fluids that they do not feel thirsty. Children should be having a drink about every 1 ½ to 2 hours, until about an hour before bedtime. This is equivalent to six to eight drinks a day. The healthiest drink is water. The body uses milk as a food, so this is often not counted as part of the daily fluid intake. Fizzy drinks and drinks containing caffeine (tea, coffee, chocolate, cola and some energy drinks) can irritate the lining of the bladder and so make problems worse. They should be avoided.

Younger children need proportionally more water than older children, and older boys need more than older girls. Children who are overweight, who are in hot environments or who are very active need more as well. The recommended intakes of water-based drinks per day are:

• 1 – 3 year olds should have 900 – 1000mls
• 4 – 8 year olds should have 1000 – 1400mls
• 9 – 13 year old girls should have 1200 – 2100mls
• 9- 13 year old boys should have 1400 – 2300mls
• 14 – 18 year old girls should have 1400 – 2500mls
• 14 – 18 year old boys should have 2100 – 3200mls

During the school holidays it is easier to encourage children to drink. Reluctant children may drink more if allowed to chose their cup or glass, add ice cubes to their drinks, or play a game or read with their parents while drinking, or have dedicated drinking times with other family members.

How are children’s bladder problems treated?

Usually the first treatments tried in children with bladder problems are establishing good drinking and toileting routines. This is more difficult to do when children are at school, which is one reason why the summer holidays are a good time to work on bladder health.

What toileting routines help children’s bladder health?

Children with bladder problems should be encouraged to go straight to the toilet as soon as they feel the need to wee. They should also be asked to go to the toilet if their parents or carers notice them ‘dancing’, holding themselves or crouching. A good toileting routine would include them going for a wee about fifteen minutes after a drink, or about every two hours.

When children go for a wee they should be encouraged to relax and stay on the toilet until they are sure they have finished. Girls should sit with their bottom and feet well supported. Boys should stand and relax. They may find it helpful to sit to wee at least once a day, if they have any bladder problems. To poo both boys and girls should sit with their bottoms well supported, their feet flat on a firm surface and their knees higher than their hips. Most children will need a step under their feet to achieve this and many will need an insert seat.

In the summer holidays there is more time for children to get into a good routine of using the toilet, including having a regular time to poo. Children should also have open access to the toilet more often when they spend more time at home. They are not always able to have this at school.

What about treatments for bladder problems?

One of the most common bladder problems is bedwetting. In addition to good drinking and toileting routines during the day, going for a wee just before sleep and avoiding all drinks and food for an hour before going to bed are important. This can be easier to achieve in the summer holidays when there are fewer organised evening clubs and activities.

There are two main treatment options for bedwetting, either medication (usually desmopressin) or an alarm. Following an assessment your healthcare professional will decide with you and your child which would be the most suitable. The alarm is a device that makes a noise when the child starts to wee during sleep. The aim is to wake the child as they start to wet. Over time the child either learns to wake to the bladder signals and is therefore able to get up and go to the toilet, or they learn to sleep through the night, without needing to wee.

As the alarm is designed to wake the child, it will inevitably disturb their sleep. Getting up for school after disturbed nights is difficult. It is also harder to get up when the bedroom is cold, as happens in the winter. Therefore, summer holidays can be a good time to start using an enuresis alarm for children who have issues with bedwetting. It may take up to three months, or sometimes a bit longer, for an alarm to work fully. Therefore, by the time school restarts most children, where the alarm is likely to be successful, are already sleeping for longer before they wet and some may be having more dry nights by the time they have to go back to school.

Where can I go for further support and advice?

Although the summer holidays can be a good time to work on bladder health, by establishing good drinking and toileting routines and starting treatments such as enuresis alarms, families should not delay seeking support and advice if they have concerns at any time of the year.

If you are concerned about your child’s bladder health then discuss these with their GP, health visitor or school nurse. You may also contact the Bladder & Bowel UK helpline at bbuk@disabledliving.co.uk or telephone 0161 214 4591.

There is also lots of information about children’s bladder health and other conditions that affect children’s bladders and bowels on the Bladder & Bowel UK website at www.bbuk.org.uk

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There are a number of contributory factors that result in wetting the bed. We now know that around one out of every three children who wet the bed have a problem with their bladder. It is therefore important for all children with a bedwetting problem to have a comprehensive assessment to find out if there is an underlying bladder problem. If there is, this can be treated.

Other main contributory factors include making too much urine during sleep and an inability to wake up to bladder signals indicating the need to wee. We are also aware that underlying constipation and fluid intake can have an impact on the bedwetting as well.

What sort of bladder problems could children have?

Most children’s bladders mature by the time they are 5 years old. By this age, we would expect them to go for a wee between 4-7 times per day. A mature bladder is one that stays relaxed as it is filling (so we only get the feeling we need to wee when it becomes full). It can hold on to the wee until we find a suitable place to empty it. From 5 years old we would expect children to be able to ‘hold on’ when they first feel the need for a wee and get to the toilet on time without getting damp or wet on the way. When they got to the toilet, they should be able to do a full wee and empty their bladder completely.

For some children this does not happen. Their bladder never relaxes while being filled. This is sometimes called a ‘twitchy’ or ‘overactive’ bladder. This results in the child frequently feeling that they need to wee. In some cases, they will have a wetting accident when their bladder suddenly decides it wants to empty, even when it is not full. These children often get little warning that they need to wee and will often have to make frequent dashes to the toilet. This is sometimes termed ‘frequency’ and ‘urgency’.

To stay dry at night, the bladder must be big enough to hold on to wee for 8-10 hours or more. A small bladder can obviously affect the child’s ability to stay dry. Having a small bladder may be because the bladder is not fully mature, but most commonly it is as a result of the child not drinking enough water-based drinks in the day.

A very small number of children may have a problem with not emptying their bladder completely at each wee. This can be as a result of several issues, but the risk is that any wee left behind might become infected. The infected wee often causes the child to want to use the toilet frequently and the wee can become ‘smelly’.

How will I know if my child has a bladder problem?

If your child is over the age of 5 years and keeps dashing to the toilet or has wetting accidents, then it could be a sign of having a bladder problem. Some parents may not consider the odd pair of wet or damp pants during the day to be a problem. They may think their child is ‘lazy’ because they always seem to wait until the last minute to go to the toilet. Other parents may think their child’s wetting problem is because they haven’t toilet trained them properly. Some are too embarrassed to ask for help.

We can check how much a child’s bladder is holding by measuring how much they wee when the go to the toilet. Children are able to hold on to more wee as they get older. To find out how much wee (in ml) your child’s bladder should be able to hold, add 1 to their age in years and then times this by 30 (age in years +1 x 30). For example, if your child is 5 years old 5 +1 = 6, 6 x 30 = 180. Therefore, their bladder should hold 180ml.

Your child may have a problem with their bladder if they are experiencing any of the following problems:

• is weeing less than 4 times or more than 7 times per day
• has some frequency and urgency
• their bladder is holding less than it should be for their age
• they are getting wet or damp during the day

If this is the case, your child may need an assessment and could need subsequent treatment for the problem.

What bladder treatment would my child need?

All children who have a daytime bladder problem should have a management programme that involves:

• regular water-based drinks
• regular toilet visits

You will be told how often they need these by the nurse, but it’s usually around every 2 hours.

How to teach a child to sit on the toilet

Children should also be shown how to sit on the toilet properly. They should have their feet flat (on a step if necessary) and their knees positioned higher than their hips. This allows the pelvic floor to relax and helps the bladder to empty completely. Programmes are individualised to the child and some children may need some medication to control the frequency and urgency and help their bladder relax.

Where can I find further information?

The Bladder & Bowel UK website has a range of downloadable resources for both families and professionals, as well as links to helpful videos. https://www.bbuk.org.uk/children-young-people/children-resources/

The booklet ‘Talk about daytime bladder problems’ can be found at the link below

https://www.bbuk.org.uk/wp-content/uploads/2018/12/Talk-about-Day-Time-Bladder-Problems.pdf

There is information about bedwetting at: https://stopbedwetting.org

For further advice and information, do not hesitate to contact Bladder & Bowel UK via the confidential helpline, 0161 214 4591 or via email: bbuk@disbabledliving.co.uk

This post was written by June Rogers, Children’s Specialist Nurse at Bladder & Bowel UK. 

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The day was as full as usual

The first talk of the day came from June Rogers, who delivered an in depth session on constipation, covering the complexity of the problem, diagnosis, slow transit, toilet refusal, pelvic physiotherapy and TENS. Dr Carol Joinson from Bristol University then gave a very engaging presentation from her research on the role of psychological factors in paediatric continence problems. She stimulated lively discussion and suggestions for further research. The consensus from delegates was that this a particularly interesting session.

The afternoon sessions started with consideration of how to work with schools to engage support for children with continence problems and included issues to consider as well as how to access and employ guidance from the Department for Education to ensure that children’s needs are met.

Vicky Hartley from Sussex NHS Community Foundation Trust was the winner of the inaugural Enuresis Award and described how her service had significantly reduced waiting times, improved access to care and NICE compliance and reduced nurse workload and financial costs through provision of a single-patient use enuresis alarms. The day was rounded off by June who talked about the use of facts and figures to support service development.

The day once again received excellent evaluation

We would like to extend congratulations to the worthy winners of the Enuresis Award and our thanks to our speakers, company colleagues and all the delegates who made together made this such a successful event.

Next year’s Paediatric Education Day will be on Thursday 17^th October 2019 and we would strongly recommend booking early to avoid disappointment. More information please visit the event page.

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