Bedwetting, also known as nocturnal enureseis is a common childhood problem.  Most children develop the ability to stay dry as they grow older. The typical development process begins with one and two year old children developing larger bladders and beginning to sense bladder fullness. Two and three year old children begin to stay dry during the day. Four and five year olds develop an adult pattern of urinary control and begin to stay dry at night.

What Age Should My Child Stop Bed Wetting?

After the age of 5, the age by which bladder control usually occurs.

How Common Is Bed Wetting?

Bed wetting is the most common childhood urinary complaint, affecting approximately 16 % of children at 5 years of age. By 10 years of age only 1-2 % continue to continue with bedwetting. Boys are twice as likely to suffer with bedwetting. (1)

Is Bed Wetting Hereditary?

There is a hereditary correlation with bed wetting.  Children who bed wet are three to four more times likely to have parents who had the same childhood problem.

What Causes Bedwetting?

The exact cause of bedwetting is often unknown .

The most common causes of bedwetting are:

1. Delay in communication between the bladder and brain (Neurological-developmental delay).
Most bedwetting children are simply delayed in developing the ability to stay dry and the brain and bladder takes longer to communicate during sleep.

2. Genetics:  Bedwetting has a strong genetic component. When one or both parents were bedwetters, the chance of bedwetting increases by 44% and 77% respectively.
Specific genes that lead to delayed nighttime bladder control have been identified in bed wetters ( on chromosome 13, 12, and 8.) (1,2).

There are medical conditions which may contribute to bed wetting in 5-10% of cases.  These may be ruled out by your GP through a detailed history, urinary test and/or ultrasound.
. Diabetes
. Urinary tract infection
. Constipation
. Pinworm
. Kidney failure

Will my child grow out of Bed Wetting?

Most Children will eventually grow out of bed wetting. Children 5 to 9 years old will grow out of bed wetting at a rate of 14% per year. Adolescents 10 to 18 years old will stop bedwetting at a rate of 16% per year.   A portion of bedwetting children (0.5 – 1%) will not outgrow the problem.

The Mechanism of Bedwetting?

Two physical functions prevent bedwetting. The first is a hormone that reduces urine production at night. The second is the ability to hold urine in the bladder and wake up when the bladder is full. Children usually achieve nighttime dryness by developing one or both of these abilities.
The first ability is a hormone cycle that reduces the body’s urine production. Around the time of  sunset each day, the body releases antidiuretic hormone (ADH, also known as vasopressin). This hormone release, reduces the kidney’s urine output well into the night so that the bladder does not get full until morning. This hormone cycle is not present at birth. Many children develop it between the ages of two and six years old, others between six and the end of puberty, and some not at all.
The second ability that helps people stay dry is waking when the bladder is full. It occurs at the same age, but is separate from that hormone cycle.

 

How your nervous system and spinal nerves affect bedwetting?

Your bladder is controlled by a combination of:
1. Your Brain: has an overall inhibitory effect over the brainstem (pons) and therefore maintaining dryness. During urination the brain releases it’s inhibitory control over the brainstem (pons).
2. Your Brain stem: Centre for the urinary process (pontine micturition center).
3. Parasympathetic nerves from the S2-4 levels of your spinal cord.

These nerves exit the base of your spine and allow your bladder wall to contract and your bladder neck to relax to pass urine. They allow your internal uretheral sphincter to relax, allowing urine to pass out of the bladder. Both of these occur unconsciously and are beyond your control. They also supply your external uretheral sphincter which you can control, giving you the choice to urinate or not.
4. Sympathetic nerves from the T11-L2 levels of your spinal cord.

These nerves exit your mid to lower spine and cause the bladder to relax and the bladder neck to contract, so you can hold on to urine. They control the internal uretheral sphincter to tighten, helping to hold stored urine in the bladder. Both of these occur unconsciously.

What happens when you urinate?

We make urine from a combination of water, waste products and from the break down protein (urea).  As Urine fills your bladder, sensors in your bladder wall are activated. They send  messages via the nerves in your back to your spinal cord and travel up your spinal cord (via doral system and spinothalamic tract) to your brain stem (pontine micturition centre) and brain, to let you know it is time to empty the bladder (micturition reflex).

Your brain sends a series of messages(inhibitory and excitatory) through your nervous system to enable your body to either hold on or pass urine:
Messages are passed from your brain and brainstrem, through your spinal cord and down to spinal nerves at the lower spine T12-L2 and S2-4.

These nerves supply your detrusor muscle in the bladder wall, telling it to contract and squeeze the urine out into the urethra (tube your urine comes out from).
These nerves supply your urinary sphincter, telling it to relax and open.
These nerves supply your pelvic floor, telling it to relax and allow the sphincter to open. Urine then flows out.

2 Areas That Must Work Properly To Help Prevent Bedwetting?

1. The sensors that tell you the bladder is full.
When the bladder fills, sensors detect the stretching of the bladder wall and send messages via your spine, to your brain and brainstem.
2. The nerves that communicate with your brain and spinal cord
If these are damaged, or irritated the messages to and from your bladder won’t work properly.

Theory Behind Chiropractic and Betwetting

The urination process occurs through the control of a combination of reflexes (inhibitory and excitatory) involving the bladder, brain, brainstem and  nerves exiting the spine (T12-L2 and S2-4).  Any interference with these messages   may delay the communication occurring between the bladder and the brain . Chiropractors propose spinal fixations cause nerve irritation (dysafferentation) which may affect the communication between the bladder and the brain ( like talking on a bad phone line). Correcting these misalignments using chiropractic adjustments, aim to re-establish optimal nerve communication and function between the bladder and brain.

More research is necessary, however some small studies have shown some improvement in bedwetting following chiropractic treatment.

TREATMENT OPTIONS FOR BEDWETTING

1. Wait and see approach: Most kids will eventually grow out of wetting but it may take up to 14 years.

2. Medical treatment : Use of medication to slow urine production at night (eg Minirin ). Although this is not a cure it can be helpful when kids are sleeping at a friends or on camp. The use of medication is usually only considered after other therapies have been trialled for at least 3 months and does have side effects (1).  Consult your doctor.

3. Bed wetting alarm:  This occurs by training the bladder and brain to communicate more efficiently. This process usually takes between 6-8 weeks.
How it works: A sensor is placed in the child’s underpants. Once a drop of urine touches the sensor it transmits a signal to the alarm ( wirelessly) and the alarm wakes the child. Over the next 6-8weeks the child learns to react quicker to the alarm until eventually waking before the alarm starts.
There are many brands and types available, however practitioners at Children’s Sunshine Chiropractic have found   the wireless dri sleeper eclipse to work well. For further information or to purchase visit:
http://www.bedwettingalarms.com.au/dri-sleeper-eclipse-with-free-training-aid-1

4. Behavioural therapy (reward chart, self wakening)

 

5. Trial of Chiropractic Care

Although more larger controlled research studies are needed, several small studies have shown some positive benefits of chiropractic care for bedwetting.

The Journal of Manipulative and Physiological Therapeutics:

• A study of 46 children received chiropractic care for a 10-week period. A quarter of those receiving chiropractic care had 50% or more reduction in the wet night frequency, while none among the control group saw a reduction. (JMPT 1994 (Nov-Dec);17 (9): 596-600 )

• Children with a history of persistent bed-wetting received eight chiropractic adjustments. Number of wet nights fell from seven per week to four. (JMPT 1991 (Feb);14 (2): 110-115)

• The lumbar spine of an eight-year-old male bed wetter was adjusted once and at a one-month follow-up. There was a complete resolution of enuresis. “This happened in a manner that could not be attributed to time or placebo effect.” (JMPT 1994 (Jun);17 (5): 335-338)

• Changes in Asthma Symptoms and Bedwetting in 4 yr old Child Receiving Chiropractic Care. A Postles, H Taylor and K Holt. Chiropr J Aust 2010; 40: 34-6.

• Asthma and Enuresis. Zell, P. International Chiropractic Pediatric Assn. Newsletter May/June 1998 • Case management of nocturnal enuresis Hough DW, Today’s Chiropractic July/August 2001 p. 59/66.

• ADD, Enuresis, Toe Walking. International Chiropractic Pediatric Association Newsletter May/June 1997. From the records of Rejeana Crystal, D.C., Hendersonville, TN.

• Chiropractic management of primary nocturnal enuresis. Reed WR, Beavers S, Reddy SK, Kern G.J Manipulative Physiol Ther Vol. 17, No. 9 Nov/Dec 1994.

• Bed-wetting; two case studies. Marko, RB Chiropractic Pediatrics Vol 1 No 1 April 1994.

• Functional nocturnal enuresis. Blomerth PR. Journal of Manipulative and Physiological Therapeutics 1994:17:335-338.

• Nocturnal enuresis: treatment implication for the chiropractor. Kreitz, BG, Aker PD. J Manipulative Physiol Ther 1994:17(7): 465-473

 

References:

  1. https://www.uptodate.com/contents/bedwetting-in-children-beyond-the-basics
  2. https://en.wikipedia.org/wiki/Nocturnal_enuresis