Health Check; Enuresis in Adults
Bedwetting is the loss of bladder control during the night. The medical term for bedwetting is nocturnal (nighttime) enuresis. Bedwetting can be an embarrassing issue, but in many cases, it’s perfectly normal. Bedwetting is a normal developmental stage for some children, but it can be a symptom of underlying illness or disease in adults. About 2 percent of adults suffer from bedwetting, according to the National Association for Continence.
For many adults, it is hard to even talk about something that is a “kid thing”. It must be noted that bedwetting in adults is actually different than what children go through. And while that might not remove the embarrassment, you must know that nocturnal enuresis is involuntary and not your fault.
To fully understand the how and why, a quick anatomy short course could be helpful. Urine is produced by the kidneys and travels through the ureters to the bladder to be stored. The bladder is basically a muscular sac that holds urine until it is ready to be released into the urethra, the tube that connects the bladder to the outside of the body. At the same time the bladder contracts, the urinary sphincter relaxes. The relaxed sphincter acts like an open door, which allows the urine to pass and exit the body. When there is a physical impediment or neurological disconnect, urination can become problematic or mistimed.
Causes of Bedwetting
There are several factors that can contribute to an adult experiencing nocturnal enuresis. Physical and psychological conditions can lead to bedwetting in some people. Like with so many medical issues, the first place to check is family history. Evidence has shown that bedwetting is hereditary. One study has shown that someone with two bedwetting parents has a 77% chance of becoming a bedwetter. When one parent wet the bed as a child, his son or daughter was found to have a 40% chance of becoming a bedwetter. These probabilities carry into adulthood as well.
Hormonal imbalances can also cause bedwetting in some people. Everyone’s body makes a hormone called antidiuretic hormone (ADH). Its main function is to signal the kidneys to decrease the amount of urine produced. ADH tells your body to slow down the production of urine overnight. The lower volume of urine helps a normal bladder hold urine overnight. People whose bodies don’t make sufficient levels of ADH may experience nocturnal enuresis because their bladders can’t hold higher volumes of urine.
Instinctively, the body normally produces more ADH to avoid nocturnal enuresis. However, some people do not produce the appropriate amount of this hormone at night, which leads to high urine production. In other cases, the body produces ADH, but the kidneys do not respond and continue to produce the same amount of urine. This excessive production of urine during sleep is defined as nocturnal polyuria. This abnormality can cause nocturnal enuresis in adults, but it is also a symptom related to type I diabetes. Consulting a healthcare professional is helpful, especially if you feel that you may be experiencing diabetes or nocturnal enuresis.
Patients with a “smaller” bladder are often dealing with primary nocturnal enuresis. The physical size of the bladder isn’t actually smaller, rather, the functional bladder capacity (FBC) can hold a smaller volume of urine.
Related to FBC, if the muscles of the bladder, known as detrusor muscles, are overactive, nocturnal enuresis can occur. In fact, detrusor overactivity has been found in up to 70-80% of primary nocturnal enuresis patients. Bladder irritants, such as alcohol and caffeine, can contribute to detrusor instability. Medications are also known to increase bedwetting in adults. Side effects from hypnotics, insomnia medications, and psychiatric medications such as thioridazine, clozapine, and risperidone can increase your risk. Be sure to talk to your healthcare provider about any medications prescribed and their side effects.
Diabetes is another disorder that can cause bedwetting. The bodies of people with diabetes don’t process glucose (sugar) properly and may produce larger amounts of urine. The increase in urine production can cause children and adults who normally stay dry overnight to wet the bed.
As for secondary nocturnal enuresis, there is plenty of research that suggests an underlying health issue is at the root of the bedwetting. Such problems can be associated with the prostate in men or pelvic organ prolapse in women.
Any of these medical issues can also cause bedwetting: diabetes, urinary tract infection, urinary tract stones, neurological disorders, anatomical abnormalities, urinary tract calculi, prostate cancer, prostate enlargement, bladder cancer, or obstructive sleep apnea.
Other common causes of bedwetting include:
Risk Factors for Bedwetting
Gender and genetics are among the risk factors for bedwetting. Both boys and girls may experience episodes of nocturnal enuresis during early childhood. Boys are more likely to wet the bed when they get older.
Family history plays a role, too. You’re more likely to wet the bed if a parent, sibling, or other family member has had the same issue.
Bedwetting is also more common among children diagnosed with attention deficit hyperactivity disorder (ADHD). Researchers don’t yet fully understand the relationship between bedwetting and ADHD.
Lifestyle Changes to Manage Bedwetting
Certain lifestyle changes may help end bedwetting.
Monitoring Fluid Intake. Limiting intake of fluids in the late afternoon and evening before bedtime causes a decreased amount of urine produced at night. Setting limits on fluid intake plays a large part in controlling bedwetting. Try not to drink water or other liquids within a few hours of bedtime to reduce the risk of having an incident. Drink the majority of your daily fluid requirements before dinnertime. This will ensure that your bladder is relatively empty before bedtime.
Bedwetting Alarm System. Multiple variations of the alarm exist, ranging from vibrating to sounding alarms and wet-detection devices that can be attached to the underwear or a pad on which the individual sleeps.
Waking. This involves randomly setting an alarm to go off in the night in order to wake one for urination. The randomness keeps from training the bladder to need to empty at a set time.
Cut Drinks. You should also cut out caffeinated or alcoholic drinks in the evening. Caffeine and alcohol are bladder irritants and diuretics. That means they’ll cause you to urinate more.
Voiding Schedule. Devise a voiding schedule to help you stay dry overnight. A voiding schedule simply means that you urinate on a regular timetable, such as every 1 to 2 hours. Use the bathroom right before you go to bed to empty your bladder fully before sleep.
Bedwetting can sometimes occur during a stressful event in a person’s life.
Management
Mattress Covers. A variety of products exist to protect the bed including vinyl, waterproof, and absorbing mattress covers or even sheet protectors, which can make cleanup easier.
Absorbent Briefs. These products are a form of modified underwear designed to absorb liquid, therefore preventing leakage. Both reusable and disposable products are available.
Skincare Products. Many products exist to protect the skin from irritation and soreness that occur when a person experiences nocturnal enuresis. A range of soaps, lotions, and cleansing cloths exist for various skin types.
Nocturnal Enuresis may be the symptom of an underlying condition. If this is the case, successful treatment of the condition can result in achieving nighttime dryness.
Medical Treatment for Bedwetting
Bedwetting that stems from a medical condition requires treatment beyond just lifestyle adjustments. Medications can treat a variety of conditions of which bedwetting is a symptom.
Before a treatment can be prescribed, your physician will want to zero in on the cause of your nocturnal enuresis. A symptom diary is one of the most useful tools for a healthcare provider.
Take care to note when you void during the day and night:
In addition, note any other symptoms associated with nocturnal enuresis such as night sweats. In addition to helping you find options to help cure bedwetting, it is also important to see a healthcare provider to rule out any other serious problems that may cause nocturnal enuresis as a side effect.
At the appointment you can expect:
Further tests may include:
For those suffering from persistent primary nocturnal enuresis, many treatments can be used at any age.
Surgical Treatment
The involvement of surgery when attempting to treat severe detrusor overactivity is limited and should only be considered when all other less invasive treatment options have proven to be unsuccessful. All of the procedures mentioned below have associated risks that must be considered and discussed with a healthcare professional.
Sacral Nerve Stimulation. Sacral nerve roots are stimulated by neuromodulation, a process where neurotransmitters control various neuron groups. This increases the external sphincter tone causing the detrusor muscle neurons to stop activity. When detrusor muscle neurons have a decreased activity level the muscle will not contract constantly, which ultimately causes less frequent urination episodes. SNS is recommended for people with moderate to severe urge incontinence and for whom other treatments have not been helpful or for whom prescriptions are contraindicated.
Clam Cystoplasty. This is a surgical treatment where the bladder is cut open and a patch of intestine is placed in between the two halves. The goal of this procedure is to reduce bladder instability and increase bladder capacity.
Detrusor Myectomy. This process is also known as autoaugmentation that involves removing a portion or all of the exterior muscle surrounding the bladder. It intends to strengthen bladder contractions while reducing the number of them.
Pharmaceutical Treatment
While no magic pill exists to totally eliminate nocturnal enuresis, there are medications available that might provide relief. When used in conjunction with behavioral modifications the positive effects of medication are more effective.
For many adults, it is hard to even talk about something that is a “kid thing”. It must be noted that bedwetting in adults is actually different than what children go through. And while that might not remove the embarrassment, you must know that nocturnal enuresis is involuntary and not your fault.
To fully understand the how and why, a quick anatomy short course could be helpful. Urine is produced by the kidneys and travels through the ureters to the bladder to be stored. The bladder is basically a muscular sac that holds urine until it is ready to be released into the urethra, the tube that connects the bladder to the outside of the body. At the same time the bladder contracts, the urinary sphincter relaxes. The relaxed sphincter acts like an open door, which allows the urine to pass and exit the body. When there is a physical impediment or neurological disconnect, urination can become problematic or mistimed.
Causes of Bedwetting
There are several factors that can contribute to an adult experiencing nocturnal enuresis. Physical and psychological conditions can lead to bedwetting in some people. Like with so many medical issues, the first place to check is family history. Evidence has shown that bedwetting is hereditary. One study has shown that someone with two bedwetting parents has a 77% chance of becoming a bedwetter. When one parent wet the bed as a child, his son or daughter was found to have a 40% chance of becoming a bedwetter. These probabilities carry into adulthood as well.
Hormonal imbalances can also cause bedwetting in some people. Everyone’s body makes a hormone called antidiuretic hormone (ADH). Its main function is to signal the kidneys to decrease the amount of urine produced. ADH tells your body to slow down the production of urine overnight. The lower volume of urine helps a normal bladder hold urine overnight. People whose bodies don’t make sufficient levels of ADH may experience nocturnal enuresis because their bladders can’t hold higher volumes of urine.
Instinctively, the body normally produces more ADH to avoid nocturnal enuresis. However, some people do not produce the appropriate amount of this hormone at night, which leads to high urine production. In other cases, the body produces ADH, but the kidneys do not respond and continue to produce the same amount of urine. This excessive production of urine during sleep is defined as nocturnal polyuria. This abnormality can cause nocturnal enuresis in adults, but it is also a symptom related to type I diabetes. Consulting a healthcare professional is helpful, especially if you feel that you may be experiencing diabetes or nocturnal enuresis.
Patients with a “smaller” bladder are often dealing with primary nocturnal enuresis. The physical size of the bladder isn’t actually smaller, rather, the functional bladder capacity (FBC) can hold a smaller volume of urine.
Related to FBC, if the muscles of the bladder, known as detrusor muscles, are overactive, nocturnal enuresis can occur. In fact, detrusor overactivity has been found in up to 70-80% of primary nocturnal enuresis patients. Bladder irritants, such as alcohol and caffeine, can contribute to detrusor instability. Medications are also known to increase bedwetting in adults. Side effects from hypnotics, insomnia medications, and psychiatric medications such as thioridazine, clozapine, and risperidone can increase your risk. Be sure to talk to your healthcare provider about any medications prescribed and their side effects.
Diabetes is another disorder that can cause bedwetting. The bodies of people with diabetes don’t process glucose (sugar) properly and may produce larger amounts of urine. The increase in urine production can cause children and adults who normally stay dry overnight to wet the bed.
As for secondary nocturnal enuresis, there is plenty of research that suggests an underlying health issue is at the root of the bedwetting. Such problems can be associated with the prostate in men or pelvic organ prolapse in women.
Any of these medical issues can also cause bedwetting: diabetes, urinary tract infection, urinary tract stones, neurological disorders, anatomical abnormalities, urinary tract calculi, prostate cancer, prostate enlargement, bladder cancer, or obstructive sleep apnea.
Other common causes of bedwetting include:
- Urinary Tract Infection (UTI)
- Stress, fear, or insecurity
- Neurological disorders (e.g. post-stroke)
- Diabetes
- Prostate gland enlargement
- Sleep apnea (abnormal pauses in breathing during sleep)
- Constipation
Risk Factors for Bedwetting
Gender and genetics are among the risk factors for bedwetting. Both boys and girls may experience episodes of nocturnal enuresis during early childhood. Boys are more likely to wet the bed when they get older.
Family history plays a role, too. You’re more likely to wet the bed if a parent, sibling, or other family member has had the same issue.
Bedwetting is also more common among children diagnosed with attention deficit hyperactivity disorder (ADHD). Researchers don’t yet fully understand the relationship between bedwetting and ADHD.
Lifestyle Changes to Manage Bedwetting
Certain lifestyle changes may help end bedwetting.
Monitoring Fluid Intake. Limiting intake of fluids in the late afternoon and evening before bedtime causes a decreased amount of urine produced at night. Setting limits on fluid intake plays a large part in controlling bedwetting. Try not to drink water or other liquids within a few hours of bedtime to reduce the risk of having an incident. Drink the majority of your daily fluid requirements before dinnertime. This will ensure that your bladder is relatively empty before bedtime.
Bedwetting Alarm System. Multiple variations of the alarm exist, ranging from vibrating to sounding alarms and wet-detection devices that can be attached to the underwear or a pad on which the individual sleeps.
Waking. This involves randomly setting an alarm to go off in the night in order to wake one for urination. The randomness keeps from training the bladder to need to empty at a set time.
Voiding Schedule. Devise a voiding schedule to help you stay dry overnight. A voiding schedule simply means that you urinate on a regular timetable, such as every 1 to 2 hours. Use the bathroom right before you go to bed to empty your bladder fully before sleep.
Bedwetting can sometimes occur during a stressful event in a person’s life.
Management
Mattress Covers. A variety of products exist to protect the bed including vinyl, waterproof, and absorbing mattress covers or even sheet protectors, which can make cleanup easier.
Absorbent Briefs. These products are a form of modified underwear designed to absorb liquid, therefore preventing leakage. Both reusable and disposable products are available.
Skincare Products. Many products exist to protect the skin from irritation and soreness that occur when a person experiences nocturnal enuresis. A range of soaps, lotions, and cleansing cloths exist for various skin types.
Nocturnal Enuresis may be the symptom of an underlying condition. If this is the case, successful treatment of the condition can result in achieving nighttime dryness.
Medical Treatment for Bedwetting
Bedwetting that stems from a medical condition requires treatment beyond just lifestyle adjustments. Medications can treat a variety of conditions of which bedwetting is a symptom.
Before a treatment can be prescribed, your physician will want to zero in on the cause of your nocturnal enuresis. A symptom diary is one of the most useful tools for a healthcare provider.
Take care to note when you void during the day and night:
- When accidents occur (time of day or night)
- Amount of urine voided
- Drinking patterns (do you drink a lot of fluids in the later afternoon/evening?)
- What you drink (sugary, caffeinated, artificially sweetened, carbonated, alcoholic drinks, etc.)
- Nature of the urinary stream (is the urinary stream strong and constant or is there difficulty initiating a void or continuous dribbling?)
- Any existing recurrent urinary tract infections
- The number of wet versus dry nights
In addition, note any other symptoms associated with nocturnal enuresis such as night sweats. In addition to helping you find options to help cure bedwetting, it is also important to see a healthcare provider to rule out any other serious problems that may cause nocturnal enuresis as a side effect.
At the appointment you can expect:
- A physical examination.
- Neurological evaluation.
- Urinalysis and urine culture. The urinalysis and urine culture are different tests that determine the contents of the urine.
Further tests may include:
- Uroflowometry. This involves urinating into a specialized funnel that measures the flow rate, amount of urine, and time required for urination.
- Post-void residual urine measurements. This test requires an ultrasound and are non-invasive procedures that determine the volume of urine left in the bladder after voiding.
For those suffering from persistent primary nocturnal enuresis, many treatments can be used at any age.
The involvement of surgery when attempting to treat severe detrusor overactivity is limited and should only be considered when all other less invasive treatment options have proven to be unsuccessful. All of the procedures mentioned below have associated risks that must be considered and discussed with a healthcare professional.
Sacral Nerve Stimulation. Sacral nerve roots are stimulated by neuromodulation, a process where neurotransmitters control various neuron groups. This increases the external sphincter tone causing the detrusor muscle neurons to stop activity. When detrusor muscle neurons have a decreased activity level the muscle will not contract constantly, which ultimately causes less frequent urination episodes. SNS is recommended for people with moderate to severe urge incontinence and for whom other treatments have not been helpful or for whom prescriptions are contraindicated.
Clam Cystoplasty. This is a surgical treatment where the bladder is cut open and a patch of intestine is placed in between the two halves. The goal of this procedure is to reduce bladder instability and increase bladder capacity.
Detrusor Myectomy. This process is also known as autoaugmentation that involves removing a portion or all of the exterior muscle surrounding the bladder. It intends to strengthen bladder contractions while reducing the number of them.
Pharmaceutical Treatment
While no magic pill exists to totally eliminate nocturnal enuresis, there are medications available that might provide relief. When used in conjunction with behavioral modifications the positive effects of medication are more effective.
- Desmopressin. By mimicking ADH or vasopressin, the kidney produces less urine.
- Imipramine. Boasts a 40% success rate but also has a fine line between an effective dose and toxic dose.
- Anticholinergic Medications. These prescription medications are effective for treating enuresis with detrusor overactivity, demonstrating success in 5-40% of cases. The main side effects with anticholinergic medications are dry mouth, dizziness, and blurred vision.
- Darifenacin. This medication relieves bladder spasms and treats overactive bladder.
- Oxybutynin. Relaxes the detrusor muscle of the bladder.
- Tolterodine. This medication is an antimuscarinic and functions much like oxybutynin.
- Trospium Chloride. Treats an unstable bladder by blocking cholinergic receptors that are found on muscle cells in the wall of the bladder. Once the receptors are blocked, the bladder then can relax so overactivity does not occur.
- Solifenacin. This is a recently introduced anticholinergic that is a more selective antimuscarinic agent with fewer anticholinergic side-effects.
Culled and edited. Images: Google
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