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Enuresis and Sleep

Nocturnal enuresis, also known as enuresis or bedwetting, is a frustrating disorder no matter your age. Although more common in children, enuresis can also continue into the teenage years and even appear in adulthood. (There is a daytime variation of enuresis, but this is usually described as urinary incontinence.)

Enuresis and sleep share a relationship which is more profound than most people are aware. Not only can bed-wetting disrupt sleep in obvious ways, but both childhood and adult enuresis can be caused by sleep disorders like Obstructive Sleep Apnea.

In this article, we will cover the causes of and treatments for enuresis, as well as examining how  sleep and enuresis affect each other. By the time you’re done reading you should understand this connection well and feel confident in knowing your options.

What is Enuresis?

The Diagnostic & Statistical Manual of Mental Disorders (DSM-IV) defines nocturnal enuresis as the accidental release of urine during sleep, at least twice a week, in children five or above with no defects of the central nervous system.

Some dispute this definition, arguing that nighttime incontinence more than twice a month in children five or above should be considered enuresis as well.

Adults can also suffer from enuresis. While this is usually considered to be separate from childhood bedwetting, the problem can be caused by similar underlying factors. The difference is that, in the vast majority of cases, adult enuresis is not related to the normal development of urinary control. Instead, it tends to be caused by a medical problem.

In both children and adults, enuresis takes two forms:

  • Primary enuresis describes cases where the patient has never achieved regular nighttime dryness. This variation can either be caused by underlying problems or ordinary development. The most common reason for bedwetting in children, it is rarer in teenagers and adults.
  • Secondary enuresis describes bedwetting which develops after a six-month or longer stretch of dryness. While this does apply to some children, it is the more common form for teenagers and adults.

Child Vs. Adult Enuresis

Nocturnal enuresis is much more common in children than teenagers or adults. At age five, one in six children suffers from bedwetting, but 15% of children will stop bedwetting each year without treatment.

Age Bedwetting Numbers
Age 5 1 in 6 children
Age 6 1 in 8 children
Age 7 1 in 10 children
Age 15 1-2 in 100 children

Enuresis is a normal part of urinary tract and urinary control development. While there are sometimes physical issues involved, most children grow out of these with time.

Because of this, primary enuresis does not usually require treatment unless the child is distressed, or is above seven years old and wetting the bed more than two or three times a week.

However, secondary enuresis, or enuresis of any kind in teenagers and adults, should always be brought to a doctor’s attention. Not only is it usually due to an underlying cause which may require medical treatment, but it can also severely damage the quality of your life.

One study of persistent adult enuresis found that sufferers had much higher rates of depression and low self-esteem. 32-40% felt the condition affects their work and social lives, while 23% said their family life was impacted. Given that treatments are available, there is no reason to suffer alone.

What Causes Enuresis?

When discussing the causes of enuresis, is it important to underline that primary enuresis is not abnormal in children. Bedwetting is, for most children, an ordinary part of development and toilet-training.

While some may have an underlying physical or medical cause in need of treatment, the cause of most childhood enuresis merely is not having grown out of it.

Physical Causes

Enuresis can be caused by biological issues which may or may not be caused by an underlying medical problem. These are considered “primary causes” and can lead to either primary or secondary enuresis.

There are three common primary causes: excessive nighttime urine production, an overactive bladder, or not being woken up by bladder sensations. Often two or more are present in cases of primary enuresis, while secondary enuresis cases may or may not involve a primary cause.

Cause Mechanism
Excessive nocturnal urine production Ordinarily, we release a hormone at night which reduces how much urine we produce. In some cases, this hormone is not released in the right amounts.
Overactive bladder Also referred to as urge incontinence, an overactive bladder can be a primary cause or the symptom of a secondary cause. Both cases result in the sudden need to release urine even when the bladder is not full.
Not waking up in response to bladder sensations There are many reasons why someone might not wake up in response to the need to “go”, but incomplete cognitive development, sleep dysfunction, and problems of the nervous system are all possible.

Medical Problems

Secondary enuresis in adults is usually caused by a medical issue in need of treatment. Children and teenagers can also be affected.

While there are many underlying medical problems which can lead to nocturnal enuresis, these are some of the most common:

If you feel that your or your child’s enuresis may be caused by a medical concern, please speak to your doctor. When enuresis is a symptom of a larger problem, treating the underlying issue is essential for recovery.

Sleep Apnea

As mentioned above, obstructive sleep apnea is a common cause of enuresis in both children and adults. While this may seem surprising, the link between sleep apnea and nighttime urination is well-documented.

Obstructive sleep apnea is a disorder which causes sufferers to stop breathing for short periods while asleep. This occurs several times a night when muscles and tissue in the airway relax and block ordinary breathing. Snoring is a common symptom, but so are two urological issues: nocturia (waking up with the need to urinate) and enuresis.

An estimated 7% of adult sleep apnea sufferers also experience enuresis. Given that 3-7% of men and 2-5% of women will develop sleep apnea, this results in a significant number of adult enuresis cases each year.

The reason why sleep apnea can cause enuresis is not fully understood. However, current theories include increased abdominal pressure from disordered breathing and increased urinary production due to the hormonal fluctuations caused by the disorder.

Whatever the cause, we do know that CPAP therapy, the gold standard for sleep apnea, is successful in treating many associated enuresis cases.

Sleep Dysfunction

Dysfunctional and disturbed sleep in general can also be a factor in enuresis. Children who suffer from enuresis are often reported to be “deep sleepers” who are difficult to wake in the morning.

While this is a common trait which can directly cause enuresis, it can also signify further sleep problems. Other studies have reflected this concern, such as one which found that children with enuresis have more fragmented sleep and higher levels of daytime sleepiness.

Research is currently being conducted into whether these concerns are a symptom or cause of enuresis, but some studies indicate that they are both. Since we know that sleep dysregulation and disruption can interfere with nighttime urinary signals and function in animals, it seems clear that there may be an underlying relationship in which sleep and nocturnal enuresis can affect one another at the same time.

How Enuresis Can Affect Sleep

Sleep Stages & Cycles

When we sleep, we pass through several sleep stages (or phases). Each of these has its own purpose — there is no such thing as “junk” sleep.

Stage Description
Stage 1 This drowsy stage is easy to wake from, and people who wake often feel as though they have not slept.
Stage 2 Awakening is more difficult at this stage. While rapid periods of brain activity continue to occur during this stage, the sleeper’s temperature begins to drop and their heart beat slows.
Stage 3 Known as deep non-REM sleep, this restorative sleep stage is very difficult to wake from.
Rapid Eye Movement (REM) Sleep Known as the “dreaming” stage, REM sleep is easier to wake up from but will cause sleepers to feel very groggy.

Over the course of each night, we repeat these stages in what are known as “cycles”. To feel well-rested the next morning, it is essential to experience the correct number of stages and cycles.

People with enuresis usually urinate outside of the REM Sleep stage, with most incidents occurring in stages 2 and 3. This may be due to the longer length of these stages versus stage 1, but in practice, it means that phases with the deepest sleep are more likely to result in enuresis.

Any use of a wetness alarm system (see How To Treat Enuresis below) also means that sleepers are likely to wake during these stages. While over time the goal is for sufferers to quickly return to sleep after relieving themselves, this will initially result in disturbed sleep cycles and potential sleep loss.

Sleep Loss & Fragmentation

Of course, enuresis can itself lead to sleep loss and fragmentation in a purely mechanical way: sufferers wake when they feel cold or wetness, stress over the issue creates sleep-onset insomnia, or sleep-maintenance insomnia keeps them up once they’ve woken in the night.

When compared to control subjects, children with nocturnal enuresis:

  • Wake up more often during the night
  • Experience more daytime sleepiness
  • Are sleepier in the morning and evening
  • Sleep for shorter periods overall

In addition to aggravating the effects of enuresis, sleep loss or low sleep quality caused by fragmentation can create problems of their own.

Experts recommend ten hours of sleep a night for children between the ages of 5 and 10, nine hours for teenagers, and seven to eight hours for adults. If an individual doesn’t get enough sleep, or if the sleep they have is fragmented and of low quality, their quality of life tends to decline sharply.

Not only does sleep loss put you at greater risk of diseases like Type 2 diabetes, but it also makes you more vulnerable to mental health conditions like anxiety and depression. Given that the mental impact of enuresis can be overwhelming to begin with, this can be a real concern for sufferers.

Parents should also be aware of the issues associated with sleep loss. While it’s natural to wake up to help your child or clean, this naturally creates a sleep deficit. In order to support your child without endangering yourself, practice good sleep hygiene and regularly swap nighttime duties with your partner when possible.

Are Children With Enuresis “Deep Sleepers”?

Parents have regularly reported to their doctor that their child with enuresis is a “deep sleeper” who is difficult to wake, whether or not they have experienced wetness on a given night.

Although this understanding was disregarded in the past, studies have now found the data to back up these anecdotal reports. In one study comparing enuretic boys against a control group, the children with enuresis were far more difficult to wake than their peers. The control group woke up 39.7% of the time, whereas the enuretic boys woke only 9.3% of the time.

This study was not an outlier. Other research has found that children with enuresis regularly sleep more deeply, with more rhythmic slow wave periods which are usually associated with younger children.

There is also a suggestion that the depth of a child’s sleep correlates to the severity of their enuresis. While research is still ongoing into this topic, a Taiwanese research team found that the depth of an enuretic child’s sleep was the factor which predicted whether they would reach over three “wet” nights a week. The study also covered common predictors such as family trauma, gender, and a genetic history of enuresis, making the findings even more extraordinary.

The Impact of Sleep Fragmentation

Although we know that enuresis usually occurs during the stages we sleep most deeply, the relationship between depth of sleep and enuresis may be caused by sleep loss and fragmentation.

Children with enuresis show an altered “sleep architecture”, meaning that the way they cycle through sleep stages each night is abnormal. The hypothesis is that this, in addition to the natural sleep loss caused by enuresis, causes a sleep deficit for affected children. In an effort to combat this, the body produces a “rebound effect” of deeper sleep that is more difficult to wake from.

Sleep debt in adults is often accompanied by similar periods of deeper slow-wave sleep, just as in children with enuresis. You may have even experienced it yourself after depriving yourself of sleep too often or for too long.

While the hypothesis has not yet been adequately studied, researchers are hopeful that it will help parents and doctors reach a better understanding of enuresis and how to treat it.

Getting enough high-quality sleep is essential to our overall health, so emphasizing the importance of sleep in treating enuresis has few potential side effects. If you think sleep loss may be contributing to you or your child’s enuresis, speak to your doctor and keep reading for further advice.

How to Treat Enuresis

Medical Intervention

Treatment for enuresis varies depending on the age of the sufferer and the underlying cause. While a six-year-old who can’t stay dry from time to time may not need medical help, all cases of secondary enuresis should be looked into, and enuresis in adults or teenagers almost always requires medical treatment.

The most common form of medical treatment for enuresis is treating its underlying cause. However, your doctor may also suggest medication for you or your child. The three most common medications for enuresis are:

Medication Effect
Desmopressin This synthetic hormone is the most common medication for enuresis and causes the kidneys to produce less urine. It is effective in approximately half of all cases.
Oxybutynin Patients with an overactive bladder can take Oxybutynin to reduce bladder contractions. This can minimize enuresis incidents in both children and adults.
Imipramine This tricyclic antidepressant has a 40% success rate when used for enuresis, but potentially severe side effects mean it is used only when necessary.

Treatment with medication is almost always done in tandem with lifestyle changes. Children in particular often take medication for special occasions where dryness is crucial (like sleepovers) while using alarms and other behavioral modification at home.

Alarms

Children above the age of five often find success with wetness alarm systems. Adults, too, sometimes use alarms if their enuresis is the result of not waking to urinate properly.

Modern alarms are tiny, lightweight, and meant to be worn on the body. Only a few drops of urine will cause a loud alarm to sound, waking the sleeper and helping condition them to bladder sensations and the need to urinate.

Most alarms are simple enough even for young children to operate. However, they require that both the child and their family are motivated and willing to wake up multiple times a night until the condition is under better control. Fourteen consecutive dry nights are usually the standard for measuring when an alarm is no longer needed.

Alarm therapy may take one-two months to have an effect and is usually continued for three to four months overall. Speak to your doctor if you think an alarm may work for you or your child.

Mental Health Care

Enuresis can be very upsetting for anyone who experiences it. Children who experience bedwetting episodes above the age of eight are more likely to have poor self-esteem and other mental health issues. They are also likely to both externalize and internalize problems. Over time, this can lead to behavioral issues, poor self-image, and unhealthy coping mechanisms.

Teenagers and adults are also affected by the mental side effects of enuresis, often feeling helpless and ashamed.

While all these feelings are common, they can do lasting damage to enuresis sufferers. Mental health care is recommended to support both children and adults with the condition, in conjunction with treatment for the enuresis itself.

Cognitive behavioral therapy, or CBT, is considered the golden standard for people of any age who suffer from enuresis. (Interestingly in the context of the sleep-enuresis connection, CBT is also regularly recommended for episodes of insomnia as well.)

A highly goal-focused form of therapy, CBT aims to change feelings and actions by examining and improving the thought processes behind them. Not only is this helpful against emotional distress, but it offers patients the chance to build a toolkit of healthy coping mechanisms and useful advice.

Lifestyle Changes

Treating enuresis is usually done on two fronts: with help from medical professionals, and at home. Different people will find relief from different advice, but these are practical steps usually suggested for children and adults struggling with enuresis:

  • Avoid caffeine and alcohol before bed, as they are diuretics which increase urine output. Similarly, limit fluid consumption after dinner.
  • Practice good sleep hygiene to avoid disturbing your sleep any more than it already is. This includes keeping a regular bedtime, ensuring bedrooms are cool and quiet, and other sleep-supporting advice.
  • Urinate directly before going to bed.
  • If your child is still wearing diapers, graduate them to underwear or training pants.
  • Equipment like waterproof mattress protectors can make clean-up less overwhelming and less intrusive for sufferers.
  • Keep fresh, clean bedding available at all times.
  • Children should be involved in clean-up in a way which does not feel shameful or like a punishment.

Conclusion

Enuresis at any age can be frustrating and upsetting, but effective treatments are available. By learning about the complicated relationship between sleep and nocturnal enuresis, we are given a greater understanding of the issue and a better chance of treating it successfully.

We hope you have found this article useful in illuminating this relationship, as well as the causes of enuresis and how you can treat enuresis in yourself or your children. There is no reason to feel ashamed of the condition, and every reason to feel hopeful that it will pass.

Additional Tuck Resources

Sleep health is essential at any age. Follow the links below to learn more about sleep and discover the tools to achieve a good night of sleep in spite of your or your child’s enuresis.

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