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Causes
for Nighttime Incontinence
After age 5, wetting at night -often called bedwetting -is more common
than daytime wetting in boys. Experts do not know what causes nighttime
incontinence. Young people who experience nighttime wetting tend to be
physically and emotionally normal. Most cases probably result from a mix
of factors including slower physical development, an overproduction of
urine at night, a lack of ability to recognize bladder filling when asleep,
and, in some cases, anxiety. For many, there is a strong family history
of bedwetting, suggesting an inherited factor.
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- Slower Physical
Development
Between the ages of 5 and 10, incontinence may be the result of a small
bladder capacity, long sleeping periods, and underdevelopment of the
body's alarms that signal a full or emptying bladder. This form of incontinence
will fade away as the bladder grows and the natural alarms become operational.
- Excessive Output
of Urine During Sleep
Normally, the body produces a hormone that can slow the making of urine.
This hormone is called antidiuretic hormone, or ADH. The body normally
produces more ADH at night so that the need to urinate is lower. If
the body doesn't produce enough ADH at night, the making of urine may
not be slowed down, leading to bladder overfilling. If a child does
not sense the bladder filling and awaken to urinate, then wetting will
occur.
- Anxiety
Experts suggest that anxiety-causing events occurring in the lives of
children ages 2 to 4 might lead to incontinence before the child achieves
total bladder control. Anxiety experienced after age 4 might lead to
wetting after the child has been dry for a period of 6 months or more.
Such events include angry parents, unfamiliar social situations, and
overwhelming family events such as the birth of a brother or sister.
Incontinence itself is an anxiety-causing event. Strong bladder contractions
leading to leakage in the daytime can cause embarrassment and anxiety
that lead to wetting at night.
- Genetics
Certain inherited genes appear to contribute to incontinence. In 1995,
Danish researchers announced they had found a site on human chromosome
13 that is responsible, at least in part, for nighttime wetting. If
both parents were bedwetters, a child has an 80 percent chance of being
a bedwetter also. Experts believe that other, undetermined genes also
may be involved in incontinence.
- Obstructive Sleep
Apnea
Nighttime incontinence may be one sign of another condition called obstructive
sleep apnea, in which the child's breathing is interrupted during sleep,
often because of inflamed or enlarged tonsils or adenoids. Other symptoms
of this condition include snoring, mouth breathing, frequent ear and
sinus infections, sore throat, choking, and daytime drowsiness. In some
cases, successful treatment of this breathing disorder may also resolve
the associated nighttime incontinence.
- Structural Problems
Finally, a small number of cases of incontinence are caused by physical
problems in the urinary system in children. Rarely, a blocked bladder
or urethra may cause the bladder to overfill and leak. Nerve damage
associated with the birth defect spina bifida can cause incontinence.
In these cases, the incontinence can appear as a constant dribbling
of urine.
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Causes
for Daytime Incontinence
Daytime incontinence that is not associated with urinary infection or
anatomic abnormalities is less common than nighttime incontinence and
tends to disappear much earlier than the nighttime versions. One possible
cause of daytime incontinence is an overactive bladder. Many children
with daytime incontinence have abnormal voiding habits, the most common
being infrequent voiding.
- An Overactive Bladder
Muscles surrounding the urethra (the tube that takes urine away from
the bladder) have the job of keeping the passage closed, preventing
urine from passing out of the body. If the bladder contracts strongly
and without warning, the muscles surrounding the urethra may not be
able to keep urine from passing. This often happens as a consequence
of urinary tract infection and is more common in girls.
- Infrequent Voiding
Infrequent voiding refers to a child's voluntarily holding urine for
prolonged intervals. For example, a child may not want to use the toilets
at school or may not want to interrupt enjoyable activities, so he or
she ignores the body's signal of a full bladder. In these cases, the
bladder can overfill and leak urine. Additionally, these children often
develop urinary tract infections (UTIs), leading to an irritable or
overactive bladder.
Other
Causes
Some of the same factors that contribute to nighttime incontinence may
act together with infrequent voiding to produce daytime incontinence.
These factors include
- A small bladder
capacity
- Structural problems
- Anxiety-causing
events
- Pressure from a
hard bowel movement (constipation)
- Ingestion of bladder
irritants such as caffeine and aspartame (an artificial sweetener)
- Sometimes overly
strenuous toilet training may make the child unable to relax the sphincter
and the pelvic floor to completely empty the bladder. Retaining urine
(incomplete emptying) sets the stage for urinary tract infections.
Treatment
for Incontinence
Most urinary incontinence fades away naturally. Here are examples of what
can happen over time:
- Bladder capacity
increases.
- Natural body alarms
become activated.
- An overactive bladder
settles down.
- Production of ADH
becomes normal.
- The child learns
to respond to the body's signal that it is time to void.
- Stressful events
or periods pass.
Many children overcome
incontinence naturally (without treatment) as they grow older. The number
of cases of incontinence goes down by 15 percent for each year after the
age of 5.
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Medications
Nighttime
incontinence may be treated by increasing ADH levels. The hormone can
be boosted by a synthetic version known as desmopressin, or DDAVP. Users,
including children, spray a mist containing desmopressin into their nostrils,
where the drug enters the bloodstream. Researchers are developing a pill
version of this drug.
Another medication, called imipramine, is also used to treat sleepwetting.
It acts on both the brain and the urinary bladder. Unfortunately, total
dryness with either of the medications available is achieved in only about
20 percent of patients.
If a young person experiences incontinence resulting from an overactive
bladder, a doctor might prescribe a medicine that helps to calm the bladder
muscle. This medicine controls muscle spasms and belongs to a class of
medications called anticholinergics.
Bladder Training and Related Strategies
Bladder training consists of exercises for strengthening and coordinating
muscles of the bladder and urethra, and may help the control of urination.
These techniques teach the child to anticipate the need to urinate and
prevent urination when away from a toilet. Techniques that may help nighttime
incontinence include
- Determining bladder
capacity
- Stretching the
bladder (delaying urinating)
- Drinking less fluid
before sleeping
- Developing routines
for waking up
Unfortunately, none
of the above has demonstrated proven success.
Techniques that may
help daytime incontinence include:
- Urinating on a
schedule, such as every 2 hours (this is called timed voiding)
- Avoiding caffeine
and the artificial sweetener aspartame
- Following suggestions
for healthy urination, such as relaxing muscles and taking your time
Moisture
Alarms
At night, moisture alarms can wake a person
when he or she begins to urinate. These devices include a water-sensitive
pad worn in pajamas, a wire connecting to a battery driven control, and
an alarm that sounds when moisture is first detected. For the alarm to
be effective, the child must awaken or be awakened as soon as the alarm
goes off. This may require having another person sleep in the same room
to awaken the bedwetter.
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