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Bedwetting
Steer clear of desmopressin nasal
spray
BY Lane Robson, MD
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Jared is a 7-year-old boy in Grade 2.
His Mom brings him to the office because he still wets the bed, which
has become more of an issue lately because Jared has had to turn down
several sleepover invitations. The parents can tell that he feels
sad about this, and there's also an overnight school trip in the spring
that the youngster would like to attend. The Mom asks you about treatment
options.
Presentation
History
- wets the bed every night and has
had only the rare dry night
- voids about 6 times a day
- has occasional urgency but no daytime
wetting, not even dampness
- the description of his stream is
normal
- wears pull-up, which is soaked in
the morning, and half the nights the urine spills over into
the bed sheets
- when he pees first thing in the morning,
the volume is large
- Mom describes him as a deep sleeper
Physical exam
- normal blood pressure
- kidneys and bladder normal to palpation
- normal male genitalia, uncircumcised
with a foreskin that retracts to reveal a normal meatus
- spine normal without dimples or birthmarks
- normal neurologic exam
Investigations
- random urine specific gravity (SG)
is 1.025
- no sugar in urine
- no red blood cells (RBCs), white
blood cells (WBCs) or bacteria in urine
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Making the case
Jared is diagnosed with primary nocturnal enuresis and is managed
by the family physician. Bedwetting affects about 7% of 7-year-old
children, which means that every Grade 2 classroom has at least
one and sometimes two kids with this problem. About 1% of adults
still wet the bed -- so statistically, the bedwetting will resolve
in 6 out of 7 children who are affected at Jared's age.
Three factors come together to cause bedwetting. For one, kids
with this condition don't wake up to the sensation of a full or
contracting bladder -- this is referred to as a problem with arousal.
Secondly, there may be an overproduction of urine at night. And
finally, children who wet the bed sometimes have a bladder that
doesn't hold as much as expected during the night, i.e. they have
a small nocturnal bladder capacity. In many kids, all three factors
play a role. Simply put, they make too much urine for the size of
their bladder and they don't wake up. Since bedwetting can have
an appreciable impact on the self-esteem of a child, it certainly
deserves treatment.
Interpreting the signs
Jared has a heavy pull-up, but half the nights urine still spills
over, and when he pees first thing in the morning, he has a full
bladder. These kinds of symptoms suggest that he overproduces urine.
But he doesn't exhibit any of the hallmark signs that indicate a
bladder acting small at night. For instance, frequent voiding during
the day, urgency and a history of daytime wetting would be signs
of a bladder acting small during the day, which makes it likely
that the same problem exists at night. Jared also doesn't have any
red flags -- such as an abnormal stream or abnormal neurologic exam
-- that suggest a urethral obstruction or neurogenic bladder, the
two uncommon structural causes of bedwetting.
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