Jennifer Davis got mad at God when she was 10 years old. 

She had gone to her best friend's house for a birthday party sleepover. And while she was excited to try out the new sleeping bag she'd gotten for Christmas just a few weeks earlier, she was scared about spending the night with the 12 girls from her fourth grade class and scared about making her friend's mother mad. But she kept her apprehension to herself, because she was embarrassed to tell them what she was scared about.

When it was time for bed, Jennifer stayed awake as long as she could. Right before she drifted off to sleep, she whispered to God and asked for one little thing: "God, please don't let me wet the bed tonight."

At five in the morning, she woke up, cold, wet, scared - and mad. The only thing she was happy about was not making a wet spot on the carpet where she had slept. Quietly, she went to task: rolling up the sleeping bag, changing her clothes and staying awake until the others arose so that it wouldn't happen again.

She didn't go to a sleepover again until she was 15.

Tonight approximately 6 million children and adolescents like Jennifer will wet their beds in the United States. It's a social stigma. It's embarrassing. It happens for unknown reasons and resolves just as mysteriously, just as it did for Davis. But current treatments offer hope to patients and parents so that they can rest easily - in their own beds or sleeping bags. 

Treatments
Enuresis treatments are classified as behavioral, motivational, physical or pharmacological. Each treatment is used with varying success for children who have enuresis - which means that patience is key for patients, parents and providers. 

"You have to be open to every treatment option," said Sandra Hassink, MD, program director of the enuresis clinic at the Alfred I. du Pont Hospital for Children in Wilmington, Del. "Some methods work very well by themselves, and others mainly only work when you use them with other treatments." 

By trying and combining different methods, most children achieve dryness a few months after therapy begins and almost certainly by adolescence or adulthood.

Behavioral Therapy
According to the Mayo Clinic, in Rochester, Minn., more than 70 percent of children stop wetting their beds with behavioral modification techniques. It's also the first line of defense for enuresis, followed by pharmacological therapies when behavior modification doesn't work or isn't appropriate for the patient or family.  

Dr. Hassink's clinic primarily uses behavioral therapy. "It's the first line of treatment because it's highly successful and it has no side effects. It's also useful because many kids who wet the bed are feeling very badly about themselves, and many times the parents are feeling very badly about the child. By using behavioral therapy, you're able to change those dynamics."

Enuresis Alarms
The most effective treatment is an enuresis alarm that buzzes or vibrates to awaken the child when he starts to urinate in his sleep. An enuresis alarm has the highest response rate of any behavioral therapy - estimated at 60 percent to 80 percent, with a relatively low relapse rate of 28 percent to 40 percent, which significantly decreases with a second round of therapy.¹ Dr. Hassink said her clinic's success rate is even higher. "Ninety-five percent of the kids we treat get dry on the first shot."

Enuresis alarms use a sensor that attaches to the child's underwear or pajamas. At urination onset, a buzzer or a vibrator activates, which awakens the child to use the bathroom. Some alarms have a second alarm unit that parents can place in their bedroom to make sure their child has used the toilet. At an average price of $55, enuresis alarms are also fairly inexpensive. Some insurance policies may cover them under durable medical equipment, and some medical suppliers rent units.

Perhaps the only contraindications of an enuresis alarm are if the child is a deep sleeper and doesn't hear the alarm, or if the child has already finished urinating by the time they hear the alarm. In the latter, enuresis alarms still may be effective because they condition the child to awaken when his bladder is full, which is the theory behind their effectiveness.

One problem with enuresis alarms is that most providers, parents and kids don't believe in their efficacy. Albert Bourbon, PA-C, sees many patients with enuresis at Las Vegas Clinic for Children and Youth, a private pediatric practice in Las Vegas, N.M. He's acutely aware of the problems associated with trying to get parents to invest their time and money into enuresis alarms.

"Parents and kids want you to put a Band-Aid on their enuresis - they want it to go away without any work," he said. "The trick is getting parents to actually believe that enuresis alarms are effective. From the beginning of treatment, I tell my patients and their parents right away that the alarms are really the most successful.

"I give them 800 numbers and the whole nine yards about how to buy and use an alarm, but the people who actually take advantage of the alarm are really few. During their follow-up visits, parents complain because they tried to decrease their child's fluids before bedtime, and they tried to wake the child up during the night. But when I ask them if they tried the alarm, they say no. And then they want to know what else they can do before they actually get the alarm. For some reason, they think the alarms are probably not going to be effective."

Dr. Hassink agrees. "Many patients aren't familiar with behavioral therapy so they have some skepticism. One of the most important things to do is have a positive approach that these alarms are a viable, workable, proven way to treat enuresis."

Other Alarms
Alarm therapy can be used before an enuresis alarm but is less effective. Parents can set an alarm to go off at regular intervals in the night to have the child awaken to urinate. It's a good idea to have the parents or the child keep a log of how often and at what time he wets the bed. This establishes wetting patterns to help determine at what times the alarm should be set. 

This therapy is less effective than enuresis alarms because the child isn't awakening when his bladder is at capacity; instead, the family is guessing at when this happens. Also, it's important that the child is given responsibility of turning the alarm off and using the toilet himself, rather than the parent using an alarm in their own room and waking the child - also called "night-lifting." 

Motivational Therapy
Motivational therapy, which incorporates parts of behavioral therapy, can be used alone or with behavioral therapy for increased success. Star charts, stickers or other forms of positive reinforcement are used to praise the child for nights when he gets up on his own to use the bathroom, dry nights or successful use of an enuresis alarm. Other forms of positive reinforcement can be used based on the size of wet spots. Parents then can give rewards for the number of stars or stickers that a child acquires within a given time. 

A word of caution, though: Encourage parents to stick by the rules of the star chart - if they promise to buy a toy for accomplishing five nights of dryness in a week, they have to stick to that promise. Studies have shown that enuretics already suffer from poor self-esteem and often think they are being unfairly punished or scolded by their parents or siblings because of their bed-wetting. By reneging on positive reinforcement, children feel punished even more, which can result in further low self-esteem and may have a negative impact on the child's dry-night progress. 

Physical Therapy
Bladder training exercises sometimes prove effective for enuresis. Like behavioral therapy, it teaches children self-awareness of full bladder sensation and also conditions them to use the bathroom once they are in bed. One study has found bladder-stretching exercise (where the child stops the flow of urine repetitively while urinating) and bladder-training (where the child lies in bed and imagines his bladder getting full and goes to the bathroom, then repeats this process several times) can be 30 percent to 40 percent successful.² 

Because Bourbon treats enuresis conservatively, he believes that physical therapy, along with getting the child on a regimented voiding schedule, can be fairly effective. 

Pharmacological Therapy
The most frequently prescribed medication for enuresis is desmopressin acetate (DDAVP). This synthetic analog of the natural hormone vasopressin decreases the quantity of urine produced in the eight to 12 hours after dosing.³ For many children, this allows them to sleep dry and is particularly useful for sleepovers and camps. 

Desmopressin is available as a nasal spray or tablet. The tablet is preferred because it delivers a more consistent and convenient dosage. If changes in the nasal mucosa occur, as with colds or allergies, unreliable absorption of the nasal spray may result.³ Dosage of desmopressin has to be individualized, with one to three tablets (0.2 mg) each night before bed as the recommended dose. The greatest number of dry nights is achieved by 0.4 mg to 0.6 mg nightly.⁴ 

If you prescribe desmopressin for a situation outside the child's home, start the medication several weeks ahead of time to establish the appropriate dose. If the child wets when taking one tablet, increase it to two. If wetting occurs with two tablets, raise the dosage to three tablets. Three tablets is the maximum amount recommended for any age group. Parents should realize that this medication doesn't cure enuresis, but it does buy time.

Desmopressin also can be prescribed for children in conjunction with the enuresis alarm. For this purpose, decrease the dosage so that the child still has nocturnal enuresis, but the voiding is closer to morning and less in amount. In many children with enuresis, the first night wetting occurs only 90 minutes to two hours after they go to bed. Since this is a particularly difficult time for independent sleep arousal to take place, moving the night wetting to several hours later may foster success using an enuresis alarm. As children learn the new behavior of waking to a full bladder and walking to the bathroom, the medication can be decreased and then discontinued.

Oxybutynin (Ditropan) is another medication that's useful in the treatment of enuresis in some children. If the child has clinical signs of small functional bladder capacity, frequency or urgency during the day, this medication also may assist with nighttime dryness. Oxybutynin works by relaxing smooth muscle in the bladder, increasing bladder capacity and delaying the initial desire to void.⁵

In children with daytime symptoms, dosing the oxybutynin two to three times per day is helpful. Oxybutynin tablets 5 mg (not the XL version) or syrup (5mg/5 mL) are recommended for children older than 5. In a 5- to 8-year-old, a dosing regimen of 0.5 teaspoon b.i.d. to t.i.d. is usually effective. A child older than 8 requires one tablet in the morning and one tablet at bedtime. Because each child is different, dosing should be individualized for optimal results. In children who don't have daytime symptoms but have a small bladder capacity, dosing only once per day at bedtime is recommended.⁶ As with desmopressin, use this medication in conjunction with an enuresis alarm, decreasing the dose as the patient learns to wake to the alarm and stay dry. 

Most research indicates that combination therapy consisting of an enuresis alarm and medication is superior to either used alone.⁷ A child who uses an enuresis alarm is nine times less likely to relapse than one who uses medication alone.⁷ The synergistic effect of alarms and medications may contribute to increased patient compliance with the alarm. As progress occurs, a slow weaning of the medication - with continued alarm use - is possible. Children who appear to be producing too much urine at night may respond to desmopressin, and those with urgency and frequency may do well with the addition of oxybutynin. Research suggests that improved response to pharmacologic treatment is achieved through the simultaneous use of desmopressin and oxybutynin.⁸ 

Staying Dry for Life
Is staying dry for life important? Bourbon said no. As he explains, enuresis doesn't cause any other physical side effects, except for maybe a rash. What's more important, he said, is keeping the child healthy, happy and well adjusted. 

"While we can try to make a kid better with enuresis, we may fail at 'curing' it," he said. "But let's keep the kid healthy and happy otherwise. I think self-esteem and confidence building is more important than rectifying enuresis. I would rather have a happy-go-lucky child getting great grades in school and having great friends and being an enuretic for the rest of his childhood versus squashing his self-esteem, confidence and pride, and making him hate everyone here at the clinic." 

And besides, isn't there plenty of time for sleepovers when the child grows up?  

References
1. Garber KM. Enuresis: an update on diagnosis and management. J Pediatr Health Care. 1996;10:202-8.

2. Clark RB. Psychosocial aspects of pediatrics and psychiatric disorders. In: Hay WW Jr, Groothuis JR, Hayward AR, Levins MJ, editors. Current Pediatric Diagnosis and Treatment. Norwalk, Conn: Appleton & Lange; 1995:154-94. 

3. DDAVP Tablets product information. Aventis Pharmaceuticals Products Inc., 2001. 

4. Skoog SJ, Stokes A, Turner KL. Oral desmopressin: a randomized, double-blind placebo-controlled trial of effectiveness in children with primary nocturnal enuresis. J Urol. 1997;158:1035-40.

5. Ditropan product information. ALZA Corporation, 1998.

6. Maizels M, Rosenbaum D, Keating B. Getting to Dry: How to Help Your Child Overcome Bedwetting. Boston: The Harvard Common Press; 1999.

7. Bosson S, Lyth N. Nocturnal enuresis. In: Barton S, editor. Clinical Evidence. London: BMJ Publishing; 2001;6:300-5.

8. Rushton H, Belamn A, Zaontz M, Skoog S, Sihelnik S. The influence of small bladder capacity and other predictors on the response to desmopressin in the management of monosymptomatic nocturnal enuresis. J Urol. 1996;156:651-5.

Jennifer Hyde Breton was formerly on staff at ADVANCE. Mercer is a pediatric nurse practitioner in Ellicott City, Md., who owns a private practice specializing in the treatment of children with enuresis.