Night Soaking Turkey
Night Soaking Turkey

This content created by Halil Tuğtepe, Prof. Dr. with attribution to scientific articles.

Night Soaking Turkey

What Is Night Soaking?

Bed-wetting, also known as nocturnal enuresis, is a health problem that describes the condition of children over the age of 5 peeing during the day or night, which they cannot control while sleeping. It is a very different situation from urinary incontinence during the daytime awake.

If the child has daytime complaints as well as nocturnal incontinence, then he/she is included in the "Day Incontinence Group" and a group-specific treatment approach is started;

  • Frequent urination
  • Sudden sign of impingement
  • Urinary incontinence
  • Intermittent urination
  • They do not have complaints such as the small amount of urination.

Causes of Bed-Wetting

Nighttime bed-wetting is considered normal up to the age of 5. Night wetting is a normal stage of development in children in this age group. It should be known that every child will learn toilet training at a different speed and thus improve bladder and pelvic floor muscle control. Parents should continue their education patiently, without seeing bed-wetting as a failure during this toilet training.

Although the root cause of enuresis in children older than 5 years is not known exactly, various factors are thought to play a role.

Contrary to popular belief, incontinence during sleep is not a psychological condition. While 2-3% of urinary incontinence during sleep is due to organic causes (urination disorder, urinary tract infection, diabetes, excessive work of the thyroid gland), 97% of them are non-natural causes.

Non-natural Reasons

1. Presence of arousal disorder: Generally, bed-wetting develops due to arousal disorder in children. Because the arousal threshold of children who wets the bed at night is too high during sleep, they either delay or cannot respond to any stimulus coming from outside. This situation causes the emptying order of the filled bladder not to be perceived and action cannot be taken.

2. Too much urine produced at night: Due to hormone imbalance, some children do not produce enough anti-diuretic hormone (ADH) to slow down their nocturnal urine production during childhood.

3. Small bladder: Your child's bladder may not be developed enough to hold urine produced during the night.

In very rare cases, bed-wetting can result from type 1 diabetes or a congenital (from birth) defect of the urinary tract. However, these conditions also cause daytime symptoms. If your child is not experiencing daytime wetting, you can be sure that they are completely healthy.

4. Sleep apnea: Obstructive sleep apnea, a condition in which the child's breathing is interrupted during sleep, sometimes due to bed-wetting, often inflamed or enlarged tonsils or adenoids, can cause nocturnal enuresis. Conditions such as snoring and daytime drowsiness may also be observed in these children.

5. Chronic constipation: The muscles that control the stool are also involved in the control of urine retention. In the long run, constipation can be seen as the cause of bed-wetting at night, rendering these muscles dysfunctional.

Natural Reasons

1. Urinary tract infection: The presence of the infection can make it difficult to control urine in children. In the presence of a urinary tract infection, besides bed-wetting, there may be daytime accidents, frequent urination, red or pink urine, and pain when urinating.

2. Diabetes: The presence of diabetes can be among the reasons for sleep loss at night. Night urinary incontinence may be the first sign of diabetes, especially in children who did not leak urine in the past and started to leak suddenly.

3. Presence of structural problem: The presence of a structural problem in the urinary tract or nervous system may be a reason for bed-wetting. This condition is associated with a problem in the child's neurological or urinary system.

When planning the treatment of nocturnal urinary incontinence, it should be investigated whether the cause is due to natural origin or not, and should be made treatment planning.

How Common Is It?

Few children manage to stay dry at night before the age of 3. Generally, most children start to stay dry at night between the ages of 3-5.

Bed-wetting is more common in young children. Looking at the frequency of the age;

  • 15-20% around age 5
  • 7% around age 8
  • 3% around age 12
  • It is seen around 1% above the age of 15.

Until your child reaches this stage, he will benefit from your patience and understanding.

Which Children Are In The Risk Group?

In the distribution by gender, it is more common in boys than in girls. It does not appear to be linked to any particular culture or race. Major risk groups are as follows;

Stress and anxiety: Bed-wetting complaints can be seen due to some emotional situations. Some children may begin to wet their previously dry beds in response to changes in their lives. Examples of these changes include moving to a new home, the inclusion of a new sibling in the family, and family members focusing on caring for the new sibling. However, night bed-wetting complaints due to these conditions do not persist in the long term. Contrary to popular belief, enuresis due to stress and anxiety is a very rare group in the clinic.

Family history (genetic predisposition): When one or both parents of a child wet the bed as a child, the likelihood of their children wetting the bed increases. Scientific publications have shown that nocturnal incontinence is inherited from the mother and/or father. Risk percentages are as follows.

  • 15% of the children of parents who did not wet bed in childhood
  • 43% of their children if one of the parents wets the bed in their childhood
  • 77% of their children if both parents wet bed in their childhood
  • 65-70% in identical twins
  • There is a 35-40% risk of incidence in fraternal twins.

Attention-deficit / hyperactivity disorder (ADHD): Complaints of bed-wetting are more common in children with ADHD.

What Are The Symptoms?

As the name suggests, the most prominent finding is that the child's involuntary incontinence that makes his underwear, clothes or places wet during sleep, whether day or night. In these children, lower urinary system disorders can be seen accompanied by daytime symptoms as well as nocturnal findings.

Daytime findings accompanying nighttime findings:

  • Daytime urinary incontinence
  • Feeling urgent about going to the toilet
  • Using various manoeuvres such as crossing the legs, pressing the genital area by hand, dancing to delay urination.
  • Intermittent urination
  • Difficulty starting urination (resistant urination)
  • The style of straining by contracting the abdominal muscles to initiate urination
  • Installation after urination
  • The feeling of not fully emptying the bladder after voiding
  • Weak flow of urination
  • Pain in the genital area (pelvic pain) during or after urination

How Is It Diagnosed?

Although it may be different in every child, to determine the underlying cause of bed-wetting;

Taking a detailed history: Some symptoms of enuresis may refer to underlying diseases such as diabetes, urinary tract infection, and intestinal parasites. Also, it is very important to evaluate bladder and bowel functions, question daily living habits and diet. Constipation is one of the most important causes of enuresis that families are not aware of or miss. Constipation and urinary incontinence are inseparable. Less frequent abductions during the day are also a part of enuresis. Sometimes families can ignore daytime symptoms. Therefore, it is very important to get a detailed history to differentiate these conditions and to determine the treatment method.

Physical evaluation: In enuresis, weight, blood pressure measurement and head-neck-abdominal examination are very important in addition to general physical examination. A detailed neurological examination, especially a hair growth, swelling or dimples (spina bifida) that appear in the midline on the waist may indicate an underlying neurological disease. Proper walking and normal tendon reflexes are also very important in clinical findings. The child's hyperactivity or attention deficit may also be noticed by your doctor during history taking or physical examination.

Noticing a constantly leaking urine during the genital examination, especially in girls, may indicate a ureter (urethra) opening into the genital area or urethra (urinary tract). Also, rectal (rectal) evaluation is valuable in understanding the status of constipation and the function of the pelvic floor muscles (rectal muscles).

Tests Requested For Diagnosis

  • Urinalysis and urine culture: Simple urinalysis is a test that should be seen in almost all pediatric urology patients. The appearance of bacteria, leukocytes (the white blood cell responsible for defence) or blood in the urine indicates a urinary tract infection.
  • Kidney and bladder ultrasonography: Ultrasonography is a simple imaging method that gives us a lot of information. It gives information about whether there is an enlargement (hydronephrosis) in the kidneys, the presence of a cystic structure in the kidneys, whether there is an enlargement in the ureters and the condition of the bladder. At the same time, ultrasonography is used to measure bladder wall thickness, bladder volume, the amount of urine remaining in the bladder after voiding, and the diameter of the rectum (the last part of the large intestine).
  • Blood analysis: It may be requested by your doctor when necessary for the evaluation of kidney and liver functions.
  • 2-day voiding schedule: It is one of the indispensable tests in the evaluation of children with urinary incontinence. If it is filled correctly, it gives information about the number of times the child urinates, how many ccs of urine you urinate, whether there is incontinence during the day and the type and amount of fluid he drinks.
  • EMG uroflowmetry test (urine flow test): It is a very simple and fast test that is used in clinical decision making. After the children drink water and squeeze well, two EMG electrodes are attached to the area where the pelvic floor muscles (muscles around the anus) are located, and they are asked to urinate into a urine container connected to a computer. With this test, important information is obtained about the type of voiding, the amount of urine, the rate of urination, the duration of urination, whether the pelvic floor muscles contract during urination, and whether or not there is urine in the bladder after urination. The test is very practical and gives the test result instantly. During the procedure, no painful or painful condition will disturb and worry children.
  • EMG pelvic floor muscle measurement test: At the same time, EMG measurements are made with superficial electrodes to evaluate the tension and functionality of the pelvic floor muscles.

How Is It Treated?

The annual rate of self-recovery without any treatment approach is 15% for enuresis. However, it should be well known that waiting for improvement over time affects both the child and the family socially, emotionally and behaviorally. When the treatment of children with enuresis is delayed or does not receive treatment, they may be exposed to social isolation, school failure, peer conflict, or become a mockery.

At the same time, it should never be forgotten that the problem of incontinence at night is not a condition that the child does deliberately and is a treatable health problem. By not treating the bed-wetting problem with the punishment method applied by the parents, it can cause the self-confidence and feelings of self to be damaged. In more advanced cases, it can cause psychological and sociological problems in children.

Night alarm treatment: It is mostly recommended as a first-line treatment. It is a system consisting of a sensor that detects wetness and a sound-emitting device. By attaching the child to his underwear, playing with the perception of wetness, he awakens the child and supports the discharge of the remaining urine into the toilet. With its regular use, the pelvic floor muscles, which allow the retention of urine over time, start to work reflexively, so the amount of urine discharged into the toilet begins to increase day by day. After a while, dry nights begin when no alarm goes off. Studies have shown that it has a longer-lasting effect than drug therapy. There are no known side effects. In cases where it is used alone without pelvic floor muscle rehabilitation, recurrence of complaints may be encountered.

Pelvic floor muscle rehabilitation: A group of muscles and soft tissues that make up the pelvic floor help control bladder functions by supporting the pelvic organs (bladder, intestine, and reproductive organ). For example, it works actively while reaching the toilet, helping to close the urethra, keeping children dry until they go to the toilet. It then relaxes and helps urine flow down the urethra to the toilet.

In some cases, pee accidents can occur because the pelvic floor muscles are not functioning. The fact that these muscles are too tense, too weak or spasm prevents them from healthily performing their functions. For this reason, re-training of these muscles and regaining their lost functions is very valuable for long-term permanent treatment.

Changes in life habits: Symptoms can be reduced with simple changes to be made about eating and toilet habits. Some suggestions for changes are as follows;

  • Regular use of night alarm
  • It should be encouraged to follow the daily water consumption according to the age and to consume water.
  • Avoiding liquids and foods that will irritate the bladder
  • Creating and monitoring urination hours
  • Illumination between bedroom and toilet throughout the night
  • Prevention of constipation
  • Encouraging going to the toilet before going to sleep

Medication: Before drug treatment, the underlying cause of enuresis should be understood thoroughly. It should be known that drug therapies alone do not provide success in the long term. Treatments combined with pelvic floor muscle rehabilitation are more likely to be successful.

  • Desmopressin (DDAVP): It is especially recommended as the first treatment option for children with a high amount of nighttime urine. Since the tablets dissolve easily in the mouth, they are very easy to use in children. Thanks to this drug, the amount of urine produced in children who produce excessive urine at night is reduced. The drug is taken orally 1 hour before going to bed. However, there is an important point that should not be forgotten in the use of this drug. Fluid intake should be stopped 2 hours before taking the medication. Otherwise, it may cause water poisoning in children as water retention will be excessive. Therefore, night fluid consumption should be restricted in children with enuresis using this drug.
  • Anticholinergic: It is recommended to be used especially in children with complaints such as urinary incontinence several times at night and with complaints of bladder contraction at night.
  • Antibiotics: In the presence of a urinary tract infection, your doctor may prescribe antibiotics.

The dosage and frequency of administration are prescribed by your doctor.

What Happens When Not Treated or Treatment Is Delayed?

Night bed-wetting is a health condition that should not be expected to pass over time and should be considered by families. If it is not treated, it may cause more serious problems affecting the lower urinary system. Identifying the conditions that cause complaints and starting treatment plays an important role in preventing more complex health problems that may occur in the future.

In children who are not treated or whose treatment is delayed;

  • Loss of self-confidence
  • Anger and despair
  • Shame and guilt
  • A sense of failure
  • Feeling more backward than your peers
  • Underestimating your self and feeling worthless
  • Isolation from society and withdrawal
  • Not wanting to communicate and not socializing
  • Psychological problems such as feeling ashamed and inadequate can be seen.

It should not be forgotten that bed-wetting at night is very rare due to psychological reasons. In other words, psychological reasons should be seen as a result of urinary incontinence, not a cause, and should be considered.

How Can You Help Your Child With Bed-wetting?

  • Give your child a descriptive talk that getting wet is not their fault and that they will get better with the treatment they receive overtime.
  • Encourage or gently remind your child to go to the toilet before going to bed.
  • Ask your child to go to the toilet routinely before bedtime.
  • Help him create toilet routines at certain time intervals during the day to create bladder training.
  • Make sure the path from your child's bedroom to the toilet is clear.
  • Include your child in night and morning cleaning routines in a way that does not punish or humiliate.

Things To Pay Attention

  • Just as you do not punish your child on wet nights, do not reward your child on dry nights. The rewarding approach may indirectly cause the child to feel embarrassed for any wet night.
  • Reward your child's motivation and effort in this process.
  • Do not wake up your child to urinate at night. This action will help keep the mattress dry. It is not an application that will help treatment for wetting at night.
  • Even if you find yourself constantly washing your child's sheets and clothes, don't be disappointed and be patient. Never punish or humiliate your child for this situation.
  • Do not let other family members joke about the situation or piss your child about it.
  • Encourage your child to comply and continue with the treatment he or she is receiving.

When To See A Doctor?

If your child is over 5 years old and has experienced sudden bed-wetting after six months or a completely dry period, they should see a pediatric urologist. Although some cases of sudden bed-wetting are due to life changes, your doctor should also check your child for any underlying medical conditions or illnesses.

Your doctor will advise you on suitable treatment options.

Published: 08 Şubat 2021
Updated: 25 Şubat 2021

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