Daytime Wetness, Nighttime Bedwetting, and Constipation

Overview • Signs and Symptoms • Diagnosis • Causes • Risk FactorsComplications • Evaulation and Treatment • Should I Be Concerned?

Overview

There are many causes of wetting and soiling problems in children.  The pattern of wetting may be due to a medical condition (such as a urinary tract infection) or emotional stress (starting a new school, new sibling etc).  It can also be a matter of normal development, with no medical cause.  Knowing the cause of wetting will help your child’s doctor decide on the best treatment.

Diurnal (Di-your-nal) enuresis (in-your-re-sis) (daytime wetting):  Diurnal enuresis is much less common than night time bedwetting.  Approximately 25% of children who wet the bed at night, will have some degree of daytime wetness.  The amount of wetting during the day can vary from dampness to complete bladder emptying, requiring changes of clothes and cleaning of the surrounding area.  Children may have urinary urgency (strong feeling to urinate), urinary frequency (urinating every 15-30 minutes), urge incontinence (urinating on the way to the bathroom) and occasional dysuria (burning or pain with urination) in addition to wetting.  In some cases, children are initially dry but then began to wet.  This is called secondary diurnal enuresis.  Daytime accidents for some children can be embarrassing and affect school performance and friendships.  Positive and productive treatment can help improve self esteem!

Nocturnal (knock-ter-nal) enuresis (nighttime bedwetting):  Night time bedwetting affects millions of children.  It can result in a night of anxiety and upset and your child may wake up feeing embarrassed and ashamed.  Nocturnal enuresis can occur every night or a few times a week or month.  Night time bedwetting is not due to your child not caring or choosing not to get out of bed to urinate.  Nighttime bedwetting is most often due to the bladder and brain not communicating!  So, when the bladder is full and sends a message to the brain to wake up your child, the brain ignores the signal and the bladder empties resulting in bed wetting.  There are steps to address your child’s bedwetting that are positive and productive and will make your relationship with your child even better!

Constipation:  Constipation is quite common in children.  In fact, about 5% of pediatric office visits are due to constipation.  Constipation is most often present in children who soil (have poop accidents into their underwear) and is very frequent in children with bladder issues. Typically, children with fewer than 2 bowel movements a week or stools that are large in diameter, hard, dry and painful or hard to pass have some degree of constipation.  Constipation is usually of sudden onset (acute) but some children have chronic constipation.  It is important to make sure that you know how often your child poops and what the poop looks like so that your doctor can determine if constipation is an issue.

 

Signs and Symptoms

Children who are potty trained may have chronic bladder and bowel issues or may go through phases of wetting and soiling problems.  If your child has the onset of urinary accidents, especially with dysuria, urinary frequency, urgency and/or urge incontinence, you should first see your pediatrician and have their urine checked to make sure there is no evidence of a urinary infection.  If the urine if infected, your pediatrician will determine the correct antibiotic and treatment period.  Your pediatrician will also determine the need for radiology imaging and will decide if your child needs a referral to pediatric urology. If your child does not have an infection, recommendations below may help.

Nocturnal enuresis often occurs in children without any signs or symptoms.  Nighttime bedwetting is strongly related to family history.  Typically, there is a family member, maybe even a distant family member, who wet the bed.  Often, your child will follow the same course and stop wetting the bed when the family member stopped.  Below are recommendations that may help.  Please remember, your child does not want to be wet!  Dealing with this issue in a positive, productive manner can improve your relationship with your child. 

Constipation may not cause symptoms.  However, some children will have large diameter, hard dry stools, pain with stooling or sit on the toilet for a long time since it is hard to pass the stool.  Children may also hold stool.  Postures such as rocking on their heels, holding their buttocks or standing on tip toes may mean they are holding their stool.  Children may also complain of belly or abdominal pain and cramping pain.  They may have poop accidents in their underwear.  This may be a large amount of stool or watery stool that has passed around a hard mass of stool. Also, children may have urinary issues such as urinary accidents, recurrent urinary tract infections or nighttime bedwetting if they are constipated. 

Diagnosis

Diagnosis of daytime and nighttime wetting is based on medical history and description of your child’s urinary habits.  It is very important for the parent or caregiver to provide as much information as possible to the doctor.  This will allow your doctor to determine the very best care for your child.  Questions that are very helpful for you to answer are listed below:

  1. How often does your child wet?
  2. How wet is your child when they have an accident?  (almost dry, damp, wet, soaked)
  3. How often does your child go to the bathroom to urinate?
  4. Does your child rush to the toilet?  If so, how often?
  5. Does your child hold their urine by crossing their legs or sitting down?
  6. Does it hurt to urinate?  If so, how often?
  7. When your child urinates, does the flow start and stop?
  8. Has your child ever had a urinary tract infection?  If so, how many times?  Did your child have a fever of > 101.5? ***If so and you have been referred to UNC Pediatric Urology, please try to bring copies of the urine samples (urine analysis and urine culture) your pediatrician or family doctor sent to the lab
  9. Does your child wet the bed at night?
  10. Does your child wake up at night to urinate?
  11. Does your child snore?

 

Constipation is diagnosed based on medial history, physical examination and sometimes an x-ray of the abdomen.  Just like the wetting history, it is very helpful for you to answer the questions below:

  1. How often does your child have a bowel movement?
  2. How long does it take for your child to have a bowel movement?
  3. Are your child’s stools hard, dry and big around (like a potato)?
  4. Does your child have poop accidents?  If so, how often and how much stool is in the underwear?

Causes of Diurnal Enuresis, Nocturnal Enuresis and Constipation

Diurnal Enuresis can be due to a medical condition (urinary tract infections), stress or simple habits related to toileting.  Below are some common reasons for daytime wetting.

  1. Urinary tract infection (UTI):  UTIs may be associated with painful, frequent urination, rushing to the bathroom (urgency), urinary incontinence, foul smelling urine or bloody urine. They may have a low grade fever.  If your child has a high fever (greater than 101.5F) with these symptoms, they may have abdominal or back pain.  Please see your pediatrician as soon as possible if you suspect your child may have a UTI.
  2. Infrequent urination:  Children may be so busy playing they forget to go to the bathroom! They will only urinate 2-3 times a day, they may not urinate when they wake up and they often rush and do not empty their bladder when they finally go to the bathroom. They may squat, squirm, cross their legs, sit on their heel, or hold themselves.  They may also stand very still and not move in fear of wetting. 
  3. Post void dribble: Sometimes children rush when they urinate.  For girls, they may trap urine in the vagina and boys may not pull back their foreskin, trapping urine under the skin or not allow urine to drain from the urethra (the urine tube).  Even with wiping, some children will fail to clear all urine prior to leaving the toilet. 
  4. Constipation:  Yes!  It is true.  Constipation can affect your child’s bladder.  The bladder and the rectum share the nerves that control both urination and passage of stool.   Your pediatrician can help you determine if your child is constipated and needs treatment. 
  5. Caffeine:  CUT OUT THE CAFFEINE!  Children should not drink caffeinated products especially if they have urinary problems.  Limiting drinks with high sugar content is helpful as well.
  6. Bladder over activity:  Some children have bladders that uncontrollably squeeze (contract).  When this happens they will feel a sudden need to urinate and may run to the bathroom.  They may not make it and urinate before they get to the toilet.  Your doctor will determine if your child likely has an over active bladder.
  7. Incomplete bladder emptying:  Some children do not fully empty their bladder when they go to the bathroom.  This can lead to frequent urination and daytime wetting.
  8. Structural or anatomical abnormality: Rarely, children can have an abnormality in the organs, including the urinary system, muscles, or nerves involved in urinary control.  These abnormalities can cause daytime and nighttime wetting.
  9. Giggle Incontinence:  Giggle Incontinence is very rare.  These children empty their bladder with laughing.  Your doctor will determine if your child has giggle incontinence and discuss treatment options with you. 

 

Nocturnal Enuresis can be due to a medical condition but the good news is that most children will stop wetting the bed with time.  In fact, only about 1-2 percent of adults wet the bed!  Below are some reasons for nighttime bedwetting: 

  1. Family genes:  The majority of bedwetting is inherited from either a parent or other family member.  It is likely that your child will follow a similar course. 
  2. Delay in bladder development:  Over time the bladder and brain began to talk, even while your child is sleeping.  In some children, it takes a bit longer for this communication to happen so the brain does not wake the child when the bladder sends the signal that it is full.
  3. Deep sleeping: Some children are very deep sleepers.  For some children, they sleep so soundly that the brain does not get the bladder signal and wake the child up to urinate.
  4. Increased urine production:  Some children have low levels of anti-diuretic hormone (ADH).  This hormone sends a signal to the kidney to make less urine.  If the hormone is low, the kidney makes more urine and may increase bedwetting. 
  5. Bladder Overactivity:  Some children have bladders that uncontrollably squeeze (contract) during the night.  This decreases the amount of urine the bladder holds at one time and pushes the urine out.  Your doctor will determine if your child likely has an over active bladder.
  6. Structural or anatomical abnormality: Rarely, children can have an abnormality in the organs, including the urinary system, muscles, or nerves involved in urinary control.  These abnormalities can cause daytime and nighttime wetting.
  7. Sleep Apnea:  Sleep apnea makes the brain work hard to take in oxygen and so it does not properly control other body functions like bladder control.  If your child snores loudly, please inform your doctor.
  8. Caffeine:  CUT OUT THE CAFFEINE!  Children should not drink caffeinated products especially if they have urinary problems.  Limiting drinks with high sugar content is helpful as well.

 

Constipation is due to stools remaining in the colon for long periods of time.  When this occurs, the water on the stool is removed by the intestines and the stool becomes hard and dry.  This makes passing stool infrequent and difficult. Below are some reasons for constipation.

  1. Poor fluid intake:  The colon absorbs water from stool to increase body water content.  If your child is dehydrated, the colon absorbs more stool water and the stools become hard and firm.
  2. Low fiber diet:  Fiber comes from plants and helps the stool stay soft.  Fruits and vegetables have lots of fiber.
  3. Holding in stool:  Some children will hold stool due to embarrassment to use a public bathroom, do not want to stop playing, are stressed about potty training or if they have had a painful stool in the past, they may become fearful to pass more stool.  These children will squeeze the muscle around the anus to avoid having a bowel movement. The stool stays in the colon where it eventually stretches the colon and the stool does not move normally.  As stool stays in the colon, more water is removed from the stool, making it dry and hard. 
  4. Functional Bowel Disorders:  Functional disorders are caused by changes in how the intestines work.  If a functional disorder is suspected, your pediatrician, family physician or pediatric urologist will refer you to a Pediatric Gastroenterologist.  These doctors specialize in bowel function and will determine if your child has a functional bowel disorder.
  5. Diseases:  Some diseases can cause constipation.  Botulism, a disease caused by bacteria that affects the nerves can result in conception.  Botulism can be seen in infants given honey to sweeten milk.  Diseases that block the flow of stool, diabetes and abnormalities of the body’s metabolism (the way the body uses food to make energy) can cause constipation.  Some birth defects of the structure of the intestines or diseases interfere with normal bowel function (Hirschsprung disease) can also result in constipation.

 

Risk Factors

Daytime wetting:

Risk factors for daytime wetting are infrequent.  Researchers have reported that children with delayed development, difficult temperament and children who have parents with mood issues (depression) may be at an increased risk of daytime wetness.  Rarely, a child may have an abnormality of the urinary system that results in daytime wetness.  Also, a child who cannot move around easily (broken leg), children with neurological challenges (spina bifida) or other mental, medical or physical limitations may be at an increased risk of daytime wetting. 

 

Nocturnal Enuresis

Nighttime bedwetting is typically associated with family history.   In fact if one parent wet the bed as a child, there is a 45% chance of bedwetting and if both parents wet the bed the risk is 75%.  Children with heart conditions, neurological condition and sleep disorders may be at increased risk as well. 

 

Constipation:

Constipation is most often associated with poor dietary habits such as limited fiber and fluid intake.  Children who have limitation in movement may also be at an increased risk of developing constipation.  Certain medications, a family history of constipation and some medical conditions increase the risk of constipation. 

 

Complications

Diurnal Enuresis (daytime wetness):  Daytime wetting in children can result in frustration for parents, teachers and other caregivers.  More importantly, it can also lead to embarrassment for the child.  In some cases, children may be picked on by other children due to wet or smelly clothing.  This may result in anxiety for the child.  Additionally, damp or wet underwear can lead to skin irritation, which may cause additional discomfort and/or itching. 

 

Nocturnal Enuresis (bedwetting):  Night time wetting can be very upsetting for children and parents, especially when children are older.  This may result in children choosing not to have or attend sleep overs or do other activities such as attend camp.  Bedwetting can become a big stressor for families.  In fact, about 30% of parents become intolerant of wetting and this affects their relationship with their child. 

 

Constipation:  Complications of constipation can include encopresis (stool accidents) which can be very embarrassing for children.  Stool can become impacted, which means it is so tightly packed that the stool cannot move.  Hard stools can tear the skin around the anus, leading to anal fissures, which are very painful, can itch or bleed.  Sometimes, the rectum will slip outside the anus, resulting in rectal prolapse.  Constipation can increase the risk of urinary tract infections, especially in girls.

 

Evaluation and Treatment

Your doctor will decide if your child needs any laboratory studies, radiology imaging or urodynamics (bladder evaluation and monitoring) is needed.  While you are waiting to see your doctor, there are a few things you can do at home.

 

Diurnal Enuresis

  1. CUT OUT THE CAFFEINE! Milk, water and moderate amounts of juice are the best fluids for your child to drink.  Caffeine increases the amount of urine your child makes and can contribute to day and night time wetting.  Also, since the body loses more water due to caffeine, it can also contribute to constipation!
  2. Encourage your child to go to the bathroom every 2-3 hours and when they feel the urge to go.
  3. Reward dry days with stickers, smiley faces on calendars, special treats and LOTS of hugs.
  4. Go to the bathroom before leaving the house for shopping or trips.
  5. Make sure your child is not constipated!  This can cause accidents.
  6. Boys and Girls should make sure all urine has been drained and dried after going to potty.  Sometimes, even when wiping, urine gets trapped in and under skin pockets. Make sure they know how to get dry.

 

 

Nocturnal Enuresis:

  1. CUT OUT THE CAFFEINE! Milk, water and moderate amounts of juice are the best fluids for your child to drink.  Caffeine increases the amount of urine your child makes and can contribute to day and night time wetting.  Also, since the body loses more water due to caffeine, it can also contribute to constipation!  Please see your pediatrician or family medicine physician for recommendations on fluid intake.
  2. Make sure your child is getting the appropriate amount of fluids during the day.  Often children do not drink well while playing or while at school.  When they become thirsty, they drink more in the afternoons and evenings.  It’s no surprise they wet the bed!
  3. Restricting the amount of fluids your child drinks during the evening is potentially not helpful and can be harmful.  However, if your child drinks plenty of fluids throughout the day, limiting fluid intake an hour before bed may be helpful.
  4. Children should always go to the bathroom and void before going to bed.
  5. Remember!  Your child does NOT want to wet the bed!  Wetting the bed is out of your child’s conscious control.  Punishment may make bedwetting worse!

 

Constipation:

  1. CUT OUT THE CAFFEINE! You know this by now but it cannot be stressed enough.  Caffeine can make pooping and peeing problems worse.
  2. Increase fiber in the diet.  Fiber is found in most fruits and vegetables.  You can buy high fiber cereals and serve whole grain breads.  Foods children like such as popcorn (watch the salt and butter), yogurt and trail mix (minus the chocolate) are also helpful.
  3. Increasing fluids will decrease the amount of fluid the intestines pull from the stool in the colon.  This keeps stools soft and makes it easier to pass stool.  Water is the very best fluid so make sure your child drinks the appropriate amount each day. 
  4. Over the counter laxative and stool softeners are an option but should be used only when the instructions are followed.  We suggest that you check with your pediatrician or family physician, or talk with your pharmacist before using these products, especially in young children.  

Should I be concerned?  

Rarely, daytime wetting, bedwetting and constipation can be the result of an underlying mecial problem.  If your child has any of these issues, you should discuss this with your pediatrician or family physician.  They will decide if your child needs a referral to a pediatric urologist.  If you child has urinary tract infections with high fevers, does not respond to the recommendations from your primary care physician or has symptoms associated with other complaints such as back or leg pain, changes in the way they walk or run, frequent headaches or other problems, please discuss this with your doctor or call UNC Pediatric Urology for an appointment.   

At UNC Pediatric Urology, we are dedicated to properly evaluating your child with wetting and soiling issues, offering the appropriate treatment and working with you and your child to help your child make great strides towards becoming dry and soil free!