What are the treatment options for bedwetting?

A lot of children who still wet the bed at the age of five grow out of it after a while, without any treatment. The problem often becomes more urgent when a child starts school. As well as the child’s age, other factors also play a role when deciding whether or not to try out treatment: How much of a problem is the bedwetting? Does the child want to stop wetting the bed? Are they willing to give treatment a try? Do they often sleep at a friend's house, for instance?

If bedwetting causes the child to suffer, treatment can be a good idea even if nighttime accidents are rare. But there's also little point in trying out treatment if the child doesn't want to, or isn't yet mature enough.

When dealing with a bedwetting problem, there are various things you can try out. You can also use a combination of different measures:

• Offering incentives: Reward the child if they stick to goals you have set together – such as going to the toilet every night before bedtime. You can agree on a suitable reward beforehand, such as stickers or temporary stick-on tattoos. "Dry nights" generally aren't a suitable goal because the child only has very little influence on that outcome, if any. One idea would be to let them put a sticker in a calendar every time they reach a goal. Then, if they have collected enough stickers by the end of the week, you could give them a stick-on tattoo or other small reward. Reward systems are most suitable for young children.
• Going to the toilet at certain times in the night: Most children are used to going to the toilet just before bedtime. Parents can also take the sleeping child out of their bed and take them to the toilet, or wake them at a certain time every night so they can go to the toilet themselves. This doesn't help the child to develop nighttime bladder control, but it can help them to stay dry on those nights. Older children can set an alarm clock to wake them up in the night, so they can go to the toilet without any help. The disadvantage of this approach: When using bedwetting alarms, the child and their family may be woken several times per night and then feel very tired the next day.
• Limiting drinks before bedtime: Some parents try to help their child stop wetting the bed by making sure that she or he mainly drinks during the day – and then doesn't drink much, or anything, in the evening. But children should be allowed to drink if they are thirsty. Diuretic (urine-increasing), caffeinated and sugary drinks like cola and soft drinks should be avoided.

There is only little research on the benefits and possible harms of these simple approaches. But they are an easy way for parents to support their child. The child has to be ready and willing to try things out too, though.

There is also an approach known as bladder training, but it isn't recommended. In this approach, the child tries to hold their urine in for as long as possible during the day. This is supposed to increase the volume of the bladder and help the child learn what a full bladder feels like. But there is no scientific proof that bladder training has an effect on bedwetting. Studies that compared bladder training with other treatments found it to be less effective.

Electronic bedwetting alarms detect wetness and trigger an alarm if the child starts to pee. They are only used at night: The alarm is designed to wake the child as soon as the very first drops of urine come out so they can hold it in and go to the toilet.

Sometimes, children don't notice the alarm when they first start using it. Then parents have to wake their child until she or he starts noticing and responding to the alarm themselves.

Over time, the child should learn to squeeze the muscles to hold their urine in when they're asleep, or to wake up before the alarm goes off (before their bladder gets too full). Bedwetting alarms typically have to be used for several weeks.

Some systems give off a sound, and others work with light signals or vibrations.

There are various types of bedwetting alarm systems, including underwear with built-in sensors, mats with built-in sensors, and mini-alarms that can be put inside the child’s underwear or pajamas. In Germany, the costs of these alarm devices are generally covered by statutory health insurers, as long as they are prescribed by a doctor and have been officially recognized as a medical aid.

When trying out a bedwetting alarm, the child and their parents have to be determined and patient. Some children aren't ready or willing to use one. It can also make sense to only use the alarm once per night so everyone's sleep isn't interrupted too much. Otherwise the child and their family might feel very tired the next day.

There is a lot of research on bedwetting alarms such as special underwear and bed mats. One review that summarized the results of this research found the following:

• Without a bedwetting alarm, about 3 out of 100 children stayed dry on at least 14 nights in a row.
• With a bedwetting alarm, between 14 and 37 out of 100 children stayed dry on at least 14 nights in a row.

In other words, bedwetting alarms helped about 11 to 34 out of 100 children to stop wetting the bed. But the studies left many questions unanswered, so these numbers can only give us a rough idea of how well the alarms worked. We can't say for sure how many children really benefited from them.

One reason why bedwetting alarms don't always work is because some children sleep very deeply, and still don't wake up when the alarm sounds.

Some children started wetting the bed again when they stopped using an alarm system. But most of them continued to stay dry at night even several weeks or months after. Compared to the medication desmopressin, the effects of bedwetting alarms probably last longer.

Parents are often advised to keep using the bedwetting alarm until their child has stayed dry at night over a period of two to four weeks. But there's no official recommendation here. The time it takes to start working can vary from child to child, varying from a few weeks to six months.

Sometimes, successful treatment with a bedwetting alarm can be followed by a second training phase. In this phase, the now "dry" child drinks more than usual in the hour leading up to their bedtime (about 0.2 liters more). The aim is that they learn to wake up soon enough with a particularly full bladder, too.

Bedwetting problems can also be treated with medication. Two medications have been proven to temporarily stop bedwetting in some children:

• Desmopressin
• Imipramine

Desmopressin is a hormone-like medication, and imipramine is an antidepressant. Both need to be prescribed by a doctor.

When people decide to treat bedwetting problems with medication, desmopressin is typically used. This drug is less likely to cause side effects than imipramine is. It starts working quite fast – sometimes even the first time it is taken.

Desmopressin can be used if, for instance, the child is staying overnight at a friend's house and would like to avoid wetting the bed. It is best to try out this medication beforehand, to make sure that it works and that the dose is correct.

One disadvantage of this medication is that it usually only works temporarily, while you take it. A lot of children start wetting the bed again after they stop taking it.

If bedwetting medication is used over a long period of time, it’s important to have a break roughly every three months, where the child stops taking it for about a week. That way you can see whether he or she still needs treatment – or can now stay dry at night without any help.

Desmopressin works in a similar way to the hormone vasopressin, which is made naturally in the brain at night to reduce urine production.

Research has found the following:

• Without desmopressin, 3 out of 100 children have dry nights on at least 14 nights in a row.
• With desmopressin, 19 out of 100 children have dry nights on at least 14 nights in a row.

About 5 out of 100 children who take desmopressin tablets have side effects such as headaches and stomach ache. Most of these arise because too much water stays inside their bodies.

To avoid side effects, children and teenagers who take the medication should stop drinking anything in the hour before they take it. They should also not drink more than one glass of liquid in the eight hours after taking the medication.

This is important in order to prevent another side effect called water intoxication, too. Although rare, water intoxication is serious. It happens if too much water stays inside your body. Early signs of water intoxication include a headache, nausea, vomiting, dizziness and weight gain.

When stopping treatment with desmopressin, it can be a good idea to gradually lower the dose over a few weeks. This reduces the risk of starting to wet the bed again.

Imipramine is a tricyclic antidepressant medication. Although it is mainly used in the treatment of depression, it has also been approved for the treatment of bedwetting. Imipramine shortens the dream phases of sleep (REM phases), increases the production of vasopressin, and affects the bladder muscles.

It is about as effective as desmopressin, but often leads to side effects. In studies, imipramine led to side effects in about 17 out of 100 children. The side effects included low blood pressure, palpitations (a racing and pounding heart), a dry mouth, constipation, sweating, nausea, tiredness and sleep problems. It is important to keep imipramine out of reach of children because an overdose could be life-threatening for them.

Other medications and treatments haven’t been proven to stop bedwetting. Complementary or alternative treatments like medicinal plants, chiropractic treatment, homeopathy, hypnosis and acupuncture haven’t been shown to help here, either.