← The Pediatrician Next Door - Simple Advice on Parenting and Family Health
The Pediatrician Next Door - Simple Advice on Parenting and Family Health
Ep. 125: Bedwetting: What’s Normal, What’s Not, and When to Get Help - with Andrew Kirsch, MD
00:28:07
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- [00:00]
Dr. Wendy Hunter
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- [00:51]
Dr. Andrew Kirsch
There.
- [00:57]
Dr. Wendy Hunter
Bedwetting is one of those issues that families don't tend to talk about. Well, except for with me, I seem to talk about it quite a lot. There's shame, there's worry. And I know there are myths floating around like kids just need to try harder or that bedwetting is a sign of trauma or bad behavior or just a heavy sleeper. But the truth is, it's usually none of those things. Most of the time it's a delay in development, but sometimes there are other factors and they can be tough to sort out. When does anxiety play a role? Sometimes it does. Did you have a new baby and now your toddler is having new potty issues? What about those situations where the child seems completely unbothered by bedwetting and they're 10 but the parents are nearing their breaking point and most importantly, is there actually anything you can do about it? I've got a very special pediatric urologist here today who breaks down what's really going on with bedwetting. Which treatments are available, including a potentially groundbreaking treatment that he is working on? And we will talk about how to know when it's time to seek help. I'm Dr. Wendy Hunter and I'm the pediatrician next door. I'm that doctor friend you call for practical advice about your kid's health. I mix the science of medicine with the reality of parenting. Let's talk about what's actually going on with bedwetting most of the time. Bedwetting, which is also called nocturnal enuresis. It's nocturnal because it's at night and enuresis because we like to translate regular language into Greek. And enuresis sounds better than the English translation Which is to urinate in. So urinating in at night anyway, it's due to what we call a maturational delay. That is to say that the brain and the bladder aren't quite on the same page yet. When it comes to nighttime, their relationship is still immature. And the brain and bladder don't really talk to each other. They're like middle school girls and boys. Your child's bladder might be sending out the signal, hey, look at me, I'm here. But the brain doesn't really register it. She just rolls her eyes, turns her back, and doesn't wake the child up in time to do anything about her full bladder. It's not laziness, it's not rebellion, and it's definitely not your parenting. It's just immature communication between two body systems that eventually will learn to recognize each other and work together. It's true that a lot of kids will outgrow bedwetting, but not all of them do. That's a really hard thing for parents to hear. Especially when your well meaning friends say things like, don't worry, they'll grow out of it. Or my nephew wet the bed until he was 12 and now he's fine. Yes, many kids do eventually stop, but for others, it doesn't magically go away. And in the meantime, it creates stress, sometimes shame, and definitely a lot of lost sleep and uses up a lot of laundry detergent. Our options for treating bedwetting are pretty limited. None of them address this underlying maturational delay. But what if we could do something different? Something that actually helps train the communication between the bladder and the brain instead of just managing the symptoms. That's where a new concept called neuromodulation comes in. It's a way of gently stimulating the nerves that help control the bladder. Almost like retraining the system to respond the right way at the right time. Thanks to today's guest, neuromodulation might finally be available. Dr. Andrew Kirsch is a pediatric urologist at Georgia Urology. He's a nationally recognized expert in treating bedwetting. He's also co author of the book the Ultimate Bedwetting Survival Guide. And here is what he shared with me.
- [05:17]
Dr. Andrew Kirsch
When we see patients with bedwetting, you get the same story from almost all of them where there's just my child's a deep sleeper and we can't get them up. If we've tried an alarm and wakes up everybody else in the house, they basically the alarm ends up kind of reminding them that they have a bedwetting issue, but it doesn't necessarily stop the problem. So the reason you have bedwetting, we mentioned the maturational delay, but the reason why you outgrow bedwetting is because the brain can sense a full bladder and it could neuromodulate, so it could control the bladder. If you think about how a bedwetting alarm works, they don't stop urinating. There's nothing to stop them from going, so they wet the bed and they may or may not get up. And then if they do get up by their parents, for example, they take them to the bathroom, they've already gone. What the teaching is in pediatrics is that the process of bringing them to the bathroom, having them change their sheets, perhaps somehow is going to improve the brain bladder connection. And that simply does not happen. That's not neuromodulation. So it's frustrating. And that's why with bedwetting alarms that have maybe a 50 to 60% success rate at best, you're supposed to use them for up to six months. There's a high dropout, 60 to 80%. And then what's the other alternative? The other alternative is medications. There's really just one medication that's thought to be the first line treatment. That's vasopressin. It will decrease the amount of urine you make at night. It's more of a band aid to allow for kind of the natural resolution. The concern is that kids might have complications from this medication, from drinking water and taking medication that makes you hold water and the consequence of doing that. So if we're explaining to a child about how their bladder matures, we just tell them we do do the reassurance that you should give them. Because it's common that it is kind of normal to have this problem when it gets to a point of being a social problem. So if there's bedwetting, that is a social issue, it might be that this child does not want to go to camp, they don't want to go to sleepovers, and they just might feel some shame involved in that. So you do want to identify that. And that could be a 6 year old or a 5 year old in some families, and it could be an 11 year old in other families. You just can't predict. We tried to explain that this is a natural process, that your brain is kind of sensing your full bladder and as you get older, that this will go away. And if it doesn't, and it's just causing discomfort or anxiety or shame, then here are some things we could do to Try to get you better faster. And we go over the different treatment options, albeit not great. But we do start with these things. And even though things like emptying your bladder before you go to bed and limiting fluid is in many cases a placebo effect, because the success reported as 18% and doing nothing is 15%, it's part of every treatment.
- [08:41]
Dr. Wendy Hunter
So when it comes to treatment, we usually start with the basics. What we call lifestyle changes. Things like limiting fluids before bed, making sure kids go to the bathroom right before sleep, and sometimes trying a bedwetting alarm. And then there's medication. The most common one is called DDAVP or desmopressin. It's a synthetic version of a hormone that your brain naturally makes that tells your kidneys to slow down urine production at night. In my experience, it's generally very safe, this medication, and it doesn't cause many side effects. But here's the it does not work for everyone. And that brings us to an important point. Before we jump into any treatment, we need to make sure we're actually dealing with straightforward developmental bedwetting, what we call primary nocturnal enuresis. That's the kind that's been going on since early childhood and usually is not linked to anything else. But if a child used to be dry at night and then suddenly starts wetting the bed again, that's a red flag. We call that secondary enuresis. And it means we need to dig a bit deeper to figure out what's really going. Here's Dr. Kirsch.
- [09:58]
Dr. Andrew Kirsch
We'd like to say that the bladder is this very sensitive organ, okay? So if you have anxiety, your bladder has anxiety, you might want to go to the bathroom more frequently. I think a lot of parents think, well, maybe there's a bladder problem, the bladder's too small. But it really is not. It just means that the sensitivity may be a little bit increased. That's when they feel like they have to rush, you know, every 15 minutes to the bathroom. That could be related to anxiety. We like to separate bedwetting or nocturnal neurosis into primary and secondary. So primary are the ones the kids have absolutely no problems during the daytime, and the ones that have daytime symptoms we say is secondary. So secondary to what? It could be secondary to bowel and bladder dysfunction. That could make night wedding worse. It could be secondary to, in some cases, child abuse. So we have to have our antennas up for things like that. Did it come on suddenly after the kid was fine, and then they moved into a different scenario and their home life was different. Was there A birth of a second child or third child. There are other things that would cause bedwetting. And so we always wanted to know, is it primary or secondary?
- [11:11]
Dr. Wendy Hunter
One of the first issues is to sort out when a person is wetting the bed is whether they have urinary symptoms during the day. Also, if a person has wedding accidents during the day or goes to the bathroom frequently or urgently during the day, that's something that needs to be addressed, but in a different way. And we get into that a little bit later. But if we are just talking about nighttime bedwetting, what can you do? Where do you start?
- [11:38]
Dr. Andrew Kirsch
If you look at the published series on this, there's one really good publication, part of the Cochrane Report. They looked at 6,000 kids in over 70 studies and they found that medications like DDAVP have a 30 to 50% success rate. Bedwetting alarms have a 50% success rate. So those are the kind of the numbers that I quote to people. By the time I see them as a specialist, they've either failed those or they've never tried anything. So in our surveys we found that the parents say that they're not aware of bedwetting treatments probably about 50% of the time, which I was kind of alarmed about that. And then of course, we're a very kind of a skewed patient population that already show up in the specialist's office. So I find that if they've tried bedwetting alarms for medications, the medications maybe were underdosed. So the recommendation is between one and three pills and you're supposed to limit fluid an hour before you take it and for eight hours while you're on it. And a lot of kids will come to me that are kind of strapping 16 year olds that are taking one pill didn't work, so they stopped after a week or two. I usually start them with the highest dose and if it works, I tell them to go down, find the lowest dose, and if it works really well, stop it after three months and see if you still need it.
- [13:08]
Dr. Wendy Hunter
Wow. I can't believe you see patients as old as 16. I think you're right. This is a very hidden problem that either pediatricians don't ask about or patients don't bring up. That's really fascinating. Or they just put up with it thinking eventually it'll go away, or this happened to dad, but it really does have a burden associated with laundry.
- [13:29]
Dr. Andrew Kirsch
It is. That burden is up to $1,200 a year just to take care of bedwetting, you know, so it's a lot.
- [13:37]
Dr. Wendy Hunter
I laugh, but it's not funny. Like it's really a burden.
- [13:40]
Dr. Andrew Kirsch
Yeah.
- [13:41]
Dr. Wendy Hunter
And sleepovers and camping.
- [13:43]
Dr. Andrew Kirsch
Right. When you're telling a five or six year old kid's family that, you know, don't worry about it, it will go away. You probably don't tell them that chance is 15% next year, right?
- [13:54]
Dr. Wendy Hunter
No. And oftentimes they don't even bring it up at the seven year old visit because they remember me reassuring them before and I forget to ask, you know.
- [14:02]
Dr. Andrew Kirsch
Yeah. And they seem to do better if they're one of their parents or both had bedwetting. Cause they could at least share that experience. But if one parent had bedwetting, the child has about a 40% CH and if both had it, it's about 75%. You know, those kids learn how to adapt. It's amazing the stories and you, you read them in the book about what kids do to avoid being identified as a bedwetter because it has a lot of stigma attached to it.
- [14:28]
Dr. Wendy Hunter
When you realize just how common bedwetting is, millions of families are dealing with it every night. It's no surprise there's a whole market built around it. Bedwetting alarms, mattress pads, overnight diapers. They help manage the problem, but they don't solve it. What if there's a better way? Like with so many pediatric issues, once we understand the root cause, what's really happening in the body, we can start to design smarter, more effective solutions. And that's exactly what Dr. Kirsch is working on. We'll talk about that right after this. Learning through play starts with Lego Duplo. With Lego Duplo, toddlers can develop real life skills while having fun with colorful bricks made just for them. Large, easy to grip and safe to explore. When children express themselves with Lego Duplo, they build patience, problem solving and empathy. See your child learn perseverance and self expression with everything they imagine and create. Visit lego.com preschool to learn more. On top of building this fake volcano for months, I give my daughter Smarty Pants vitamins to support her brain health. So her science fair project sounds more like and less like. And while I may say it's not a competition, of course it's a competition. Choose Smartypants vitamins to support your kid's brain health and save the science fair. Shop on Amazon, smartypantsvitamins.com or at target today. Hey, it's Ryan Reynolds here for Mint Mobile Now.
- [16:12]
Dr. Andrew Kirsch
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- [16:33]
Dr. Wendy Hunter
Of $45 for three month plan equivalent to $15 per month required new customer offer for first three months only. Speed slow after 35 gigabytes of networks busy taxes and fees extra see mint mobile.com now you know how common bedwetting is, how frustrating it can be for families, and how limited the current treatment options are. But what if we just stopped managing the symptoms and started treating the underlying issue? That's the question Dr. Kirsch started asking. And it led him to develop something new. A device that uses the science of neuromodulation to help kids overcome bedwetting in a whole new way. He explains.
- [17:13]
Dr. Andrew Kirsch
There's an option that we're looking at. I have a a colleague in Brazil, Ubere Jaro Barroso. He's an expert in this area in bedwetting and childhood continence. It's a big part of what I do as well. We brainstormed several years ago about this kind of very popular problem that has very little good success in the current treatments and have come up with a device. The device is wearable, so you basically put it inside your underwear. It has some electrodes or stickers that go on your bottom. There's a moisture sensing area where if one drop of urine hits it, a nerve stimulator will stimulate the electrodes and make the sphincter close. There's also what's called the guarding reflex. So if your sphincter closes, that's your urinary control muscle. The bladder will reflexively relax. Now, with that one drop, you've stopped bedwetting. You actually stop in the process. The bladder is relaxed. And then we have an app that will send a message to the parent's phone that it went off. You don't even need an alarm, but there is one if you want one. The parent will then go in with the child in bed with a full bladder. Now, the brain, when they wake up, senses a full bladder and they take them to the bathroom and they can empty and then reapply the device. And in our first trial in Brazil, we had an 83% success within two months. And one year after stopping the device, all of the successes were still successes. This teaches neuromodulation, which no other treatment currently addresses. We're very excited about it. We're about to start clinical trials per the fda because we need to show safety and efficacy. It's not a painful process. So even though there's a nerve stimulator, it goes off for five seconds while a child is asleep, doesn't really cause pain. It might wake them up in some cases, but it doesn't cause pain. We've involved Children's Hospital of Philadelphia, Vanderbilt, two sites in Brazil. So we're going to do a very large study that's going to be double blind, randomized, controlled, multi institutional. And we hope to show that this is going to be the only FDA approved treatment of bedwetting besides medications. And I think if given a choice between medications and something like this, I think any parent would not want their kids to be taking medications. So we're happy with the direction we're going right now. The nice thing, at least I feel better about the future that we have a product that we think is going to change the paradigm of earlier treatment. So when I surveyed pediatricians and I said if you knew of a non pharmacologic device that would cure a bedwetting within two months, what age would you try it? That age dropped to like 6. And before that bedwetting alarms were age 10. So I think pediatricians do know that the current treatment options aren't perfect.
- [20:25]
Dr. Wendy Hunter
And just to put a name to it, Dr. Kirsch's device is called Solu and it's being developed by his company, Global Continence, which honestly sounds like the kind of company you want on your side when you're knee deep in laundry and overnight pull ups. Now earlier in our conversation, Dr. Kirsch mentioned something that made my pediatrician ears perk up. He said the device works by helping the bladder relax. And again, he co wrote the ultimate bedwetting survival guide. So I think he knows what he's talking about. But that phrase stuck with me. The bladder relaxes. So I want to take a step back here and look at how that works. Because when you understand how the whole pee system operates, this device makes even more sense. So let's talk about what happens when you urinate. And yes, of course there is a fancy name for it. It's called micturition, which really just means emptying the bladder. Here's the gist. Your bladder is a stretchy little balloon that fills up with urine over time. You know that as it fills, sensors in the bladder wall send signals to the brain that say, hey, we're getting full down here. Then your brain decides if it's a good time to Pee. And when you give the green light, a whole series of events happen. The bladder muscle contracts, the urethral sphincter. That's a ring of muscle that acts like a valve that relaxes. And everything works in perfect coordination to let the urine out. But if that coordination is off, or if the brain doesn't get the signal or the bladder doesn't respond properly, then things don't go so smoothly. It's actually quite complicated. And I want to emphasize here that it's not easy to learn to pee on demand or on the potty. There are a lot of different systems in the body that need to mature for this orchestration to work. And in some kids, it takes past age 3 or 4 to get it right. So you need to be patient. Anyway, the nighttime immaturity of the signals is where bedwetting comes in. You can talk to your kid and take them to the bathroom during the day, and you can see them doing a pee pee dance. But all of that is a lot more difficult at night. There's one more piece, and that's the pelvic floor muscles, which help support all the organs down there, including the bladder and bowel. They also play a big role in keeping things under control. And in a lot of kids, constipation and bedwetting are more connected than you'd think. So let's get into that next.
- [22:53]
Dr. Andrew Kirsch
Your pelvic floor is like a hammock, and your urethra goes through the front and your rectum goes through the back. In urology, we see a lot of problems that affect both. Like kids that have holding problems, they have constipation, they have urinary incontinence, things like that. But with bedwetting, it's thought to be totally unrelated to a pelvic floor problem. It's more of a maturation problem. So think about it. If you're kind of walking down the stairs and you decide to jump off the third step, most people don't leak. Okay.
- [23:27]
Dr. Wendy Hunter
If you've had a baby, you do.
- [23:29]
Dr. Andrew Kirsch
Yes. We could talk about that in another.
- [23:31]
Dr. Wendy Hunter
Episode, but we're talking about kids here.
- [23:34]
Dr. Andrew Kirsch
Yeah. So kids and kids with bedwetting, they're not leaking during the day either. So their sphincter's working, their bladder's working. So if they jump off, they jump up and down, their sphincter will shut close, and their bladder will relax. That's basically what we do with the salud device, is we initiate that guarding reflex, and that gives them time to have somebody come in, or if it doesn't wake them up that they still have a full bladder. The current alarms don't wake you up, or they wake you up when you're already emptied your bladder completely with no way of stopping you from peeing. A lot of these kids with bowel and bladder dysfunction, maybe your little type A that maybe they don't. First of all, they like control. And so they will like, honey, you need to go to the bathroom now. We're about to go on a car trip. I don't need to go. Okay, they'll need to go like two minutes into the trip. But they will say they don't need to go. And so that probably comes from some struggles within the family and control. But for the most part, they'll figure it out. The problem is time they get to see us. They have fecal incontinence, they have urine tract infections, they're wearing pull ups, and it has become a big deal. If you look at the adult population, every urologist has heard about the truck driver bladder. These are the guys that drive across country and they just drink cokes and energy drinks and they don't want to stop. They come to the emergency room with two or three liters in their bladder. So that's a big deal. We don't really see that in any frequent fashion within the pediatric population. But there is one condition that's very rare called a Hinman bladder. And a Hinman bladder are kids that have learned to basically put off voiding so long that their sphincters are really tight. And they present with renal failure a lot of times. But the first thing you might notice is urinary incontinence during the day. So every kid that comes to a pediatric urologist with daytime incontinence is getting an ultrasound. You just want to make sure their bladders aren't huge and their kidneys are normal. It's an easy screening test, but it's rare. But we see it every year. One or two kids that have this problem.
- [25:59]
Dr. Wendy Hunter
Bedwetting affects families in all kinds of ways. For some kids, it's no big deal. They're not bothered and life goes on. For others, it's a nuisance. That means extra laundry and some frustration. And then there are kids who really care a lot. They miss out on sleepovers, camp outs, and they miss the confidence that comes with waking up dry. And at the more extreme end, we start to see behavioral layers. Kids who hold their urine all day, who use control as a coping mechanism, or even adults who, believe it or not, still hold their bladder so long that it leads to real medical issues. The important thing to remember is if your child is still wetting the bed after age 5, you're not alone and you're not without options. There's help now and even more promising help on the horizon. A great place to start is Dr. Kirsch's book, the Ultimate Bedwetting Survival Guide. I want to give a Huge thanks to Dr. Andrew Kirsch for sharing his time, his knowledge, and his hopeful approach to a problem that's often met with frustration and misunderstanding. And as always, I want to thank you for listening. For more from the Pediatrician Next Door, find me on the web@ pediatriciannextdoorpodcast.com if you've got a question about the weird things kids do, send an email to helloediatriciannextdoorpodcast.com for a chance to hear your voice on the show. I'm Dr. Wendy Hunter and I'm the Pediatrician Next Door. This show is produced by Red Rock Music. Make sure to subscribe and leave a review wherever it is you're listening. I'll be back next time with more.