Q: What treatments are available for enuresis?
A: There are several aspects of treatment, and doctors will choose the most appropriate method depending on the type and degree of nocturnal enuresis.
The first is life coaching, which is the basis of what is internationally regarded as “expert recommendation”, but there is hardly any evidence-based medical evidence to verify its effectiveness. In the experience of many physicians, nocturnal enuresis can be significantly improved by controlling the amount of water the child drinks at night. Life coaching is more appropriate for older children.
Medication is available in Chinese herbal medicine and Western medicine.
Behavioral therapy, i.e. alarm therapy, is also available, and biofeedback therapy can be chosen for more severe cases.
Psychotherapy or reward therapy is also important in the treatment process. Suppose some children do not wet the bed for several days in a row, parents should give them rewards to encourage their confidence. Conversely, an occasional bedwetting should not be easily blamed and should not put pressure on the child.
Q: How old is life coaching for children? How long does it take to see results?
A: Generally speaking, it is suitable for children over 5 years old. Life habits take process and time to change, and this is true for parents as well.
Whether it is life coaching or medication, it is generally emphasized to stick to it for at least 3 months.
Q: What are the Chinese herbal medicines?
A: Traditional Chinese medicine is a holistic treatment. From experience, the TCM theory of kidney fixation is effective. However, the formulas and drugs vary from hospital to hospital, so it is difficult to evaluate specifically. The overall efficiency of TCM is not particularly high.
Q: What are the Western medicines?
A: There are two main categories of western drugs, especially synthetic antidiuretic hormones, which are characterized by targets designed for the pathogenesis of nocturia.
The application of antidiuretic hormone to nocturnal enuresis is a major breakthrough. After falling asleep at night, the level of antidiuretic hormone increases in normal people. This hormone has several effects: it concentrates urine, reduces urine output, wakes up the bladder when it is full, and reminds the person to get up to relieve urination. Many studies have confirmed that children who have nocturnal enuresis have decreased levels of antidiuretic hormone in their bodies at night. This results in more urination and less wakefulness. Some parents say, “My child doesn’t wake up at night and doesn’t know when he’s peeing. This is a common problem in children with low levels of antidiuretic hormone.
It is important to say that some parents are afraid when they hear about hormones. But this is a hormone that is specifically for urination and is not the same thing as adrenal hormones that act systemically.
The second type of medication is for atypical nocturnal enuresis. This means that the amount of urine is not much, but the frequency is high. Sometimes there is also frequent urination during the day. This is mainly caused by uncoordinated bladder muscles, and antispasmodics such as oxybutynin work against excessive contraction of the bladder muscles.
It is mainly the first class of drugs that are currently used more often in clinical practice.
Alarm therapy can be combined with medications
Q: What is meant by behavioral therapy?
A: Behavioral therapy is mainly alarm therapy, a physiological feedback training of behavior, which is more commonly used abroad.
It is a small, simple device that can be placed on top of a bed sheet or underwear. As long as a little wet, the alarm will sound. Parents can get up as soon as possible and call the child up to pee as well. Through this process of wetting – waking up – relieving urine, the child will form a conditioned reflex to wake up after having the urge to urinate.
For children with severe enuresis, biofeedback therapy is available in the hospital to control urination by specifically training the bladder muscles to contract and relax.
Q: Can all affected children be treated with alarms?
A: Yes. The alarm is one of the easiest methods, and the volume can be adjusted by itself. There are some differences in the models, with one sound and multiple sounds. The Department of Nephrology and Rheumatology of the Pediatric Hospital of Fudan University conducts a special mini-class once a month, at noon on Saturday, to teach people how to treat nocturnal enuresis, and parents will also share their experience in using alarms and precautions in taking medication.
Q: Can the methods mentioned above be used in combination? For example, can the alarm be used together with some medication?
A: Yes. This requires an analysis of the type of nocturnal enuresis. Some children have a lot of urine, which means that there may be several problems, so at the beginning of the treatment, several methods need to be used in combination, which is more efficient. If the child has a single problem, one method may be used.
We do not want to burden the child and parents with medication or treatment. We choose one when we can, to make it as easy as possible for parents and children.
Q: How do I use antidiuretic hormone?
A: The method of administration is very simple. You take the medication one hour before bedtime at night. When you take the medicine, you can take a sip of water and drink as little as possible. After taking the medicine, you cannot drink any more water.
Domestic currently mainly use tablets. In foreign countries, there are nasal drops and orally disintegrating tablets, the latter of which is put on the tongue and the medicine will dissolve on its own, so there is no need to drink water.
Q: How long does it take for nocturnal enuresis medication to work? How long do I have to take it?
A: The onset of action of this medicine varies from person to person, depending on the child’s own hormone secretion rhythm or degree. Most children are effective that night; some children may take two or three days to get results. Generally, we continue to use the medication for 4-6 weeks without effect before judging it to be ineffective. During these 4-6 weeks, there is a process of dosing. We will start with 0.2 mg. If the effect is not good, we have to review it in about two weeks and increase the dosage under the doctor’s guidance, which can be used up to 0.4-0.6 mg.
If the medication is effective, it will continue for another 3 months as a course of treatment. Even if the symptoms improve in the middle, you have to take this dose for 3 months, and you cannot reduce the dose. Some studies have shown that reducing the dose too quickly makes it easy to relapse.
Q: What is the follow-up treatment when one drug does not work?
A: We expect to re-evaluate the voiding diary to see what type of nocturnal enuresis it is, and then consider changing the medication or using an alarm.
Q: What are the side effects of medication and how can I avoid them?
A: Normal people have a self-regulatory mechanism. If you drink more water, you will urinate, and if you drink less water, you will urinate less. The application of antidiuretic hormone will make the urine thicker and reduce the volume of urine. If water is not controlled at this time, water will accumulate in the body, causing hyponatremia and water toxicity. This may cause mild headaches, discomfort, etc., and in severe cases, convulsions. However, this drug has no accumulation effect and is quickly excreted from the body.
To avoid this side effect, it is important to take the drug at the right time and not to drink water after taking the drug.
Q: How to deal with side effects after they occur?
A: It is recommended to stop the medication for 1 week and then consider the treatment plan under the guidance of a doctor.
Q: If I have a fever during the treatment of nocturnal enuresis and the doctor asks me to drink more water to reduce the fever, how can I resolve this conflict?
A: Then stop the antidiuretic hormone, it’s okay to stop for a few days. Moreover, when the fever is high, the parents will stay by the child’s side at night and wake him up when they find that he is urinating.
Q: When will the medication be stopped?
A: When the fever subsides and the child recovers, then the medication will be resumed. This stopping time should be added to the course of treatment, such as stopping the medicine for a week, the course of treatment should be extended by 1 week accordingly.
Q: Do nutritional supplements or medications such as calcium tablets, vitamins, cold and flu medications, and antidiuretic hormone have an effect?
A: No.
Q: What should I do if my enuresis suddenly worsens during medication?
A: This is the time to seek medical attention and discuss and analyze the cause, and never increase or decrease the dosage on your own. A urination diary will help, whether you drink too much water, and how the situation is during the day. The cause can usually be found.
Q: After 3 months of taking the medication, can I stop it? Will there be a relapse?
A: The effect of the medication is good and can be stopped. After stopping the medicine, 50% of people may relapse. This is related to living habits. Even if you stop the medicine, you need to stick to good habits.
Q: If I stop the medicine for a long time without urine loss and once in a while I wet the bed, is it a relapse?
A: This cannot be considered a relapse. Many normal children may occasionally wet themselves at night, drink too much water, or just can’t get up at night. This needs to be grasped by the parents themselves.
Q: How do I treat a relapse? Is it more difficult than the first treatment?
A: Treatment can be continued and is still effective. In most cases, anti-diuretic hormone is still used and the course of treatment is still three months. In a very small percentage of cases, enuresis is really stubborn and difficult to treat.
Q: I mentioned earlier that water intake for children with enuresis is very important. What does this water include?
A: Water to drink, soup, porridge, milk, etc. You can put these in the daytime and stop drinking water especially after dinner. Try not to drink a lot of soup at dinner.
Some parents insist that their children drink milk before bedtime, you can change this meal to the afternoon.
Q: Can I drink cola and tea?
A: You can’t drink them at night, and it depends on the situation during the day. However, we do not advocate that children drink more of these sweet drinks like cola, which can also affect the appetite and the normal intake of nutrients.
Q: How long is appropriate from dinner to bedtime?
A: It has to do with the family’s lifestyle. Hopefully, the time between dinner and drinking, and bedtime is slightly longer, such as three hours.
Q: Should I restrict fruit consumption for children with enuresis?
A: Personally, I don’t recommend too much restriction of activities, diet, etc. for children with nocturnal enuresis. Because it is important to be happy, especially in a child who is enuresis, we need to understand that the purpose of getting him/her into treatment is to improve the effects of nocturnal enuresis on him/her and be happy. I will encourage the child that you did not wet the bed tonight without drinking water, the whole family slept well, and you went to school or kindergarten in good spirits. This way the child is also happy and energized during the treatment process. We want to see happy smiling faces of our children.
If this and that is not allowed because of the treatment, it defeats the purpose of the treatment.
Q: What is the significance of developing good urination and defecation patterns and habits?
A: It is very important, especially to pay attention to the constipation problem of a child with enuresis, and treat it accordingly once it appears, otherwise it will affect his bladder function.
Q: How to exercise the habit of urination?
A: It takes a process. A good urination habit is to have the urge to urinate and be able to get rid of it in time.
We also have to work on bladder contraction and release of the sphincter. For children over 5 years old, when they have the urge to urinate, we can exercise them to hold it for a while and wait until the right time to urinate. For example, if a child has the urge to urinate on the weekend when both parents are home, he or she can hold it for a while under parental supervision. After a while, the time to hold urine will be extended appropriately. But overall, you should not hold it for too long.
To summarize, for younger children, we encourage them to urinate when they have the urge to do so; for children over 5 years old, we encourage them to consciously hold urine appropriately and then go to urinate.
Q: For children who urinate, do they need to be woken up in the middle of the night to urinate?
A: Many parents ask this question.
Some parents put on an alarm clock and get up once in the middle of the night to tell their child to urinate. This does prevent him from peeing in bed, but it is not very therapeutic, unlike a wetting alarm.
The alarm will go off just like the alarm clock, but the point at which it goes off is the point at which the urine comes out. The alarm clock does not have the right time and does not serve as a training behavior.
From the point of view of avoiding bedwetting, this method is feasible. After using this method for a period of time, you can stop for a while, and if the child stops wetting, it means that the child has cured itself.
Q: Do I have to insist on waking up my child if he or she is sleeping extraordinarily well and cannot be woken up?
A: Generally waking up and going to urinate is closer to physiology and good for training. It also depends on the child’s age and degree.