Parents whose older children suffer from bedwetting often feel ashamed and isolated, and their kids frequently feel embarrassed, too — even depressed and anxious.
"It's such a stigma," said Jeannie, who didn't want to use her last name to protect her 8-year-old daughter, who used to struggle with nighttime wetting.
"When she had sleepovers, it was like a covert operation getting the pull-up on," said Jeannie. "The last thing you want is your kid to be known at school as the bed-wetter."
Nocturnal enuresis, as the condition is formally called, is defined as bedwetting in kids 5 or older. Children who suffer from the condition often have low self-esteem and in general more depressive problems and issues at school, according to an article on the National Institutes of Health website.
But the reality is that bedwetting in older children is not uncommon and, fortunately, is treatable. The American Academy of Family Physicians estimates between 5 million and 7 million kids in the U.S. deal with it.
Most important, clinicians in the field agree that it is not the child's fault.
"The first thing we say is, 'Please don't blame the child,' " said Amanda Berry, a nurse practitioner who works with enuretic patients at the Children's Hospital of Philadelphia.
"We never wanted to shame her, because we could tell she wanted to be dry," Jeannie said of her 8-year-old daughter.
Cheryl Tierney, section chief for behavior and developmental pediatrics at Penn State Hershey Children's Hospital, stressed that nocturnal enuresis is highly genetic and that the condition is far from rare. "Kids don't go to school and talk about it," she said. "They feel ashamed. They don't realize how common it is."
According to CHOP experts, nocturnal enuresis is most common in 5- to 7-year-olds. Only 1 percent to 2 percent of older teens suffer from the condition.
No one knows exactly what causes nocturnal enuresis, but a lot of factors may be at play.
"Fifty years ago, we were taught that it was deep-seated psychological unrest," said Stephen Zderic of the urology department at CHOP. Zderic, a world expert on nocturnal enuresis, said he does not believe that bedwetting after age 7 is generally a neurotic psychological condition, except in a few rare cases, such as when a child has lost a loved one or has suffered some other trauma or extreme stress.
"My bias is that for many of these children, the issue is how the bladder sends its message to the brain during sleep," Zderic said.
As the bladder fills, it sends sensory information up the spinal cord to the brain. But if the nerves that control the bladder sphincter are slow to mature, a child may not wake up when his or her bladder is full, especially if that child sleeps deeply.
Berry emphasized the hereditary nature of nocturnal enuresis. "We definitely know it runs in families."
If one parent suffered from it, a child has a 40 percent chance of also having the condition, and if both parents had it, a child's likelihood of bedwetting increases to 70 percent. In fact, there may be a bedwetting gene — and probably several, Zderic said.
What makes this hereditary mystery even more fascinating is that the average age a child will outgrow nocturnal enuresis is the average age his or her family member outgrew it, and no one knows exactly why, Tierney explained.
Other contributing factors include a small bladder that is unable to hold the urine a child produces throughout the night, a lack of the anti-diuretic hormone that slows urine production, and/or chronic constipation. Sleep apnea, urinary tract infections, or diabetes may also cause bed-wetting.
About 15 percent of children with nocturnal enuresis grow out of the condition without any specific treatment. For the rest, medication sometimes helps.
Desmopressin, the most common one, works by concentrating the urine, decreasing production so the bladder does not completely fill throughout the night.
Doctors generally recommend using medication for special occasions, such as sleepovers or overnight camp. But it works in only about half of children who take it, usually in those who produce a lot of urine, Berry said.
"I wouldn't [use] it without doing lifestyle modification: drinking more in the morning, voiding twice before bed," Zderic said. "I think you can do better than 50 percent if you combine it with lifestyle changes."
But the most common treatment for nocturnal enuresis — aside from lifestyle modifications — is a bed-wetting alarm. A sensor detects the moment a child's undergarments are wet, triggering the alarm, which usually wakes the child.
"Night after night, your brain starts to figure out, 'Aha! That is what it feels like when you have a full bladder,' " Tierney explained.
Having a parent wake a child several times a night to urinate usually doesn't work because the child's bladder may not be full at those moments, Zderic said. Plus, often the child isn't fully awake, meaning that a well-intentioned parent may inadvertently be encouraging sleep-wetting, Berry said.
"We like the bedwetting alarm because it really trains what needs to be trained, which is to somehow get the signal to their brains" that it's time to urinate, Berry said.
But Berry added that it's not a quick fix. "It requires a motivated child and a motivated family, and it's a process. It's definitely a lot of work, and timing is important. You wouldn't want to do it when there's a lot of other things going on in a child's life," she said.
If used correctly for three months, the alarm has an 80 percent success rate. When coupled with family counseling and education, Tierney said she sees a success rate closer to 97 percent.
"Often it will be a child who has been wetting every might, and within weeks they are dry — and it's pretty much a permanent response," said Renee Mercer, a nurse practitioner and author of Seven Steps to Nighttime Dryness: A Practical Guide for Parents of Children with Bedwetting, who also started the website BedwettingStore.com in 2000 after decades of watching patients struggle with nocturnal enuresis.
"If you don't kind of address it, it can go on for years," added Mercer, who treats patients in Elk Ridge, Md. "I see children every summer who are about to go off to college, and I say, 'Oh, my goodness! Why did you wait so long?' "
Jeannie's pediatrician referred her to Mercer, who recommended the family use the alarm for their daughter, who was 7 at the time. It took a couple of months to work.
"I was skeptical at first, but my gosh, we went from horrific, every night, very full Pull-up to this!" Jeannie said. Her daughter has been completely dry now for more than six months.
"Now my husband and I in the middle of the night, we'll hear the toilet flush, and we'll smile," Jeannie said.