Children who soil or wet themselves

Enuresis is a term used for wetting or passing of urine without control at an age when it would be expected. This can occur either during the day or night.

Bedwetting (also called Nocturnal Enuresis) is when a child passes urine when asleep at night. Bedwetting is normal in children under two years of age. Most children will develop night-time dryness between two and five years of age, but some children can still wet the bed at some stage.

If your child reaches the age of 6 years and is still regularly wetting the bed, this is known as ‘Primary Enuresis.  If your child starts to wet the bed after a period of being dry (e.g. for 6 months), this is known as ‘Secondary Enuresis.’

In either case you should seek advice.

There are several reasons why children may still wet the bed after the age of five.

• Some children may just be slow developers or are not yet able to wake themselves up when their bladders are full.
• Children are more likely to wet their bed if they are very tired and sleeping deeply. Some children, who are normally dry, may wet their bed when this happens or when unwell.
• Bedwetting is more likely to happen when children drink a lot before they go to bed. Their bladder may not be able to hold all the urine that is produced and empty without them waking up.
• For some children, where they have been dry for a period of time, bedwetting can be a sign of emotional distress. They may be experiencing anxiety or stress, or it may be a reaction to major changes in their life (such as when a new baby arrives in the family or when they start school).
• Bedwetting may also be caused by constipation, urinary tract infection (UTI) or lack of a hormone called ‘vasopressin’.
• Children are more likely to experience bedwetting if one or both of their parents had wet the bed as children too.

Bedwetting may mean that your child misses out on sleepovers, holidays or trips away. They may feel embarrassed or ashamed that they still wet the bed. This can affect the child’s self-esteem.

Parents/carers rarely talk about their children wetting the bed. This may be because people often think that their child is the only one with a problem. It may also be because you feel guilty or responsible that you haven’t been able to do something about the problem.

Is it deliberate or due to laziness?

Bedwetting is an ‘involuntary’ loss of urine at night when a child is sleeping. This means it is an accident and it is not their fault.  You should never blame your child. Making your child feel bad, ashamed or anxious will only make the problem harder to deal with.

Below are some things that you can try out initially.

• Make sure your child drinks normally until about an hour before they go to bed. After this allow small mouthfuls of water to relieve thirst. Avoid fizzy or caffeine based drinks as these will stimulate the kidneys and lead to more urine being produced.
• Ensure that going to the toilet is part of your child’s bedtime routine every night. Encourage them to sit long enough to fully empty their bladder.
• You may sometimes find it helpful lifting your child from their bed and sitting them on the toilet. Older children may try waking themselves up (like setting an alarm).
• Make sure that you praise and encourage your child’s steps towards dry nights - tell them ‘well done’ for any dry nights - this often helps.
• Set up a positive reward system for behaviour that is likely to contribute to night time dryness, without focusing on the actual bed-wetting.  For example, rewards may be given for: drinking recommended levels of fluid during the day, using the toilet to pass urine before going to bed/sleep, engaging in management (for example, taking medication or helping to change sheets).

If bedwetting continues and you don’t see an increase in dry-nights, you should seek advice from your GP, school nurse or family health visitor. They will be able to offer you support and advice, and to refer your child to a specialist like paediatrician or continence nurse, if they feel this is appropriate.

If the bedwetting started after your child has been dry at night for a period of time (secondary enuresis), and physical problems have been ruled out, your GP or school nurse might suggest that you see someone from your local child and adolescent mental health service.

It is important to note positive rewards for agreed behaviour (like changing sheets rather than just dry nights) should to be used along with treatments described below.

Bell and pad

The ‘enuresis alarm’ is a pad that is connected to an electrical buzzer. When your child starts to wet the bed, the buzzer goes off. This should wake your child, who then gets up to go to the toilet. Gradually, your child will recognize the sensation of a full bladder and learn to wake by themselves when it is full. It may take your child weeks or months to become completely dry at night. To be successful your child must be motivated to become dry at night and fully involved with the process

Medication

Sometimes children may be prescribed medication by their GP or specialist clinic. The medications work by either relaxing the bladder so it can expand and hold more urine, or help the kidneys produce less urine.

Daytime wetting affects about 1 in 75 children over the age of five and is more common in girls. The daytime wetting can occur by itself or when a child is also bed wetting. This problem can be very stressful or embarrassing for children when they go to school, as it may lead to teasing or bullying.

A variety of physical or emotional reasons can cause daytime wetting. In younger children in particular, they may be so busy playing or doing their work that they simply forget to use the toilet or leave it too late. They may also be in a hurry when going to the toilet and do not completely empty their bladder.

Some children may be constipated as this can put pressure on the bladder, or have a urinary tract infection that needs medical treatment. It can also happen if your child is anxious or has experienced emotional upset.

On a practical basis, encourage your child to drink around 6-8 glasses of water based drinks throughout the day, as this helps the bladder to fill properly. It is also important to encourage healthy eating to avoid any constipation.

Parents can set up a toilet routine, with set toilet times to discourage ‘holding on’ or forgetting to go to the toilet. Children may need regular reminders to go to the toilet, or they can be given a timer or a vibrating wristwatch to remind them to go to the toilet regularly. To increase a child’s motivation to go to the toilet regularly, set up a ‘star chart’ with small rewards for going to the toilet and for dry pants at the end of the day.

If accidents do happen, try not to get angry, shout or use punishments. This is likely to add to any shame or embarrassment that the child may already feel and raise their anxiety, all of which are likely to make the problem worse.

Speak to your GP or school nurse if difficulties persist as they can refer you to a specialist if necessary.

Soiling (encopresis) occurs when a child does not reliably use the toilet for a poo/bowel motion. They may dirty their pants, or go to the toilet in inappropriate places.

Obviously, this is normal in toddlers and younger children as they learn to control their bowels in the toilet. However, if it is having a negative effect on family life, you may wish to seek additional support. Under normal circumstances, healthy children will develop control over their bowels by the age of four.

There can be a number of different reasons that affect a child’s ability to go to the toilet for a poo.

• Not learning a regular toilet routine is a common cause of soiling. The child may be reluctant to use the toilet. This may sometimes be part of a general pattern of behaviour, where a child refuses to do what you want them to.
• Sometimes a change in diet, an infection, taking medication or life events such as a house move, starting nursery or another change within the family can trigger constipation.
• Severe constipation causes the bowel to be blocked with hard poo. The child finds it painful to pass this hard poo, and so becomes more constipated. Liquid poo then leaks around the blockage, staining clothes. Children who are constipated may become irritable, with a lack of energy and a loss of appetite.
• Sometimes a child links pain with pooing. They are fearful and try to hold in their poo, making it even harder and difficult to pass. This happens when a child in the past has had hard poo in the bowel, causing a small split in the anus called a ‘fissure’ that is extremely painful.

If your child is soiling because they have never had a toileting routine, you can help by encouraging your child to establish a regular routine by praising them for their effort and any successes. You can ask for support from your health visitor or school nurse with this. Star charts and stickers can prove motivating for children. Ensure that any of your responses are not punishing.

If you suspect your child is constipated or their poo is painful to pass, it is a good idea to visit your GP. Your GP may recommend some helpful medication to help clear your child’s bowel. Alongside this you can help by making sure that they eat a lot of fruit, vegetables and foods high in fibre, as well as exercising and drinking lots of water. This will make the poo softer and easier to pass.  Again, toileting routines, star charts and non-punishing responses can be helpful.

If your child is not constipated, the cause may be emotional or psychological. If they start to soil or to smear faeces after no previous difficulties, they may be emotionally upset. If you can find out what is upsetting them and sort it out, the soiling may then improve. If it carries on, your GP may suggest specialist help from the local child and adolescent mental health service (CAMHS).

Emily developed night time dryness at around age 4 years. Despite being dry for many years, following the birth of her baby brother, she regularly wet the bed at night (this is known as secondary enuresis). Her parents felt very stressed and angry about this, and viewed this behaviour as being lazy, attention seeking and defiant. They responded by shouting and criticising her and enforcing consequences. In response, Emily tried to cover up her bedclothes being wet and seemed more withdrawn and quieter than normal.

Physical causes were ruled out. The parents were told that a setback in normal development when previously dry was more likely a reaction to psychological (or in some cases physical) stress i.e. the arrival of a new baby rather than being caused by laziness, attention seeking or defiance.

The family limited Emily’s intake of fluids before bedtime, particularly fizzy and caffeinated drinks. She was encouraged to have a routine regarding going to the toilet before bedtime.

To help reinforce bladder control, she was encouraged to change her own nightwear and bedding following episodes of wetting. Praise and encouragement were given to Emily by her parents for steps taken towards dry nights. A reward system was set up for her. She could earn rewards for performing activities, such as going to the toilet before bedtime each night and taking responsibility for changing her wet nightwear and bedding.

To help Emily adjust to having a new brother, her parents also spent time with her each day engaged in some positive activities, such as playing and talking. To help her feel more involved, she was also given some specific jobs to help with the care of the baby.

From very young Jack's parents felt he was a "picky eater" preferring crisps, coke, chips and processed cheese. Jack became constipated and his poo became dry and hard to pass. When Jack tried, it was very painful.

Jack became fearful of going to the toilet so he hung on. His poo became increasingly hard and stuck in bowel, causing liquid faeces to trickle around the blockage, causing him to his soil pants. Jack was very ashamed, and hid his pants in many different places. This caused lots of arguments between him and his dad. Dad shouted at him to go to the toilet. Jack became reluctant to co-operate with anything for his parents. He became quite grumpy and pale.

Jack's treatment focused on moving the blocked, dry stools with medication prescribed by his GP. He was encouraged to drink water and eat healthy foods, with a very simple reward chart.

Jack's school nurse advised his mum to make the toilet a rewarding place, by allowing him a special comic or game he could only use when he was practising pooing. His parents were also given some information on constipation and soiling.

Jack's dad worked at reducing the conflict around Jack's toileting routine by reinforcing 'trying to poo', rather than passing a poo. They praised him for taking medication and rewarded him with family days out.

Jack’s soiling improved and family felt relieved and positive about each other.

Offers information and advice about day and night wetting to parents, young people and professionals.

NHS Choices - Has information on day and night wetting, and soiling problems on their website.

Handsonscotland - This website gives practical information, tools and activities to respond helpfully to troubling behaviour and to help children and young people to flourish.

References

• National Institute for Health and Clinical Excellence (2010),Constipation in Children and Young People, Diagnosis and Management of Idiopathic Childhood Constipation in Primary and Secondary Care, London: National Institute for Health and Clinical Excellence.
• National Institute for Health and Clinical Excellence (2010), Nocturnal enuresis: The Management of Bedwetting in Children and Young People. NICE Clinical guideline 111,London: National Institute for Health and Clinical Excellence.
• Rutter, M. & Taylor, E. (eds) (2008)'Child and Adolescent Psychiatry' (5th edn). London: Blackwell.
• Wells, M. & Bonner, L. (2008)‘Effective Management of Bladder and Bowel Problems in Children’London: Class Publishing

Credits

Revised by the Royal College of Psychiatrists’ Child and Family Public Education Editorial Board.

Series Editor: Dr Vasu Balaguru

With grateful thanks to Clinical Psychologists Dr Beverley Dayus, Dr Lindsey Hampson and Emma Ridoch.

This page reflects the best possible evidence at the time of writing.