No More Bedwetting: How to Help Your Child Stay Dry

INTRODUCTION

A child’s bedwetting can be a baffling and frustrating fact of life for the whole family. It tries the patience of the most well-meaning parents, and it torments the bedwetting child. Many parents mistakenly believe that bedwetting is a deliberate failure to get out of bed by a lazy, careless, disobedient, or immature child. As a result, long-term bedwetting creates feelings of anger, shame, and confusion—feelings that pull families apart and cause children to become unfortunate victims of emotional and even physical abuse, with serious damage to their self-esteem, family relationships, and social life.

I would like to share with you the story of how I became aware that long-term bedwetting from birth is caused not by psychological or maturational problems but by physical factors that are beyond the child’s control—most of which factors are treatable—and why I have felt it necessary to write this book.

About 35 years ago, I believed (along with most doctors of that period) that if no urinary infection was present, bedwetting, along with daytime urinary problems such as frequent running to the bathroom, difficulty making it to the bathroom in time, and spotting underpants with urine, were mainly psychological in origin. Because I was a urological surgeon rather than a psychiatrist, I did not encourage pediatricians and general practitioners to refer bedwetting children to me for treatment: I felt that I could help only a few.

To spare the majority of bedwetting children and their parents the stress (and expense) of needless urological examinations, I designed a questionnaire that could be filled out by the children’s doctor and the parents, which I thought would allow me, without examining the children, to identify the few wetters who might require urological treatment. I felt that the rest of the bedwetting children could continue to be treated by their pediatricians (who might refer them to psychologists or psychiatrists).

The questionnaire I designed probed for both psychological problems (such as sibling rivalry, anxieties, or too much parental discipline) and physical problems (such as pus in the urine, fever, pain on urination, or other difficulties with urination). I assumed that if the child had no fever or pus in the urine, and if any possibility of an emotional problem existed, then the basis for the wetting was psychological.

I distributed the blank questionnaires to my referring pediatricians and general doctors and asked them to send me only the completed forms, not the children.

The method failed. Some children who I did not examine because their questionnaires suggested psychological problems developed urinary infections. Others remained wetters despite the best efforts of their pediatricians and the psychologists to whom they were referred. At last I began examining the children themselves. To my surprise, I found physical problems in the majority of them. Sometimes I found easily detectable physical problems, but most often I found subtle ones—small abnormalities such as narrowings or constrictions in the urethra (the tube leading from the bladder to the outside). These small abnormalities were easily corrected through minor surgical procedures, which, I soon discovered, relieved the daytime urinary symptoms in a high percentage of cases almost immediately (so that the child no longer had to rush to the bathroom to avoid daytime accidents) and relieved the night-wetting in a highly significant percentage of cases within a few months.

In treating my first bedwetting child, I began to question the thinking of the time about the causes of bedwetting. A family physician had sent me a questionnaire he obtained from the mother of a nine-year-old bedwetter. From the completed questionnaire, I learned that the boy, who had been difficult to toilet-train, wet his bed every night. During the day, he spotted his underpants with urine and dashed often to the bathroom, clutching his penis, sometimes not getting to the toilet in time. The boy did poorly at school and had frequent temper tantrums.

The mother was divorced and sharing their home with a man whom she planned to marry. As I read the questionnaire, it occurred to me that the mother’s relationship with this man may have caused the boy emotional distress, and thus the bedwetting. Without seeing the boy, I recommended to the referring physician that the boy get psychological counseling.

While the mother considered this recommendation, the boy happened to take a routine urine test for school athletics, which revealed pus in the urine. The mother took the child back to the child’s doctor, who referred him to me. Because of the pus in the urine, I agreed to see him.

On examining the boy, I found that his penis had an extremely narrow opening and his urethra was somewhat inflamed. After I corrected this simple physical problem by enlarging the opening, the boy’s urine cleared of pus, and his urethra returned to normal. In addition, he no longer needed to rush to the bathroom, no longer needed to urinate frequently, and no longer wet the bed except when he was overly tired or catching a cold. Even his temper tantrums disappeared. I saw that not the pus in the urine, but the narrowing of the penile opening that led to the inflamed urethra was the cause of both the wetting and the urinary infection.

This experience prompted me to read every piece of medical literature I could find on the subject of abnormal narrowings or constrictions of the penile opening. I found that several eminent urologists of the past (particularly Meredith Campbell—the father of pediatric urology) had described how such minor abnormalities could produce bedwetting and daytime symptoms (even if the urine contained no pus).

I decided to undertake my own study of 160 hospital charts of boys who had been diagnosed as having such narrowings. Like the published material I had read, my study of the hospital records showed clearly that these constrictions could make a child urinate much too often, rush to the bathroom, and wet the bed. Such constrictions also led to irritable erections—that is, erections caused not by erotic play or self-stimulation, but by inflammation and irritation of the nerve endings. I published my findings in the Journal of Urology to inform the medical community.

Unfortunately, the paper with my findings failed to reach enough members of the urological community. If the patient’s urine did not contain pus or blood, most physicians continued to blame bedwetting and daytime urinary symptoms on emotional factors, imperceptible nervous system disease, or irritable bladders.

During this time, my experience with bedwetting children and my knowledge about bedwetting increased rapidly. Among other things, I learned from a majority of the parents that their bedwetting children slept so heavily that they could scarcely awaken them, even with noise, lights, shaking, and lifting. I learned that the majority of the night-wetters who came to see me also had daytime urinary symptoms. In addition, I noted that in children with such daytime symptoms, not only small penile openings but also a number of other small urethral abnormalities that many doctors dismissed as variants of normal or as not significant, actually did also cause or contribute to bedwetting. Finally, I learned from the work of researchers Richards P. Lyon and Donald R. Smith, published in the Journal of Urology, that other small abnormalities occurred in girls; these, too, caused bedwetting.

When I questioned parents who had themselves experienced bedwetting along with daytime urinary problems in childhood, I learned that, contrary to general opinion, bedwetters did not necessarily outgrow their disorders. Far more men who had been bedwetters as children suffered later in life with inflammation of the prostate and the urethra than did nonwetters. They also tended to have sexual symptoms, such as painful and/or premature (overly rapid) ejaculations.

Women who were former wetters often complained of involuntary loss of urine when they coughed, sneezed, or strained to do various tasks. Many experienced recurring urinary infections, vaginal irritations, and pain with intercourse. Many former wetters of both sexes still had to awaken from one to three times a night to urinate. During the day, they still had to urinate frequently, often having to rush to the bathroom for fear of wetting themselves. In other words, they had outgrown their bedwetting, but the physical abnormalities that had caused their wetting still caused problems.

Local physicians, particularly pediatricians, were delighted that a urologist finally showed an interest in bedwetting, and they sent me many patients. When I had accumulated data on 187 cases of my own, I presented my findings at the Sixtieth Annual Meeting of the American Urological Association, in New Orleans. My presentation was received coolly, although it was reported in the news section of the Journal of the American Medical Association. In addition to their general lack of interest in bedwetting, other urologists could not conceive of the significance of the small abnormalities that I found so instrumental in bedwetting.

The data I accumulated had enabled me to formulate three hypotheses:

1.   Psychological problems rarely (if ever) cause persistent bedwetting from birth.

2.   A bedwetter who also has persistent daytime urinary symptoms has a physical condition, mostly in the lower urinary organs.

3.   A heavy-sleep factor prevents the bedwetter from awakening to urinate. (The child who has daytime urinary symptoms but not an unusually heavy sleep pattern awakens—sometimes several times—to go to the bathroom at night instead of wetting the bed.)

My studies also allowed me to conclude that the more careful the doctor’s physical and urological examination of the bedwetting patient, the more likely a physical cause for the bedwetting would be found. At the same time, I saw that the minority of bedwetters who did not have daytime urinary symptoms (urgency, frequency, loss of urine) could not be treated urologically. They did not have physical abnormalities in the urinary tract. (The causes of long-term wetting in children who do not have daytime symptoms are also physical rather than psychological: unusually deep sleep; deficiency of the hormone vasopressin; intolerances to foods or other substances; and other physical causes.)

My experience with bedwetting children continued to grow and to reinforce my findings. Soon, Dr. Arthur Ginsburg joined me in practice and, working with his own patients, confirmed what I had reported. When our combined experience with bedwetters reached approximately five hundred cases, we presented our new study at the annual meeting of the American Medical Association. Still, most urologists remained skeptical of the role of small urethral abnormalities in bedwetting and daytime urinary symptoms.

But Dr. Ginsburg and I continued our studies and often presented our findings so that other doctors, too, could use our methods to help many more bedwetting children. We published a first-time-ever photostudy that matched up X rays of bladders and urethras with photographs taken through a cystourethroscope (pronounced sis-toh-yoo-re-throh-scohp), the instrument that urologists use to look inside the bladder and urethra. With these pictures we were able to show the following things: the areas we considered problem areas, such as small urethral folds, flaps, and narrowings (constrictions); the simple operations used to correct these abnormalities; and the changes the operations produced as seen on follow-up X rays. We were able to explain the connections (in most cases) between the surgical changes and the relief or lessening of the bedwetters’ symptoms. After the publication of this study, several urologists wrote to tell us that they had used our techniques and had similar experiences with patients.

Unfortunately, many physicians and the general public still cling to the theory that bedwetting from birth is psychological, and in doing so they perpetuate the frustration and misery of millions of bedwetters and their families.

Here is a case in point. An 11-year-old boy, desperate about his bedwetting, wrote to a nationally syndicated, well-respected advice columnist, asking for her help. He described himself as the unhappiest person in the world because he had been unable to stop bedwetting no matter how hard he tried. He had even tried starving himself and going without water for days at a time. His mother had taken him to a doctor, who reassured her that her son had no disease and would outgrow the problem. When the mother heard that the son had no physical disease, she tried to disgrace him out of his bedwetting by telling everyone that her 11-year-old baby boy still wet the bed. The boy concluded his letter with a promise to follow the columnist’s advice, no matter what it might be.

The columnist answered that many adolescents wet the bed because they are insecure and unhappy and suggested that the boy’s parents take him to a doctor who could work out emotional problems. How unfortunate that this total misconception was passed on to many millions of readers.

Over the years, I have taken other opportunities to share my experiences and findings. Doctors Willet Whitmore, John Lattimer, David Utz, and Pablo Morales, who were nationally known chiefs of urology at Sloan-Kettering, Columbia Presbyterian, Mayo Clinic, and New York University Medical School, gave me opportunities to express my views. Dr. Frank Field, when he was with NBC-TV, gave me a chance to air my opinions nationally and locally.

The rewards for my efforts to understand and treat bedwetting and other urinary problems in children have come from the children themselves and from their families. Children, free of the embarrassment of bedwetting, have blossomed. Their reactions have been touching and heartwarming. A first-grader sent me a carefully printed note on lined paper decorated with her drawings of flowers:

Dear Dr. Arnold,

Thank you for helping me with my problem. I slept over at my friend’s house, for the first time… .

Letters such as the one from a former patient describing her feelings about having been cured of bedwetting are great sources of professional satisfaction to me:

Dear Dr. Arnold,

This letter is terribly overdue … about eight years overdue… . I have just taken it for granted all these years that I am able to do all the things I want to do because you helped me. It was an amazing thing how one day I was being beaten for wetting my pants, and then the next I was cured—totally. And I have had no problems at all since then. I no longer have to … be embarrassed [by hearing] in front of my friends what I did and that I did it because I wanted attention… .

I will never forget the embarrassment, humiliation, and utter despair that I went through. I still remember everything today… . I can talk openly about it, and I am really surprised at how many people went through the same thing I did. I feel lucky that my problem was taken care of when I was young, although I wish it had been taken care of even earlier.

I am very happy now. I was really miserable before my parents brought me to you, after all the other doctors told me I was just lazy. I am not lazy now, so I know I wasn’t lazy then. I have worked since I have been old enough to work, and I just graduated from college with a Bachelor’s in Fine Arts.

I am 22 years old now, still single, and having a blast. I go out to parties and to other people’s homes, and I travel. I have been to Europe twice. In June, I will go to Greece for two months. The most wonderful thing is that I can go anywhere without worrying about wetting… .

I do want to thank you again. Thanks.

Sincerely,

Althea

Parents, relieved of guilt (and laundry burdens), have also been thrilled to have their children cured. An example is a letter from a mother in Indiana who had read one of my articles in a medical journal and taken her son to a urologist who (perhaps guided by the article) enlarged a narrow area within the boy’s urethra and cured him. With her note, she sent me a photograph of her very cheerful-looking son.

Correspondence came from very distant places. A lady in Australia, for example, wrote to ask for copies of my articles, and then later wrote to thank me. It appeared that over time she had taken her daughter to five different doctors to treat the girl’s bedwetting and daytime urinary symptoms. Of the five doctors who examined the girl, not one suggested that she should see a urologist. They blamed the girl’s symptoms on laziness, stubbornness, and jealousy over her newborn baby sister. They reassured the mother that the daughter would outgrow her symptoms. After receiving the articles, the mother consulted a urologist who quickly cured the child by removing a minor physical obstruction.

I have great faith in the ability of people supplied with facts to arrive at logical conclusions. Unfortunately, too many books about bedwetting written for parents, and too many urological textbooks as well, ignore the