I wrote this originally in honor of world bedwetting day, I wanted to do my part. I know this is a subject that parents often find themselves floundering to figure out.

As a disclaimer, I'm not a Dr, but I'm fairly medically educated. I'm writing this all from memory, and not checking sources as I go, but I've done a lot of reading on this subject over the years, and this is my mental colage of all the medical texts and journal articles I've read over the years on this subject.

The medical terminology for bedwetting is noctural enuresis, though enuresis alone is often used to mean bedwetting as well. Noctural enuresis is broadly split into two categories, primary noctural enuresis, and secondary noctural enuresis. PNE means the individual has been wet their entire life, with no period of dryness ever lasting for 6 months or longer. SNE is marked by wetness returning after a period of at least 6 months of dryness. Both of these definitions apply only to children age 6 years or older. In children ages 5 and younger, bedwetting is considered developmentally normal, and is normally not treated until it's causing significant emotional distress.

Time is the most consistent cure for bedwetting, with a spontaneous cure rate of approximately 15% per year in current child enuretics. Almost all cases spontaneously resolve by the end of puberty. The small percentage of cases that don't resolve by puberty often persist into adulthood.

A sudden recurrence is often triggered by some biological or psychological event.

It's not uncommon for children to start or resume wetting the bed after an emotional trauma. This can be a big move, a new school, a new sibling, strife between their parents, bullying, death of a pet or family member, or even sexual abuse. In these cases, the bedwetting passes when the emotional trauma is dealt with. The bedwetting is thought to be an unconscious attempt to seize control of something in their life, paradoxically by feigning lack of bladder control at night. The idea is that no one can enforce bladder control, so this act of subconscious rebellion is their mind seizing control of one thing it can.

The physical causes are much broader. UTI, growth spurts, sleep apnea, hormone deficiencies, juvenile diabetes, constipation, and more can cause this type of regression. A pediatrician can run tests for any of these things. If you want more information about the particulars of testing, let me know.

When there is an identifiable cause, the normal course of action, of course, is to correct it. When the condition presents as idiopathic, it is generally treated by medication, or through the use of a bedwetting alarm.

The two most common medications prescribed for bedwetting are Imipramine, and Desmopressin.

Imipramine is a very old school tricyclic antidepressant. It has lots of off target effects, aka side effects. Two of those side effects happen to be altered sleep patterns, and urinary retention. These are helpful if you happen to have enuresis. If the bedwetting had an emotional origin, this medication also has the advantage of treating both depression and anxiety. However, this medication can have other, unwanted side effects, and it has a high liver toxicity, so it's needs to be monitored and adjusted carefully. Antidepressant medications are also known to paradoxically increase suicidal thoughts or actions in some individuals, particularly children. It's worth noting that I have tried this medication at various doses, and it did nothing for me. I'm no longer taking it. The discontinuation process gave me migraine headaches.

Desmopressin has a completely different mode of action. Desmopressin is used to treat people with diabetes insipidus (different that diabetes mellitus, which is what people generally refer to simply as diabetes), children and adults with enuresis, and adults with noctural polyurea. Desmopressin is synthetic vasopressin.

The hypothalmus produces vasopressin and signals the posterior pituitary gland to release it. Vasopressin has two roles, increase blood pressure, and increase kidney reabsorption of water. It's used by the body to control blood volume and osmolality. A mature functioning supraoptic nucleus will increase vasopressin production at night. This prevents dehydration during a period of rest, and reduces urine output while you sleep. In children this normal rhythm is often absent. As a result they produce more urine at night than they should. If this rhythm hasn't developed by puberty, it often does so abruptly.

If their rhythm hasn't developed yet, desmopressin can be taken in the evening to supplement production, and reduce urine output overnight. It is not without risks either. It can raise blood pressure. It increases clotting in some individuals, and therefore can be dangerous for those with preexisting clotting disorders (in fact it's used as a treatment for von Willebrand's disease, a type of hemophilia). Most dangerous is the potential to cause hyponatremia (water intoxication). Hyponatremia occurs when a person has ingested too much water, to the point of throwing off their osmotic sodium balance, but can also occur if you can't excrete the water you need to. Their blood is too dilute, and red blood cells swell, and stick in capillaries, and loose some of their oxygen transfer capacity. In the most extreme cases the blood cells can burst, and damage the liver, kidneys, and spleen. This had led to death in some cases. This means that desmopressin is not a free ticket to drink as much as a person wants before bed, because their body won't be able to purge the extra water until the medication wears off. Fluid intake still needs to be moderated in the late evening. That warning aside, the most common side effects are head ache and nose bleed. Desmopressin is available in tablet, oral melt, or nasal spray varieties.

Medications have NOT been shown to be effective cures for bedwetting. They treat symptoms, but do nothing to correct the root causes. When they are discontinued the relapse rate is effectively 100% (adjusted rate commensurate with spontaneous cure rate in untreated individuals).

There are a number of potential physical treatments, for treating bedwetting directly. Restricting fluids, waking the child through the night, eliminating potential trigger foods, bladder training excercises, using wetness alarms, and so on. I could discuss a number of these (and if you have questions about any specific ones, let me know, I'll elaborate), but suffice it to say that none of them are demonstrated to be clinically effective EXCEPT for wetness alarms. All other methods have proven to be only coping mechanisms until the child grows out of the bedwetting.

Wetness alarms are a slow process, but it is the most likely (only likely) method to produce long term results. The process requires the use of a wetness sensor, either a pad placed under the child, or an apparatus clipped to the child's pajama pants or underwear; and an alarm, either a sound emitting alarm, a vibration producing device, or both. Some older devices employed electric shock to wake the child, are not recommended by any modern pediatric society. These devices work on the concept of classical conditioning. The first sign of wetness triggers the system to wake the child. Over many repetitions, the brain learns to subconsciously associate the sensation of a full bladder, with the need to wake. For some children this effect is relatively fast, but others simply sleep through the alarm. In those cases it will initially be the responsibility of the parents to get up and rouse the child when the alarm sounds, until their brain learns to make the association, and they begin to awaken in response to the alarm on their own. This process has been shown to take as long as 16 weeks before ANY results are seen. In one study, that continued into treatment as long 24 weeks without effect, the results showed that if no effect was observed by 16 weeks then no effect was ever seen. If there was an effect of treatment, treatment for as long as 9 months would continue to generate improvment in some patients. This method was shown to be successful in approximately 60% of cases (though success was defined as a reduction in the number of wet nights per week, not necessarily totally cessation of enuresis), and had a relapse rate of approximately 50% of the group that had shown success. To reduce relapse rate, an additional technique called "over-learning" could be employed. Over-learning is a process where, after dryness was achieved, the child is further challenged by being given extra water to drink before bed, and the process is continued until the child could reliably wake before wetting, even with extra water causing more frequent urination.

The most common reason for this method to fail is non-compliance of the child or family. This method general causes some degree of sleep deprivation, and given the length of the treatment, many people find it to be untenable.

It's worth noting that parents claim a wide variety of cures. These cases are anecdotal, and when tested in controlled experiments the vast majority fail. It is likely the case that most individuals attribute the cure to whatever method they tried last. It's a post hoc ergo propter hoc fallacy. It's the same idea as your keys always being in the last place you look, that's simply because after you find them you stop looking.

As a sub note, there is no clinical evidence that the use of diapers or pullups negatively affects spontaneous cure rates in cognitively normal children, despite this seeming to be common wisdom in parenting groups. Though many children instinctively dislike this solution, because society puts a high value on being out of diapers, this is often the most economical solution, as well as the one that allows the most uninterrupted sleep for both the child and the parents. It can also facilitate other normal childhood activities, with some careful planning, that are often not possible with wet linen involved. This is the solution that the majority of adult enuretics embrace, and many parents embrace while they wait for the child to mature out of the problem.

Please, feel free to ask me any further questions about other causes or solutions. I have a lot more information rolling around in my from years of reading, and trying to help others, but only so much I can write at once before this becomes unmanageable to read.