Chronic constipation is a common but often unrecognised cause of both primary and secondary nocturnal enuresis. Constipation is when bowel movements are large, hard and difficult to pass. In children aged between 3 and 12 years, having less than one bowel movement a day may also be considered constipation. Constipation is quite common among children, with between 5-30% of children suffering from the condition. Constipation can occur if your child’s diet is low in fibre, they do not drink sufficient liquids, is very inactive or develops a habit of holding onto their stools.
When children suffer from constipation they are at a much higher risk of developing urinary tract infections and nocturnal enuresis. Recent research shows that over 60% of children diagnosed with chronic constipation also experience difficulties with nighttime continence. As the rectum and bladder are very close to each other, when constipated, the bladder can become squashed leaving only limited space. The restricted bladder can no longer hold the normal amount of urine and requires frequent emptying, placing children at risk of wetting the bed while asleep. Due to the large stool mass pressing against the bladder children often do not feel the sensation of having to urinate, leading to both daytime and nighttime enuresis.
The signs and symptoms of childhood constipation include: poor appetite, lack of energy, irregular bowel movements, excessive and foul smelling flatulence, irregular stool texture, withholding of stools, daytime soiling or overflow, nighttime incontinence, abdominal pain or discomfort, and irritability. Some children with physical disabilities or impaired mobility, such as Cerebral Palsy or Downs Syndrome, are more prone to constipation. The management of bowel dysfunctions and nocturnal enuresis is a highly sensitive matter and can require ongoing and prolonged treatment. As such parents of children with bowel problems will require considerable patience as they help children break old habits and develop new routines and practices. The good news is that once children are treated for their constipation and they develop regular bowel habits most will stop wetting the bed.
MANAGEMENT AND TREATMENT
Medical Intervention
It is recommended that parents first consult with a medical professional if you suspect your child is suffering from chronic constipation. Children may require an x-ray or colonoscopy (which involves placing a scope within the colon) to see if there are any physical abnormalities. Some children may be so impacted with a hard stool that they require medical intervention. Although not recommended for long-term use, laxatives are often needed to help children re-establish regular bowel movements. Once children’s bowel movements have been improved, the nocturnal enuresis should also improve.
Dietary and Fluid Control
Monitoring your child’s fluid intake is very important in the management of bedwetting, particularly when constipation is identified as a significant contributor. The amount of fluid your child should drink each day varies depending on the time of year (Summer vs Winter), their dietary intake as well as how physically active they are. The suggested minimum is approximately 1 litre of fluid per day if your child is aged 5 years, increasing to 1.5 litres for a 10-year-old. Children with constipation are encouraged to adopt a diet high in fibre. High fibre foods include whole grain breads, bran or barley cereals, fruits and raw vegetables (celery, lettuce, pear, apples, plums, peaches, grapes). Keep to a minimum those foods that cause constipation, such as rice, rice cereal, pasta, white bread, carrots, bananas, cheese or foods high in sugar. Parents of children who wet the bed often restrict fluids at night in an attempt to help their child become dry. Restriction of fluids can be a cause of constipation, thus it is very important not to restrict your child’s drinking as a means of managing bedwetting, particularly if your child shows any signs of constipation.
Reward Systems
Improving bowel habits can help with the resolution of children’s bedwetting. While reward systems are not generally encouraged in the management of children’s bedwetting they can be quite helpful in managing chronic constipation. Positive rewards can be used either in isolation or in combination with a bedwetting treatment. You should decide in advance with your child what type of behaviours you would like to encourage and how you will reward these. Some children respond particularly well to reward charts that can cumulate or be “cashed-in” for a more significant prize or reward. In order to help your child improve their bowel habits, you need to encourage them to go to the toilet. Rewards may be given for a range of behaviours including sitting on the toilet for 10 to 15 minutes after each meal, eating healthy food, drinking regularly throughout the day, or taking their medication. The impact on a child’s social life and self-esteem can be profound, particularly if your child is also experiencing incontinence during the day. You can use both verbal praise and rewards to help highlight to your child all those things in their life that they do well. Help them to understand that this is in no way their fault and with time, patience and effort this will all come to an end.
